Umar Zaryab, Ilyas Usman, Shah Deesha, Nso Nso, Foster Allison, Zirkiyeva Milana
Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA.
Medicine, Ichan School of Medicine at Mount Sinai, NYC Health and Hospitals (H+H) / Queens, New York, USA.
Cureus. 2022 Apr 3;14(4):e23774. doi: 10.7759/cureus.23774. eCollection 2022 Apr.
Ischemic colitis is one of the most common ischemic pathologies of the gastrointestinal system and can be divided into non-gangrenous and gangrenous forms. The pathophysiology involves restricted blood supply to the colonic mucosa. Several risk factors have been implicated in the development of ischemic colitis. Lactulose, one of the mainstay therapies for the treatment of hepatic encephalopathy in patients with cirrhosis, has been rarely reported as a cause of ischemic colitis. To the best of our knowledge, there has been only one case report associating lactulose use with the development of ischemic colitis. The exact pathophysiology is unknown but might be associated with the fermentation of lactulose by intestinal bacteria, causing gaseous distention and increasing the intraluminal pressure. We present the case of a 77-year-old African American male, a known case of non-alcoholic liver cirrhosis with portal hypertension and esophageal varices, brought in by his family to the emergency department for altered mental status, non-bilious vomiting, abdominal distension, and pain for one day. On physical examination, the patient had upper extremity asterixis and was alert but disoriented to place and person. Diagnostic paracentesis was performed, which revealed leukocytosis, predominantly neutrophils. The patient was admitted for spontaneous bacterial peritonitis and hepatic encephalopathy with decompensated liver cirrhosis. The patient was started lactulose with a goal of three to four bowel movements per day. Despite adequate treatment, the patient continued to develop worsening mental function and abdominal distension. This was later followed by a bloody bowel movement. Laboratory assessment showed an elevated white blood cell count, worsening kidney function, and high anion gap metabolic acidosis. CT scan revealed dilated loops of bowel with air and fluid along with submucosal wall edema, findings suggestive of ischemic colitis. Given the poor prognosis and the patient's condition, colonoscopy was deferred. Lactulose was discontinued, as it was thought to be a contributing cause of the patient's ischemic colitis. His condition continued to deteriorate, and he passed away on Day 18 of admission.
缺血性结肠炎是胃肠道系统最常见的缺血性病变之一，可分为非坏疽型和坏疽型。其病理生理学涉及结肠黏膜血液供应受限。缺血性结肠炎的发生与多种危险因素有关。乳果糖是肝硬化患者肝性脑病的主要治疗药物之一，很少被报道为缺血性结肠炎的病因。据我们所知，仅有一例病例报告将乳果糖的使用与缺血性结肠炎的发生相关联。确切的病理生理学尚不清楚，但可能与肠道细菌对乳果糖的发酵有关，导致气体扩张并增加肠腔内压力。我们报告一例77岁非裔美国男性病例，该患者为已知的非酒精性肝硬化伴门静脉高压和食管静脉曲张患者，因精神状态改变、非胆汁性呕吐、腹胀和腹痛一天，被家人送至急诊科。体格检查时，患者有上肢扑翼样震颤，神志清醒但对地点和人物定向障碍。进行了诊断性腹腔穿刺，结果显示白细胞增多，以中性粒细胞为主。患者因自发性细菌性腹膜炎和失代偿期肝硬化肝性脑病入院。开始给予患者乳果糖治疗，目标是每天排便三到四次。尽管进行了充分治疗，患者的精神功能和腹胀仍持续恶化。随后出现了一次血性大便。实验室评估显示白细胞计数升高、肾功能恶化以及高阴离子间隙代谢性酸中毒。CT扫描显示肠袢扩张，伴有气液平面以及黏膜下壁水肿，这些表现提示缺血性结肠炎。鉴于预后不良及患者病情，结肠镜检查被推迟。由于认为乳果糖是患者缺血性结肠炎的一个促成因素，故停用了乳果糖。患者病情继续恶化，于入院第18天去世。
