ABSTRACT
A previously healthy 36-year-old woman was admitted to the hospital with vaginal discharge, bilateral ankle pain, and a lower extremity skin rash, all of which developed after unprotected ...vaginal intercourse with a new male partner. On examination, there was a petechial and purpuric rash involving the lower extremities and bilateral tenosynovitis of the ankle dorsiflexor tendons. Urine NAAT was positive for
Neisseria gonorrhea
, confirming disseminated gonococcal infection (DGI). The patient was initially treated with oral azithromycin and intravenous ceftriaxone, but as a result of psychosocial circumstances, she was prematurely discharged on an oral cephalosporin agent. She represented with treatment-failure DGI and was treated with a 7-day course of intramuscular ceftriaxone. Repeat urine NAAT was negative for gonorrhea and the patient remained asymptomatic. This case features an atypical cutaneous manifestation of DGI, characterized by a painless petechial and purpuric skin rash rather than the tender papulo-pustular lesions that are typically seen. Additionally, it highlights the importance of DGI treatment with a 7-day parenteral cephalosporin therapy when antibiotic susceptibility is not available.
Introduction
The role of anorectal and defecatory dysfunction in opioid-related constipation is unclear. We aimed to evaluate the relationship between opioid use and rectal sensation, defecatory ...function, and balloon expulsion on anorectal physiology testing.
Methods
This was a retrospective cohort study of consecutive adults undergoing high-resolution anorectal manometry (HRAM) at a tertiary center for constipation. Clinical characteristics, medication use, and HRAM findings were obtained. Statistical analyses were performed using Fisher-exact/student t-test for univariate analyses and logistic/general linear regression for multivariable analyses to compare patients with no opioid use, recent (< 3 months) use, and distant (> 3 months) use.
Results
424 patients (49.8 ± 17.2 years; 85.6% female) were included. Compared to those without opioid history, patients with recent use had increased volumes for first rectal sensation (70.4 mL vs 59.4,
p
= 0.043), urge (120.5 mL vs 101.5,
p
= 0.017), and maximal tolerance (170.2 mL vs 147.2,
p
= 0.0018), but not patients with distant use. Recent opioid use was associated with increased risk of dyssynergic defecation (DD) (61.8% vs 46.4%,
p
= 0.035), but not failed balloon expulsion. On multivariable models controlling for potential confounders, recent opioid use, but not distant use, remained independently correlated with increased volumes for first rectal sensation (β-coefficient 9.78,
p
= 0.019), urge (β-coefficient 16.7,
p
= 0.0060), and maximal tolerance (β-coefficient 22.9,
p
= 0.0032), and higher risk for DD (aOR = 2.18,
p
= 0.026).
Conclusion
Recent opioid use was an independent risk factor for rectal hyposensitivity and DD on HRAM in patients with constipation, but that effect may decrease with discontinuation of use. Anorectal physiology testing should be considered in patients with opioid-associated constipation.
Biliary stents are commonly used for internal drainage of biliary obstruction, both malignant and benign. Intestinal perforation is a rare but potentially severe complication associated with plastic ...biliary stents. To date, this has been described exclusively in the setting of preceding stent migration. We present an unusual case of non-migrated biliary stent causing duodenal perforation which to our knowledge is the first described in the literature. A 65-year-old woman presented with three day history of malaise and severe right upper quadrant pain with associated fever and nausea. Her past medical history was notable for cholangiocarcinoma complicated by common bile duct obstruction requiring 10 Fr x 12cm plastic biliary stent placement with single external and internal flap 2 months prior. Physical exam was notable for tachycardia and right upper quadrant tenderness to palpation without rebound or guarding. Labs were notable for recurrent liver function tests (AST 154, ALT 280, AP 246, total bilirubin 0.9) above her prior baseline. CT abdomen and pelvis showed perforation of the second portion of the duodenum from the distal tip of the biliary stent with the proximal aspect of the stent remaining within the common bile duct (Figure 1, black arrow). She was started on antibiotics and underwent urgent EGD and ERCP. The plastic biliary stent was seen perforating through the wall of the duodenum opposite to the papilla and was removed via rat tooth forceps (Figure 2). An OVESCO clip was successfully used to close the perforation. A new 10 Fr by 10 cm plastic biliary stent with a full external pigtail and a ½ internal pigtail was placed in the left hepatic duct. At 3-month interval for scheduled stent exchange with an uncovered metal stent, her symptoms had significantly improved. The risk of perforation from endoscopically placed plastic biliary stents is extremely low, though it has been described in prior case reports. These reports have universally been reported in the setting of stent migration and perforation through the small bowel. This case illustrates a rare case of perforation from a non-migrated plastic biliary stent, and is the first in the literature to our knowledge. Our patient responded well to immediate endoscopic removal with closure of the duodenal wall defect via OVSCO clip and replacement of the stent with a new stent with external pigtail to prevent recurrent perforation.
INTRODUCTION:
Achalasia is a disorder leading to significant difficulty eating that typically leads to weight loss. Historically, obesity in achalasia patients is uncommon; however, with the obesity ...epidemic, the epidemiology of achalasia may be evolving, and treatment may need to be tailored. Few studies have investigated patient characteristics such as age and gender that predict response to therapy. There is paucity of literature studying presence of obesity in achalasia and its effect on outcomes.
METHODS:
This was a retrospective cohort study of patients diagnosed with achalasia on high-resolution esophageal manometry (HREM) at a tertiary care center in 1/2008 – 12/2015. Data on patient demographics, including age at diagnosis, gender, body mass index (BMI), race, and presenting symptoms were reviewed. Interventions, including botox injection, dilation, or surgery were also reviewed. For consistency, only the interventions after HREM diagnosis at a tertiary center were assessed.
RESULTS:
131 achalasia patients were included. Median age at diagnosis was 58 years old with 15% being ≤ 40 years and 85% > 40 years. Median BMI was 27 (17–51) with 69% having BMI < 30 and 31% having BMI ≥ 30. Percent of male to female patients were 52% to 48%, respectively. Percent of patients who received botox injection, dilation, or surgery as first intervention were 10%, 11%, 53%, respectively. 26% did not receive any intervention. Heller’s myotomy accounted for 89% of all surgeries. Interventions in the lower BMI group were 14% (botox), 15% (dilation), and 71% (surgery) similar to 13.3%, 13.3%, 73.4%, respectively in the higher BMI group. 100% of patients in the younger group received surgery as the first intervention, while older group had 16% botox, 18% dilation, and 66% surgery. 19 patients failed initial treatment requiring a second intervention; majority (74%) had lower BMI < 30. More patients in > 40 years group failed first intervention. There was no significant difference between gender and treatment failure.
CONCLUSION:
Patients with achalasia underwent similar treatment(s) regardless of their BMI or gender. Younger patients underwent surgical interventions at a higher rate, primarily Heller’s myotomy. Patients with lower BMI (<30) needed a repeat intervention at a higher frequency than their higher BMI counterpart. This was true for all interventions. Factors such as BMI may play an important role in achalasia treatment outcome; however, more controlled studies are needed.
Purpose of Review
The opioid epidemic in the USA has led to a rise in opioid-related gastrointestinal (GI) side effects that are often difficult to diagnose and treat. The aim of this report is to ...discuss opioid pathophysiology, opioid-related GI side effects, clinical presentation, and diagnostic criteria and to review the current pharmacotherapy available.
Recent Findings
Opioid-related GI disorders are increasingly recognized and include, but are not limited to, opioid-induced esophageal dysfunction (OIED), gastroparesis, opioid-induced constipation (OIC), narcotic bowel syndrome (NBS), acute post-operative ileus, and anal sphincter dysfunction. Treatment of these conditions is challenging. OIC has the most available pharmacotherapy for treatment, including classical laxatives, peripherally acting μ-receptor antagonists (PAMORAs), novel therapies (lubiprostone, prucalopride- 5-HT agonist), and preventative therapies (PR oxycodone/naloxone).
Summary
The gastrointestinal effects of opioid therapy are variable and often debilitating. While medical management for some opioid-related GI side effects exists, limiting or completely avoiding opioid use for chronic non-cancer pain will mitigate these effects most effectively.
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