Unusual case of retroperitoneal hematoma and duodenal ulcerative bleeding after nephrectomy: Case report

RATIONALE

Retroperitoneal hematomas are relatively common in patients undergoing nephrectomy. Herein, we report an unusual case involving a giant retroperitoneal hematoma and subsequent duodenal ulcerative bleeding following a radical nephrectomy.

PATIENT CONCERNS

A 77-year-old woman was admitted to our hospital for lower back pain, and she had severe right hydronephrosis and a urinary tract infection.

DIAGNOSES

The patient was diagnosed and confirmed as high-grade urothelial carcinoma.

INTERVENTIONS

After ineffective conservative treatments, a right radical nephrectomy and ureteral stump resection were performed. The patient received proton pump inhibitors to prevent stress ulcer formation and bleeding. On the first day post-surgery, she had normal gastrointestinal (GI) endoscopy findings. On the second day post-surgery, abdominal computed tomography revealed a retroperitoneal hematoma. Notably, 14 days post-surgery, massive GI bleeding occurred, and GI endoscopy identified an almost perforated ulcer in the bulbar and descending duodenum.

OUTCOMES

The patient died on day 15 after surgery.

LESSONS

Duodenal ulceration and bleeding might occur following a retroperitoneal hematoma in patients treated with nephrectomy. Timely intervention may prevent duodenal ulcers and complications, and thus could be a promising life-saving intercession.

Retrospective evaluation of the incidence of gastrointestinal bleeding in dogs receiving ophthalmic nonsteroidal anti-inflammatory drugs

OBJECTIVES

To report the incidence of gastrointestinal (GI) bleeding and associated risk factors in a population of dogs receiving ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs).

ANIMAL STUDIED

Medical records of dogs prescribed ophthalmic NSAIDs (cases), dogs receiving systemic NSAIDs alone and dogs receiving systemic prednisone alone (controls).

PROCEDURES

Data were collected retrospectively from the medical records of 204 dogs prescribed ophthalmic NSAIDs (diclofenac, ketorolac, or flurbiprofen), which were subdivided based on if they received any concurrent systemic NSAIDs or glucocorticoids, 136 dogs receiving a systemic NSAID (carprofen or meloxicam) alone, and 151 dogs receiving a systemic glucocorticoid (prednisone) alone at a referral hospital from 2015 to 2019.

RESULTS

Gastrointestinal bleeds developed in 8/79 (10.1%) of topical NSAID-only cases, 10/136 (7.4%) of systemic NSAID controls, and 14/151 (9.3%) of systemic glucocorticoid controls, with no significant difference between the three groups (p = .6103). There were no significant differences in GI bleed rates between cases treated with ketorolac, diclofenac, or flurbiprofen (p = .160), although severe GI bleeding was only seen in ketorolac-treated dogs. Presence of a known concurrent risk factor for GI bleeding was significantly associated with the development of GI bleed in dogs on ophthalmic NSAIDs (p = .032).

CONCLUSIONS

Dogs treated with ophthalmic NSAIDs developed GI bleeding at a frequency comparable to dogs receiving systemic NSAIDs or systemic glucocorticoids alone, suggesting that dogs receiving ophthalmic NSAIDs may be at increased risk of GI bleeding.

Evaluation of gastroprotectant administration in hospitalized cats in a tertiary referral hospital

OBJECTIVES

The primary objective of this study was to evaluate the prescription patterns and appropriateness of the use of gastroprotectant medication in cats.

METHODS

Pharmacy dispensation logs from an academic tertiary referral center were reviewed between 1 January 2018 and 31 December 2018. Cats that were administered proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, misoprostol, antacids or a combination were included. Data regarding medication, dosage, formulation, duration of administration, completeness of discharge instructions and clinical rationales for administration were obtained from medical records. The appropriateness of gastroprotectant use was assessed according to the American College of Veterinary Internal Medicine consensus statement guidelines.

RESULTS

Of the 110 cases, 67 (60.9%) were prescribed a gastroprotectant medication without an appropriate indication. The most common reason for prescription was acute kidney injury in 26/67 (38.8%). PPIs were the most common gastroprotectant medication administered in 95/110 (86.3%) cats, followed by sucralfate in 18/110 (16.4%) and H2RAs in 11/110 (10%). Of the 35 cases in which gastroprotectant therapy was indicated, the medication chosen or dosage administered was considered suboptimal in 16 (45.7%). Instructions regarding the duration of administration, potential adverse effects and timing of administration in relation to meals or other medications were inconsistently provided in discharge instructions to pet owners. Of the 29 cases discharged with omeprazole, only 13 (44.8%) instructions included a duration of administration, while 6 (20.7%) recommended continuing gastroprotectants indefinitely until further notice, 16 (55.2%) discussed the timing of the administration in relation to a meal and six (20.7%) mentioned potential adverse effects; none advised tapering of omeprazole before discontinuation.

CONCLUSIONS AND RELEVANCE

When prescribed, gastroprotectant medications were frequently prescribed injudiciously to cats in this referral population over a 12-month period. Discharge instructions to pet owners also often lacked information and recommendations regarding optimal administration, potential adverse effects, and tapering or discontinuation of the medications.

Presumptive Lornoxicam Intoxication in Four Dogs

Lornoxicam is a nonsteroidal anti-inflammatory drug extensively used in human medicine, which is not approved for canine use. Lornoxicam intoxication has been rarely reported in dogs. Four dogs of various breeds, aged 7 months to 10 years, were admitted with a recent history of melena, anorexia and depression, occurring 1-4 days after the ingestion of lornoxicam (dose range: 0.53-2.7 [median 1.17] mg/kg). No clinically relevant comorbidities were documented, but low doses of prednisolone had been given in 3 of the dogs, in close temporal association with lornoxicam. Major clinical and clinicopathologic findings on admission included mucosal pallor, melena, depression, severe anemia, neutrophilic leucocytosis, and panhypoproteinemia. Perforated pyloric and duodenal ulcers were documented in 3 dogs by exploratory celiotomy or postmortem. Prolonged hospitalization (5-20 days) with extensive supportive care and multiple blood transfusions was required in 3 of the 4 dogs who survived to discharge. Lornoxicam ingestion may cause protracted and severe gastrointestinal tract injury and bleeding, blood loss anemia, panhypoproteinemia, and perforated gastrointestinal ulcers, associated with significant morbidity and mortality in dogs.

Subserous invasion of VEGF-C-producing cancer cells is a possible risk factor for ileal ulceration in the non-metastatic mucosal layer during bevacizumab-combined chemotherapy for recurrent ovarian cancer: A case report

A 65-year-old woman received chemotherapy using taxane and carboplatin prior and following optimal debulking surgery for ovarian cancer stage IV. Five months later, intra-abdominal recurrence was diagnosed, and second-line chemotherapy using nogitecan and bevacizumab was administered. After five courses, the patient presented with a symptom of subileus and subsequent intestinal perforation occurred. An emergent surgery revealed two perforation sites and longitudinally extended ulcerative lesions in the ileum. Pathologically, although metastatic sites were not observed in the submucus layer just beneath the ulcers, there were a number of vascular endothelial growth factor (VEGF)-C-positive cancer cell invasion sites along with marked edema and an increase of the lymphatic endothelial cell marker 'podoplanin'-positive cells in subserous regions. Since bevacizumab is able to inhibit VEGF-A, but not VEGF-C, and induce compensatory increase in VEGF-C production, these findings suggest that the local disturbance of lymphatic circulation in the subserous regions by VEGF-C-producing cancer cells is a possible risk factor for the development of intestinal ulceration and perforation during bevacizumab therapy.

How do we manage serious gastrointestinal adverse events associated with anti-thrombotic therapy?

Antithrombotic therapy (ATTs) is increasingly used worldwide for preventing primary or recurrent thrombotic events. Moreover, newer oral anti-platelet drugs and anti-coagulants have been introduced for clinical use, accelerating the number of patients under ATT. Not infrequently, these drugs are used in combination. These drugs, however, are well-known for adverse events in which gastrointestinal bleeding (GIB) is most common. Bleeding during ATT can be fatal, but even when patients survive, their prognosis is rather poor. Therefore, it is imperative to minimize such events. So far, co-prescription of proton pump inhibitor (PPI) has been documented to be the most effective in reducing upper GI injury and bleeding, though deliberate use of PPIs is required to minimize drug interaction and associated adverse events with acid suppression. In addition, we should note that PPI is not effective in preventing mid- or lower-GI injury/bleeding for which only limited evidence on preventive measures is available.

Modulation of the pharmacokinetics, therapeutic and adverse effects of NSAIDs by Chinese herbal medicines

INTRODUCTION

Concomitant use of NSAIDs and Chinese herbal medicines (CHMs) is frequent, yet summarized information on their interactions is lacking.

AREAS COVERED

A systematic review of literature in four evidence-based English databases was performed. Articles which reported CHMs altering the pharmacokinetics, therapeutic and adverse effects of NSAIDs were identified and summarized. Such interactions may lead to beneficial, detrimental or no change in outcomes. The current review covers four therapeutic effects of NSAIDs, including: i) anti-inflammatory; ii) analgesic; iii) antiplatelet, cardiovascular and cerebrovascular; and iv) anticancer effects and four adverse effects of NSAIDs, including: i) gastrointestinal ulcer; ii) nephrotoxicity; iii) hepatotoxicity; and iv) antiplatelet effects and bleeding.

EXPERT OPINION

While majority of CHMs demonstrated effectiveness in alleviating NSAIDs-induced adverse effects and potentiating the therapeutic effects, this review provides insights for development of CHMs as add-on medications to NSAIDs therapies. However, since limited information was from well-designed clinical trials, the findings are not yet conclusive and more clinical studies are warranted to provide guidance for healthcare professionals. In future, researches on interactions between NSAIDs and CHMs are expected to grow and modern approaches such as pharmacogenomics might enhance the throughput and accuracy of identifying clinically relevant interactions.

Beneficial effects of Camellia Oil (Camellia oleifera Abel.) on ketoprofen-induced gastrointestinal mucosal damage through upregulation of HO-1 and VEGF

Nonsteroidal anti-inflammatory drugs, such as ketoprofen, are generally used to treat pain and inflammation and as pyretic agents in clinical medicine. However, the usage of these drugs may lead to oxidative injury to the gastrointestinal mucosa. Camellia oil ( Camellia oleifera Abel.) is commonly used in Taiwan and China as cooking oil. Traditional remedies containing this oil exert beneficial health effects on the bowel, stomach, liver, and lungs. However, the effects of camellia oil on ketoprofen-induced oxidative gastrointestinal mucosal lesions remain unknown. The objective of this study was to evaluate the effect of camellia oil on ketoprofen-induced acute gastrointestinal ulcers. The results showed that treatment of Int-407 cells with camellia oil (50-75 μg/mL) not only increased the levels of heme oxygenase-1 (HO-1), glutathione peroxidase (GPx), and superoxide dismutase (SOD) mRNA expression but also increased vascular endothelial growth factor (VEGF) and prostaglandin E2 (PGE2) protein secretion, which served as a mucosal barrier against gastrointestinal oxidative injury. Moreover, Sprague-Dawley (SD) rats treated with camellia oil (2 mL/kg/day) prior to the administration of ketoprofen (50 mg/kg/day) successfully inhibited COX-2 protein expression, inhibited the production of interleukin-6 (IL-6) and nitrite oxide (NO), reversed the impairment of the antioxidant system, and decreased oxidative damage in the gastrointestinal mucosa. More importantly, pretreatment of SD rats with camellia oil strongly inhibited gastrointestinal mucosal injury induced by ketoprofen, which was proved by the histopathological staining of gastrointestinal tissues. Our data suggest that camellia oil exerts potent antiulcer effects against oxidative damage in the stomach and intestine induced by ketoprofen.

[Ultrasonographic findings for selected gastrointestinal tract diseases]

OBJECTIVE

In addition to general and specific examinations, ultrasonographic and endoscopic examinations of the gastrointestinal tract may be necessary. This study aimed to determine possible relationships between the ultrasonographic and histopathological findings in the following diseases of the gastrointestinal tract: IBD (inflammatory bowel disease), FRD (food-responsive diarrhoea), ulcer and infection with GHLO (gastric Helicobacter-like organisms).

MATERIAL AND METHODS

The data of 41 dogs and 19 cats were analysed. The inclusion criterion was the presence of acute or chronic gastrointestinal symptoms in patients that had also undergone the standard diagnostic tests to rule out extragastrointestinal diseases. The patients underwent ultrasonographic and endoscopic examinations of the gastrointestinal tract, and a histopathological examination of the tissue samples from the endoscopy was performed. Patients with intestinal foreign bodies, neoplasms of the gastrointestinal tract or inconclu- sive histopathological results were excluded.

RESULTS

In a total of 41 dogs, 16 were diagnosed with IBD, 14 with FRD, 5 with ulceration and six with an infection with GHLO. Of the 19 cats, 12 had a diagnosis of IBD, 2 of FRD, 2 with ulceration and 3 with an infection with GHLO. In 26 dogs and 4 cats of the evaluated patients, the ultrasonographic examination did not show pathological changes, even though the patients had clinical symptoms and significant histopathological findings. However, in 14 dogs and 4 cats of the included patients, one or more pathological changes of the extragastrointestinal organs were found. In particular, cats with a diagnosis of IBD often presented lymphadenopathies (4 cats) or thickening of the zona muscularis (six cats). There were no specific ultrasonographic findings confirming an FRD or an infection with GHLO. Only 5 dogs and 1 cat without a primary diagnosis of infection with GHLO were positive for colonization with GHLO. The presence of ulcers was ultrasonographically indicated as areas showing a loss of wall layering with accumulation of gas.

CONCLUSION AND CLINICAL RELEVANCE

Changes can be found during ultrasonographic examinations of patients with IBD and ulcer. However, the absence of findings in ultrasonographic examinations does not necessarily rule out serious gastrointestinal diseases. The histopathological examination still plays an important part in diagnosing the evaluated diseases.