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Koguchi H, Nakatsutsumi K, Ikuta T, Fujita A, Otomo Y, Morishita K. Gastric rupture caused by intragastric perforation of splenic artery aneurysm: a case report and literature review. Surg Case Rep 2024; 10:147. [PMID: 38884824 PMCID: PMC11182992 DOI: 10.1186/s40792-024-01944-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/05/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND The rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach. CASE PRESENTATION A 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma. CONCLUSIONS We successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.
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Affiliation(s)
- Hazuki Koguchi
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan.
| | - Keita Nakatsutsumi
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
| | - Takahiro Ikuta
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
| | - Akihiro Fujita
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
| | - Yasuhiro Otomo
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Koji Morishita
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
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2
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Han YJ, Roy S, Siau AMPL, Majid A. Binge-eating and sodium bicarbonate: a potent combination for gastric rupture in adults-two case reports and a review of literature. J Eat Disord 2022; 10:157. [PMID: 36348449 PMCID: PMC9643985 DOI: 10.1186/s40337-022-00677-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Disordered eating behaviour including binge-eating often results in significant medical conditions, which are at times fatal. It can result in acute gastric dilatation which can lead to ischemic necrosis and stomach rupture. Dyspepsia and bloating are common symptoms following binge eating. Patients commonly use over-the-counter medications like sodium bicarbonate or home remedies for relief. However, in very rare, reported cases, sodium bicarbonate has been attributed to cause acute gastric dilatation and spontaneous gastric rupture instead. METHODS We report two cases of spontaneous gastric rupture following consumption of sodium bicarbonate containing antacids after a large meal, and a review of the literature of similar cases. RESULTS A total of 36 cases were identified. Approximately half of the cases (47.2%) were correlated with eating disorders, with higher prevalence in females (69%) and a very high mortality rate (41.6%). Amongst the 36 cases, sodium bicarbonate ingestion was associated with 10 cases. The lesser curvature (36.1%) and anterior wall (33.3%) are the most common sites of rupture. Associated causes include binge-eating, gas release from sodium bicarbonate, gastric content fermentation, proximal and distal outlet obstruction, and muscular atony. DISCUSSION Sudden distension and impaired emptying mechanism of the stomach is necessary for spontaneous gastric rupture to occur. Acute gastric dilatation with perforation requires definitive surgical management. There should be a low threshold of suspicion for patients presenting with severe abdominal pain and abdominal distension following an episode of binge-eating. There is a need for patient education around the use of over-the-counter medications or home remedies.
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Affiliation(s)
- You Jin Han
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, Newcastle, NSW, 2308, Australia
| | - Susmit Roy
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, Newcastle, NSW, 2308, Australia. .,Calvary Mater Hospital, Newcastle, Edith & Platt St, Waratah, Newcastle, NSW, 2298, Australia. .,University of Newcastle, Newcastle, Australia.
| | - Ashley Maria Pei Ling Siau
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, Newcastle, NSW, 2308, Australia
| | - Adeeb Majid
- Calvary Mater Hospital, Newcastle, Edith & Platt St, Waratah, Newcastle, NSW, 2298, Australia
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3
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Cioffi A, De Simone S, Cipolloni L, Baldari B. Binge-eating episode as a direct cause of death in a young individual without eating disorder. Med Leg J 2022; 90:152-155. [PMID: 35634997 DOI: 10.1177/00258172221091329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Binge eating is characterised by the ingestion of large quantities of food in a short time. Cases in the literature deal exclusively with gastric perforation in people with a history of anorexia nervosa, binge eating disorder or bulimia nervosa.We report the case of a young woman with no previous diagnosis of mental illness and a history of only two binge-eating episodes that occurred a few years earlier. She died suddenly during a binge-eating episode from stomach rupture resulting from a single perforation of the stomach with leakage of food material within the abdominal cavity. There was no sign of gastric necrosis or peritonitis. The deceased died quickly.Our case, which appears unique in the literature, shows that there is a risk of death even in people with no diagnosis of eating disorders and a history of only few and isolated binge-eating episodes. Physicians should carefully investigate a patient's history to assess any risks.
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Affiliation(s)
- Andrea Cioffi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Italy
| | - Stefania De Simone
- Department of Clinical and Experimental Medicine, University of Foggia, Italy
| | - Luigi Cipolloni
- Department of Clinical and Experimental Medicine, University of Foggia, Italy
| | - Benedetta Baldari
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Italy
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4
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Swed S, Ezzdean W, Sawaf B. Chronic gastric dilatation with gastric fundus perforation in anorexia nervosa patient. Int J Surg Case Rep 2022; 90:106645. [PMID: 34991050 PMCID: PMC8741521 DOI: 10.1016/j.ijscr.2021.106645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION As a complication of anorexia or bulimia nervosa, gastrointestinal problems such as stomach dilatation and necrosis are extremely rare. Our purpose is this case to pay attention on anorexia and bulimia patients to envisage the occurrence of chronic digestive injuries by performing the accurate diagnosis and selective prompt treatment. CASE PRESENTATION A 40-year old female patient admitted to the emergency department with complaints of digestive symptoms. In his history there was just anorexia nervosa. Computed tomography and X-rays showed major gastric distension reaching the pelvis and perforation of the fundus. The large curvature of the stomach and the necrotic part was removed surgically. But the patient died in the second day after admission in the hospital because he was affected by a septic shock as a complication of distribution the infection because the doctors didn't resect whole the stomach during the open surgery. DISCUSSION We report a rare case that shows gastric dilatation and necrosis post-anorexia nervosa, which requires accurate X-ray and CT scan, but treatment depends on whether or not gastric necrosis is present and the size of the necrosis. According to what mentioned in the medical literature this is the second case that cause death of the patient after surgery for treatment the gastric dilatation as a complication of anorexia nervosa. CONCLUSION The thing that distinguishes this case is the large size of the extension of the stomach from the diaphragm to the pelvis and the perforation of the fundus with a diameter of 5 cm and the death of the patient after surgery, so we can add it in the medical literature to avoid the complications of these psychiatric diseases.
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Affiliation(s)
- Sarya Swed
- Faculty of Human Medicine, Aleppo University, Aleppo, Syria
| | - Weaam Ezzdean
- Department of Urology, Ibn Al Nafees Hospital, Damascus, Syria.
| | - Bisher Sawaf
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
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5
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Gibson D, Watters A, Mehler PS. The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic?-A systematic review. Int J Eat Disord 2021; 54:1019-1054. [PMID: 34042203 DOI: 10.1002/eat.23553] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/22/2021] [Accepted: 05/08/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Although multiple pathophysiologic changes develop within the gastrointestinal (GI) system in the setting of malnutrition, the etiology of the reported multitude of symptoms in those with anorexia nervosa and avoidant restrictive intake disorder, as well as their contribution toward disordered eating, remain poorly understood. This systematic review seeks to better understand how these physiologic changes of malnutrition of the esophagus, stomach, intestines, and pancreas contribute toward the reported GI symptoms, as well as better understand how celiac disease, inflammatory bowel disease, pelvic floor dysfunction, and Ehlers-Danlos syndrome contribute toward disordered eating. METHODS Studies of any design exploring the pathogenesis of complications and treatment strategies were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to structure and complete the review. RESULTS A total of 146 articles were used for the review. The majority of studies were observational or case reports/case series. DISCUSSION Pathophysiologic changes of the esophagus, stomach, and intestines develop with malnutrition, although these changes do not consistently correlate with expressed GI symptoms in patients with restrictive eating disorders. Celiac disease and inflammatory bowel disease also contribute to disordered eating through the associated somatic GI complaints, while pelvic floor dysfunction and Ehlers-Danlos syndrome contribute through both somatic symptoms and functional symptoms. Indeed, functional GI symptoms remain problematic during the course of treatment, and further research is required to better understand the extent to which these symptoms are functional in nature and remit or remain as treatment ensues.
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Affiliation(s)
- Dennis Gibson
- ACUTE at Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ashlie Watters
- ACUTE at Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Philip S Mehler
- ACUTE at Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,Eating Recovery Center, Denver, Colorado, USA
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6
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Chen YH, Zhu XY, Liu XQ. Acute and life-threatening complications in patients with anorexia nervosa: A case report and literature study. Nutrition 2021; 87-88:111204. [PMID: 33744639 DOI: 10.1016/j.nut.2021.111204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/21/2021] [Accepted: 02/08/2021] [Indexed: 11/27/2022]
Abstract
Anorexia nervosa (AN) is characterized by a strong fear of weight gain and body image disorders and is classified as a mental illness that can cause direct damage to one's mental health and body. Many individuals with AN tend to commit suicide. Additionally, the disease can lead to chronic undernutrition and low body weight, adversely affecting each body system, exacerbating systemic medical complications, especially acute life-threatening complications. Therefore, AN has the highest mortality and disability rates among all mental diseases. There is a basic clinical need to identify and address the acute and critical complications of this disease as soon as possible. However, the current literature has a poor description of the acute and critical complications of AN and lacks a systematic review. We report a case of a patient with AN and severe hypokalemia, significant Q-T interval prolongation, stomach dilation, and intestinal obstruction who recovered after conservative treatment. The defecation method we used, to our knowledge, has not been previously reported in the literature. We also briefly review the various acute and life-threatening complications of AN.
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Affiliation(s)
- Yun-Hu Chen
- Department of Internal Medicine, Taicang Hospital affiliated with Nanjing University of Traditional Chinese Medicine, Suzhou, China.
| | - Xing-Yu Zhu
- Department of Clinical Pharmacy, Taicang Hospital affiliated with Nanjing University of Traditional Chinese Medicine, Suzhou, China
| | - Xue-Qian Liu
- Department of Emergency Medicine, Taicang Hospital affiliated with Nanjing University of Traditional Chinese Medicine, Suzhou, China
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7
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Achamrah N, Grigioni S, Coëffier M, Ainseba N, Déchelotte P. Gastric Necrosis After Binge Eating in Bulimia: Recovery From Eating Disorder After Total Gastrectomy. Front Psychiatry 2020; 11:741. [PMID: 32903630 PMCID: PMC7438759 DOI: 10.3389/fpsyt.2020.00741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/15/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Gastric necrosis following acute gastric dilatation is rare but more common in females with eating disorders, such as anorexia nervosa or bulimia, during which patients often alternate restriction and binge eating behaviors. CASE PRESENTATION A 37-year old female patient with a history of 15 years of bulimia nervosa was admitted to the emergency department 24 h after binge eating. Abdominal Computed Tomography imaging showed major gastric distension reaching the pelvis and compressing the digestive organs. Total gastrectomy was required because of gastric necrosis. The patient reported significant reduction in bulimic symptoms after gastrectomy. CONCLUSION We discuss here the possible mechanisms underlying this recovery, including changes in gut-derived factors that could mediate eating behavior changes.
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Affiliation(s)
- Najate Achamrah
- Nutrition Department, Rouen University Hospital Center, Rouen, France.,Normandie Univ, UNIROUEN, INSERM UMR 1073, Nutrition, Inflammation et dysfonction de l'axe Intestin-Cerveau, IRIB, Rouen, France.,Clinical Investigation Centre CIC 1404, INSERM and Rouen University Hospital, Rouen, France
| | - Sébastien Grigioni
- Nutrition Department, Rouen University Hospital Center, Rouen, France.,Normandie Univ, UNIROUEN, INSERM UMR 1073, Nutrition, Inflammation et dysfonction de l'axe Intestin-Cerveau, IRIB, Rouen, France
| | - Moïse Coëffier
- Nutrition Department, Rouen University Hospital Center, Rouen, France.,Normandie Univ, UNIROUEN, INSERM UMR 1073, Nutrition, Inflammation et dysfonction de l'axe Intestin-Cerveau, IRIB, Rouen, France.,Clinical Investigation Centre CIC 1404, INSERM and Rouen University Hospital, Rouen, France
| | - Nadjib Ainseba
- Digestive Surgery, Beauvais Hospital Center, Beauvais, France
| | - Pierre Déchelotte
- Nutrition Department, Rouen University Hospital Center, Rouen, France.,Normandie Univ, UNIROUEN, INSERM UMR 1073, Nutrition, Inflammation et dysfonction de l'axe Intestin-Cerveau, IRIB, Rouen, France.,Clinical Investigation Centre CIC 1404, INSERM and Rouen University Hospital, Rouen, France
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8
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Riedlinger C, Schmidt G, Weiland A, Stengel A, Giel KE, Zipfel S, Enck P, Mack I. Which Symptoms, Complaints and Complications of the Gastrointestinal Tract Occur in Patients With Eating Disorders? A Systematic Review and Quantitative Analysis. Front Psychiatry 2020; 11:195. [PMID: 32425816 PMCID: PMC7212454 DOI: 10.3389/fpsyt.2020.00195] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/27/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Eating disorders (ED) such as anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) are often accompanied by a variety of psychological and physical comorbidities. Gastrointestinal (GI) symptoms are a classical feature in most patients with ED. The heterogeneity of studies on this topic is high, making it difficult to have a clear overview. The aim of this systematic review is therefore to provide an overview of subjectively and objectively measured differences and changes in the GI tract in patients with EDs, along with the occurrence of GI complications. METHODS A systematic literature search was conducted in PubMed, Web of Science, and Google Scholar to find all relevant studies examining GI problems in AN, BN, and BED. Quantitative analyses were performed for objective GI physiology measures where applicable. RESULTS The review differentiated between ED types and also between studies that report GI outcomes of ED in (i) human studies with an ED diagnosis excluding case reports that provide an overview of GI problems in ED and (ii) case reports with an ED diagnosis describing rare GI complications in ED. GI symptoms and impaired gastric transit times were frequent features of EDs with specific differences found for the ED types. During the time course of treatment, GI symptoms changed and/or improved but not completely. GI complications extended the range of GI problems observed, including a variety of serious complications such as gastric dilatation. CONCLUSIONS Problems of the GI tract are frequent in patients with ED and it is likely that they complicate therapy, especially in patients with AN. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42019100585.
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Affiliation(s)
- Caroline Riedlinger
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.,Competence Center for Eating Disorders (KOMET), Tübingen, Germany
| | - Greta Schmidt
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.,Competence Center for Eating Disorders (KOMET), Tübingen, Germany
| | - Alisa Weiland
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.,Competence Center for Eating Disorders (KOMET), Tübingen, Germany
| | - Andreas Stengel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.,Competence Center for Eating Disorders (KOMET), Tübingen, Germany
| | - Katrin Elisabeth Giel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.,Competence Center for Eating Disorders (KOMET), Tübingen, Germany
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.,Competence Center for Eating Disorders (KOMET), Tübingen, Germany
| | - Paul Enck
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.,Competence Center for Eating Disorders (KOMET), Tübingen, Germany
| | - Isabelle Mack
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.,Competence Center for Eating Disorders (KOMET), Tübingen, Germany
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9
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Tayyeb JZ, Popeijus HE, Mensink RP, Konings MC, Mulders KH, Plat J. Amoxicillin Modulates ApoA-I Transcription and Secretion, Predominantly via PPARα Transactivation Inhibition. Int J Mol Sci 2019; 20:ijms20235967. [PMID: 31783518 PMCID: PMC6928897 DOI: 10.3390/ijms20235967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 12/28/2022] Open
Abstract
In a recent human study, we observed that amoxicillin treatment decreased HDL-C concentration. We hypothesize that antibiotics lower the transcription and secretion of ApoA-I, the responsible protein for HDL production. HepG2 and Caco-2 cells were exposed to increasing dose of amoxicillin, penicillin, and streptomycin. Secreted ApoA-I protein and mRNA transcripts were analyzed using ELISA and qPCR, respectively. To unravel underlying mechanisms, KEAP1, CPT1, and CHOP mRNA expressions were determined as well as PPARα transactivation. In HepG2 and Caco-2, amoxicillin decreased ApoA-I transcription and secretion. Effects on ApoA-I expression were clearly there for amoxicillin while no effects were observed for penicillin or streptomycin. KEAP1, CPT1, and CHOP mRNA expressions were reduced by amoxicillin treatments. Moreover, a significant correlation between ApoA-I and CPT1 mRNA expressions was found. Furthermore, amoxicillin lowered PPARα transactivation. All together, these data suggest that inhibited PPARα transactivation is involved in the effects of amoxicillin on ApoA-I. In conclusion, the direct effect of amoxicillin in treated HepG2 and Caco-2 cells was a lower ApoA-I secretion and transcription. Based on evaluating alterations in KEAP1, CPT1, and CHOP mRNA expressions plus PPARα transactivation, we suggest that a reduced PPARα activation is a potential mechanism behind the observed amoxicillin effects on ApoA-I expression.
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Affiliation(s)
- Jehad Z. Tayyeb
- Department of Nutrition and Movement Sciences, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ET Maastricht, The Netherlands; (J.Z.T.); (R.P.M.); (J.P.)
- Department of Biochemistry, Faculty of Medicine, University of Jeddah, Jeddah 23218, Saudi Arabia
| | - Herman E. Popeijus
- Department of Nutrition and Movement Sciences, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ET Maastricht, The Netherlands; (J.Z.T.); (R.P.M.); (J.P.)
- Correspondence: ; Tel.: +31433881639
| | - Ronald P. Mensink
- Department of Nutrition and Movement Sciences, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ET Maastricht, The Netherlands; (J.Z.T.); (R.P.M.); (J.P.)
| | - Maurice C.J.M. Konings
- Department of Nutrition and Movement Sciences, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ET Maastricht, The Netherlands; (J.Z.T.); (R.P.M.); (J.P.)
| | - Kim H.R. Mulders
- Department of Nutrition and Movement Sciences, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ET Maastricht, The Netherlands; (J.Z.T.); (R.P.M.); (J.P.)
| | - Jogchum Plat
- Department of Nutrition and Movement Sciences, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ET Maastricht, The Netherlands; (J.Z.T.); (R.P.M.); (J.P.)
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10
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Schalla MA, Stengel A. Gastrointestinal alterations in anorexia nervosa - A systematic review. EUROPEAN EATING DISORDERS REVIEW 2019; 27:447-461. [DOI: 10.1002/erv.2679] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/20/2019] [Accepted: 03/15/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Martha A. Schalla
- Charité Center for Internal Medicine and Dermatology, Department for Psychosomatic Medicine; Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Berlin Germany
| | - Andreas Stengel
- Charité Center for Internal Medicine and Dermatology, Department for Psychosomatic Medicine; Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Berlin Germany
- Department of Psychosomatic Medicine and Psychotherapy; Medical University Hospital Tübingen; Tübingen Germany
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11
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Madea B, Doberentz E. Commentary on: Di Luca A, Ricci E, Grassi VM, Arena V, Oliva A. An exceptional case of acute respiratory failure caused by intrathoracic gastric perforation secondary to overeating. J Forensic Sci 2019;64(1):292–4. J Forensic Sci 2019; 64:965-966. [DOI: 10.1111/1556-4029.14059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Burkhard Madea
- Institute of Forensic Medicine of the University of Bonn Stiftsplatz 12 D‐53111 Bonn Germany
| | - Elke Doberentz
- Institute of Forensic Medicine of the University of Bonn Stiftsplatz 12 D‐53111 Bonn Germany
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12
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di Luca A, Ricci E, Grassi VM, Arena V, Oliva A. An Exceptional Case of Acute Respiratory Failure Caused by Intra‐Thoracic Gastric Perforation Secondary to Overeating. J Forensic Sci 2018; 64:292-294. [DOI: 10.1111/1556-4029.13825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/07/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Alessandro di Luca
- Institute of Public Health, Legal Medicine Section Catholic University Medical School Largo Francesco Vito 1 ‐ 00168 Rome RM Italy
| | - Eleonora Ricci
- Institute of Public Health, Legal Medicine Section Catholic University Medical School Largo Francesco Vito 1 ‐ 00168 Rome RM Italy
| | - Vincenzo M. Grassi
- Institute of Public Health, Legal Medicine Section Catholic University Medical School Largo Francesco Vito 1 ‐ 00168 Rome RM Italy
| | - Vincenzo Arena
- Institute of Pathological Anatomy Catholic University Medical School Largo Francesco Vito 1 ‐ 00168 Rome RM Italy
| | - Antonio Oliva
- Institute of Public Health, Legal Medicine Section Catholic University Medical School Largo Francesco Vito 1 ‐ 00168 Rome RM Italy
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13
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Dumouchel J, Lvovschi V, Joly LM. Obstructive acute renal failure by severe gastric distension after binge. Am J Emerg Med 2017; 35:1210.e5-1210.e7. [PMID: 28615144 DOI: 10.1016/j.ajem.2017.03.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 03/19/2017] [Indexed: 11/30/2022] Open
Abstract
Binge eating occurs in patients with eating disorders and can result in metabolic complications, leading to gastric rupture or necrosis. However, organ failure as acute renal failure is rarely observed. We report the case of an overeating episode resulting in massive gastric dilatation and acute renal failure with abdominal pressure and bilateral ureteral obstruction. The outcome was favorable with gastric aspiration and fasting.
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Affiliation(s)
- Julie Dumouchel
- CHU Charles Nicolle Rouen, 45 rue de la Tour d'Auvergne, 3700 Tours, France.
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14
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Serum atrial natriuretic peptide (ANP) as an objective indicator for the diagnosis of neurogenic shock: animal experiment and human case report. Int J Legal Med 2016; 131:473-478. [PMID: 27726028 DOI: 10.1007/s00414-016-1455-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
Abstract
In forensic medicine, the diagnosis of death due to neurogenic shock is considered to be an aporia, as lacking objective indicators and presenting atypical symptoms in autopsy. Medico-legal disputes and complaints occasionally result from this ambiguity. To explore potential objective indicators of neurogenic shock, we set up a model of neurogenic shock by applying an external mechanical force on the carotid sinus baroreceptor in rabbits. The serum atrial natriuretic peptide (ANP) level was measured by radioimmunoassay in the control group (n = 8), survival group (n = 15) and death group (n = 5) both before and after the insult. The serum ANP level showed a significant increase after the insult in the death group compared with the serum obtained before the insult (P = 0.006), while the serum ANP level after the insult in the survival group and control group was not statistically significant compared with the serum obtained before the insult (P = 0.332 and P = 0.492, respectively). To verify the repeatability of the model and the postmortem behavior of serum ANP, five healthy adult rabbits underwent the same procedure as the experimental group. The mortality rate was consistent with the former experiment (20 %). There were no significant changes in serum ANP level in vitro and in vivo (within 48 and 24 h, respectively). But there was a significant decrease in serum ANP level at 48 h postmortem in vivo (P = 0.001). A female patient who expired due to neurogenic shock during a hysteroscopy was reported. Neither fatal primary disease nor evidence for mechanical injuries or intoxication was found according to the autopsy. The serum ANP level was assayed as a supplementary indicator and was found to be three-fold higher than the normal maximum limit. Combined with the animal experiment, this case highlights that serum ANP has the potential to be an objective indicator for the diagnosis of death due to neurogenic shock.
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15
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Ishigami A, Tokunaga I, Nishimura A, Kubo SI. Postmortem Diagnosis of Anorexia Nervosa: An Endocrinological and Immunohistochemical Approach. THE JOURNAL OF MEDICAL INVESTIGATION 2016; 63:305-9. [PMID: 27644577 DOI: 10.2152/jmi.63.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A female in her 30s was found dead after a fire. She was severely emaciated and had been diagnosed with anorexia nervosa (AN) about 5 years ago, but had not been treated recently. Therefore, we investigated not only her cause of death but also her condition of AN. Some of her organs weighed less than normal although no clear lesions were observed. In the pituitary gland, the number of follicle-stimulating hormone-immunopositive cells was markedly decreased although a normal number of thyroid-stimulating hormone-positive cells were detected. A histological examination of the ovary suggested that she had been suffering from amenorrhea. The thyroid gland was atrophic, and marked variations in follicle size were observed. Because we could not obtain enough volume of her blood for endocrinological examinations, we tried to investigate her endocrinological condition by immunohistochemistry. Immunohistochemical staining detected decreased triiodothyronine immunoreactivity and normal thyroxine immunoreactivity. The adrenal glands were also atrophic. Based on these findings, it was considered that she had been suffering from AN at the time of her death. The autopsy and other findings revealed that she had died of burning with carbon monoxide intoxication. J. Med. Invest. 63: 305-309, August, 2016.
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Affiliation(s)
- Akiko Ishigami
- Department of Forensic Medicine, Institute of Biomedical Sciences, Tokushima University Graduate School
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16
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Norris ML, Harrison ME, Isserlin L, Robinson A, Feder S, Sampson M. Gastrointestinal complications associated with anorexia nervosa: A systematic review. Int J Eat Disord 2016; 49:216-37. [PMID: 26407541 DOI: 10.1002/eat.22462] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE A systematic review identifying gastrointestinal (GI) complications attributable to anorexia nervosa (AN) was completed. METHOD Studies of any design exploring the pathogenesis of complications and treatment strategies were included. The review was completed in accordance with PRISMA standards. RESULTS A total of 123 articles were retained, including one randomized control trial. The majority of included studies were case reports and case series. Controlled studies demonstrated that patients with AN were more likely to have delays in gastric motility, gastric emptying and intestinal transit than comparator groups although results were not uniform across all studies. Published reports suggest that complications can occur at any segment of the GI tract. These issues may derive as a consequence of severe malnourishment, from eating disorder related symptoms such as self-induced purging or from the refeeding process itself. Multiple studies noted that patients with AN report high rates of GI symptoms although in the few cases where medical testing was undertaken, correlations between self-reported symptoms and measurable pathology were not demonstrated. DISCUSSION GI complications may occur throughout the entire GI tract in patients with AN. It is recommended that clinicians use careful judgment when pursuing targeted investigation or introducing symptom specific treatments in response to GI complaints. Evidence suggests that most GI complications resolve with refeeding and cessation of ED symptoms.
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Affiliation(s)
- Mark L Norris
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Megan E Harrison
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Leanna Isserlin
- Department of Psychiatry, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy Robinson
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Feder
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Margaret Sampson
- Library and Media Services, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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17
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Kimura A, Masuda N, Haga N, Ito T, Otsuka K, Takita J, Satomura H, Kumakura Y, Kato H, Kuwano H. Gastrojejunostomy for pyloric stenosis after acute gastric dilatation due to overeating. World J Gastroenterol 2015; 21:1670-1674. [PMID: 25663789 PMCID: PMC4316112 DOI: 10.3748/wjg.v21.i5.1670] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/05/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
A 34-year-old woman presented at our hospital with abdominal distention due to overeating. Acute gastric dilatation was diagnosed. The patient was hospitalized, and nasogastric decompression was initiated. On hospitalization day 3, she developed shock, and her respiratory state deteriorated, requiring intubation and mechanical ventilation. Nasogastric decompression contributed to the improvement in her clinical condition. She was discharged 3 mo after admission. During outpatient follow-up, her dietary intake decreased, and her body weight gradually decreased by 14 kg. An upper gastrointestinal series and endoscopy revealed pyloric stenosis; therefore, we performed gastrojejunostomy 18 mo after her initial admission. The patient was discharged from the hospital with no postoperative complications. Gastric necrosis and perforation due to overeating-induced gastric dilatation are life-threatening conditions. Surgical intervention may be required if delayed pyloric stenosis occurs after conservative treatment. We report a case of pyloric stenosis due to overeating-induced gastric dilatation treated by gastrojejunostomy 18 mo after the initial presentation.
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18
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De-Giorgio F, Lodise M, Pascali VL, Spagnolo AG, d'Aloja E, Arena V. An unusual case showing fatal rupture of a gastric ulcer or gastromalacia? The importance/role of histology for differential diagnosis. J Forensic Sci 2014; 60:240-2. [PMID: 25388056 DOI: 10.1111/1556-4029.12665] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 09/06/2013] [Accepted: 10/18/2013] [Indexed: 11/28/2022]
Abstract
Gastromalacia is the acute autolytic erosion of the gastric wall. It generally occurs postmortem, and it appears as a slimy brownish black region of the wall which occurs principally in the gastric fundus. A 59-year-old woman died in the Emergency Department following a 2-day period of mild abdominal pain, vomiting, and diarrhea. A forensic autopsy was performed which revealed a rupture of the gastric fundus that had caused leakage of gastric content into the abdominal cavity. There was no macroscopic evidence of peritonitis, and the stomach wall adjacent to the rupture site showed marked thinning. The gross appearance was typical of gastromalacia. In contrast, histological observations revealed the presence of an ulcer at the site of perforation and a severe acute inflammatory reaction indicating a robust reaction with an antemortem rupture.
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Affiliation(s)
- Fabio De-Giorgio
- Institute of Public Health, Section of Legal Medicine, School of Medicine, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
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19
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Letale Magenruptur eines 5-jährigen Mädchens mit Rett-Syndrom. Rechtsmedizin (Berl) 2014. [DOI: 10.1007/s00194-014-0944-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Plötzlicher Tod bei massiver Magendilatation. Rechtsmedizin (Berl) 2012. [DOI: 10.1007/s00194-012-0844-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Eating disorders are usually associated with an increased risk of premature death with a wide range of rates and causes of mortality. “Sudden death” has been defined as the abrupt and unexpected occurrence of fatality for which no satisfactory explanation of the cause can be ascertained. In many cases of sudden death, autopsies do not clarify the main cause. Cardiovascular complications are usually involved in these deaths. The purpose of this review was to report an update of the existing literature data on the main findings with respect to sudden death in eating disorders by means of a search conducted in PubMed. The most relevant conclusion of this review seems to be that the main causes of sudden death in eating disorders are those related to cardiovascular complications. The predictive value of the increased QT interval dispersion as a marker of sudden acute ventricular arrhythmia and death has been demonstrated. Eating disorder patients with severe cardiovascular symptoms should be hospitalized. In general, with respect to sudden death in eating disorders, some findings (eg, long-term eating disorders, chronic hypokalemia, chronically low plasma albumin, and QT intervals >600 milliseconds) must be taken into account, and it must be highlighted that during refeeding, the adverse effects of hypophosphatemia include cardiac failure. Monitoring vital signs and performing electrocardiograms and serial measurements of plasma potassium are relevant during the treatment of eating disorder patients.
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22
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Severe intestinal ischemia can trigger cardiovascular collapse and sudden death via a parasympathetic mechanism. Shock 2012; 36:251-62. [PMID: 21617580 DOI: 10.1097/shk.0b013e3182236f0f] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemorrhagic shock and splanchnic arterial occlusion (SAO) followed by reperfusion are associated with high mortality. However, rapid cardiovascular failure and death may also occur before reperfusion in hemorrhagic shock and SAO. We show in a rat SAO model that, upon gut ischemia, mean arterial blood pressure transiently elevates and then drops fatally in one of two time courses: (i) gradually over ∼1 to 3 h or (ii) rapidly (often by >80 mmHg) over a period of 1 to 6 min. We hypothesize that fast fatal pressure drops (FFPDs) are due to failure of autonomic nervous system control. To test this, we treated rats with Glucose (10%) in the small intestinal lumen and intramuscularly administered xylazine to activate the parasympathetic nervous system or with a muscarinic anticholinergic (glycopyrrolate) or by total subdiaphragmatic vagotomy to attenuate parasympathetic nervous system activity. We also tested nafamostat mesilate (ANGD [6-amidino-2-naphthyl p-guanidinobenzoate dimethanesulfonate]), a protease inhibitor efficacious in preventing blood pressure loss in SAO with reperfusion, in the intestinal lumen. Fifty percent of animals receiving xylazine and Glucose died by FFPD (vs. 33% with neither, not statistically significant). Total subdiaphragmatic vagotomy or glycopyrrolate treatment significantly reduced the incidence to 0% (P < 0.008), although slow fatal pressure drops still occurred. ANGD did not prevent FFPDs, but delayed onset of slow fatal pressure drops (P < 0.013). These results suggest that gut ischemia can cause sudden death via an autonomic nervous system mechanism and that SAO with Glucose and xylazine may serve as a useful model for the study of neurogenic shock or autonomic dysregulation associated with sudden death.
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23
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Steen S, Lamont J, Petrey L. Acute gastric dilation and ischemia secondary to small bowel obstruction. Proc (Bayl Univ Med Cent) 2011; 21:15-7. [PMID: 18209748 DOI: 10.1080/08998280.2008.11928348] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Acute gastric dilation leading to ischemia of the stomach is an under-diagnosed and potentially fatal event. Multiple etiologies can lead to this condition, and all physicians should be aware of it. Without proper and timely diagnosis and treatment, gastric perforation, hemorrhage, and other serious complications can occur. We report a case of acute gastric dilation and ischemia secondary to small bowel obstruction. We also review the world literature and discuss the etiology, diagnosis, and management of this condition.
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Affiliation(s)
- Shawn Steen
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA.
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Morse JL, Safdar B. Acute Tension Pneumothorax and Tension Pneumoperitoneum in a Patient with Anorexia Nervosa. J Emerg Med 2010; 38:e13-6. [PMID: 18375092 DOI: 10.1016/j.jemermed.2007.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 05/15/2007] [Accepted: 07/12/2007] [Indexed: 10/22/2022]
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Watanabe S, Terazawa K, Asari M, Matsubara K, Shiono H, Shimizu K. An autopsy case of sudden death due to acute gastric dilatation without rupture. Forensic Sci Int 2008; 180:e6-e10. [PMID: 18757145 DOI: 10.1016/j.forsciint.2008.07.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 07/28/2008] [Accepted: 07/28/2008] [Indexed: 12/29/2022]
Abstract
We report the first autopsy case of fatal gastric dilatation without rupture. A 31-year-old woman who lived alone was found dead in her living room. Despite being very thin, she showed marked abdominal distention. Autopsy and histological findings revealed that a severely distended stomach, of which walls notably thin and displayed transmural necrosis, occupied the entire abdominal cavity. Severe congestion was observed in the intestine and cecum. Theses findings suggest that bulimia nervosa together with anorexia nervosa resulted in rapid dilation of the stomach. We conclude that the cause of death was acute circulatory failure from hypovolemic shock that occurred following compression of the inferior vena cava and superior mesenteric vein, and by loss of circulatory volume to the third space.
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Affiliation(s)
- Satoshi Watanabe
- Department of Legal Medicine and of Pharmacy & Pharmacology, Asahikawa Medical College, Midorigaoka-higashi 2-1-1-1, Asahikawa 078-8510, Japan.
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26
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Matsuyama T, Komeda S, Nobayashi M, Imanishi M, Kawaguchi S. Acute gastric dilatation causing bacterial cerebral aneurysm--case report. Int J Eat Disord 2008; 41:380-2. [PMID: 18213687 DOI: 10.1002/eat.20487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Acute gastric dilatation (AGD) is a very rare entity which can sometimes be life-threatening. We report a case of a patient presenting with a rupture of a BCA during the treatment of AGD. METHOD A 24-year-old woman, who had a history of bulimia and vomiting episodes, was transferred in shock with marked abdominal distension. A large nasogastric tube was inserted, and 9 liters of viscous gastric contents were drained out. Her circulation became stable. RESULTS About 3 months after admission, she became drowsy and presented with a right hemiparesis and aphasia. Computed tomography of the head showed a diffuse thick subarachnoid hemorrhage. Left carotid angiograms revealed an obscurely-shaped aneurysm in the left middle cerebral artery. CONCLUSION Trapping of the aneurysm was performed. Thirty-four days after admission, the patient had a residual right hemiparesis and motor aphasia, and was discharged.
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Affiliation(s)
- Takeshi Matsuyama
- Department of Critical Care and Emergency Medicine, Nara Prefectural Nara Hospital, Nara city, Japan.
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