Rodrigues A, Duarte A, Marques A, Magalhães M, Camarneiro R, Silva R, Ferreira Á, Dionísio I, Val Flores L, Brito E Melo M
General Surgery Department of Centro Hospitalar do Oeste, Portugal.
General Surgery Department of Centro Hospitalar do Oeste, Portugal.
Int J Surg Case Rep. 2018;53:262-264. doi: 10.1016/j.ijscr.2018.10.067. Epub 2018 Nov 1.
Spontaneous free perforation of the small bowel is unusual. There are many causes of spontaneous small bowel free perforation such as: immune-mediated or inflammatory, infections, drugs and biological agents, congenital, metabolic, vascular and neoplasm. A severe adverse effect of antipsychotic drugs is intestinal ischemia, which could lead to perforation.
The authors report the clinical case of a 42-year-old schizophrenic patient, smoker, medicated with clozapine 600 mg per day, admitted to the emergency room with diffuse abdominal pain. On physical examination the patient presented abdominal rebound tenderness and peritoneal sign with raised inflammation markers and the abdominal tomography revealed pneumoperitoneum. An emergency laparotomy revealed multiple jejunal and ileal perforations. The patient was subject to small bowel resection complicated with anastomosis dehiscence, respiratory tract infection and intra-abdominal abscess. Histologic specimens showed nonspecific inflammatory findings with ischemia. The main infectious, inflammatory, congenital, auto-immune and vascular causes of spontaneous perforations were excluded.
Spontaneous free perforation of the small bowel is uncommon. An intestinal ischemia might be a rare adverse effect of antipsychotics. However, only colon perforations due to ischemic colitis are described in the literature. While diagnosis of the precise cause might be challenging, and after excluding other causes, these perforations may be attributed to an adverse effect of clozapine.
The cause was attributed to clozapine as the other etiologies were excluded. The clozapine's reintroduction is controversial. In this case the clozapine dose was reduced successfully.
小肠自发性游离穿孔并不常见。小肠自发性游离穿孔有多种原因，如免疫介导或炎症性、感染性、药物和生物制剂、先天性、代谢性、血管性和肿瘤性。抗精神病药物的一种严重不良反应是肠道缺血，这可能导致穿孔。
作者报告了一名42岁精神分裂症患者的临床病例，该患者吸烟，每天服用600毫克氯氮平，因弥漫性腹痛入住急诊室。体格检查时，患者出现腹部反跳痛和腹膜征，炎症标志物升高，腹部CT显示气腹。急诊剖腹探查发现多处空肠和回肠穿孔。患者接受了小肠切除手术，术后出现吻合口裂开、呼吸道感染和腹腔内脓肿。组织学标本显示有缺血的非特异性炎症表现。排除了自发性穿孔的主要感染性、炎症性、先天性、自身免疫性和血管性原因。
小肠自发性游离穿孔并不常见。肠道缺血可能是抗精神病药物罕见的不良反应。然而，文献中仅描述了缺血性结肠炎导致的结肠穿孔。虽然准确病因的诊断可能具有挑战性，且在排除其他原因后，这些穿孔可能归因于氯氮平的不良反应。
由于排除了其他病因，病因归因于氯氮平。氯氮平的重新使用存在争议。在本病例中，成功降低了氯氮平剂量。
