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Fits faints and the IUD.

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NOTES AND LETTERS
Colonic Pseudoobstruction
in Patients with Stroke
Barbara J. Reynolds, MD,
and Sven G. Eliasson, MD, PhD
T h e syndrome of pseudoobstruction of the colon has been
recognized among surgeons for some time [ 1-41 but has not
as y e t become well known among the nonsurgical
specialists, including neurologists. Within the last year we
have seen 4 cases.
A 54-year-old man was admitted after being found unconscious at home. Angiography showed occlusion of the left
vertebral and distal basilar arteries. O n the fourth hospital
day a guaiac-positive nasogastric aspirate was obtained, and
he was started on a regimen of magnesium and aluminum
hydroxides. Seventeen days after admission abdominal distention was noted. The patient was passing liquid stools, and
the abdomen was diffusely tender with rebound. O n the
twenty-first day the patient suffered a hypotensive episode,
and a roentgenogram showed free air in the abdomen. An
emergency exploratory laparotomy was performed, and a
cecal perforation was found approximately 10 cm from the
ileocecal valve. No mechanical obstruction was found; a
cecostomy was performed, but, the patient died three days
later. On postmortem examination the cerebral vessels were
found to be patent.
A second patient, a 49-year-old man, had a pontine
hemorrhage. O n the eleventh day abdominal distention was
noted, and serial abdominal roentgenograms showed increasing cecal diameter. The cecum continued to expand
and was over 15 cm in diameter when the patient underwent
cecostomy to decompress the colon. At operation serosal
tears were seen, hut perforation was not complete. H e
recovered and was discharged essentially well.
The third patient, a 75-year-old man, had left hemiparesis
and dysphasia. Ten days after admission he was noted to
have abdominal distention. The abdomen was tympanitic,
with normal bowel sounds. The distention did not resolve,
and when the cecal diameter was shown by roentgenogram
to be about 18 cm, the patient underwent exploratory
laparoromy. The cecum was found to b e markedly dilated,
with two serosal tears but no complete perforation, and a
cecostomy was performed. The patient was discharged from
the hospital about seven weeks after the operation.
A 33-year-old woman without a history of trauma gradually became comatose due to bilateral internal carotid artery
occlusion. The patient’s bowel function was regular until t h e
eleventh day after admission, and then there were no bowel
movements for six days. The next day abdominal distention
was noted, and the patient .was passing large amounts of
From the Deparrment o f Neurology, Washington University
School of Medicine, St Louis, MO.
Accepted for publication Sept 20, 1976.
Address reprint requests to Dr Eliasson, Department o f Neurology, Washington LJniversity School of Medicine, Sr Louis, MO
63110.
diarrheal stools. O n e day later roentgenograms showed
massive pneumoperitoneum, and at operation a perforation
was found on the anterior surface of the cecum. The patient
recovered from her peritonitis but not from the coma.
Colonic pseudoobstruction is characterized by progressive abdominal distention following avariable time course in
the absence of mechanical obstruction. The seriousness of
the distention may not be appreciated early, since it is often
associated with the passage of stools and gas, absence of
tenderness, normal bowel sounds, and a normal blood electrolyte picture. The syndrome is best diagnosed by an
abdominal flat-plate roentgenogram rhat shows a dilated
colon with or without associated small bowel involvemenr.
The dilatation is usually gaseous hut may show air-fluid
levels. I t involves the proximal colon in a segmental manner,
with a characteristic cutoff point beyond which the bowel
size appears normal. The transition point is usually at the
splenic flexure but may be at the hepatic or sigmoid flexures.
Barium studies show n o obstructing lesion in the bowel. It
has been suggested that both the cecal diameter and the rate
ofcecal dilation must be monitored carefully [l-41. A cecal
diameter greater than 12 cm or lack ofimprovement within
7 2 hours is an indication for operation. The possibility of
pseudoobstruction must be kept in mind when dealing with
stroke patients if the potentially fatal complication of cecal
perforation and ensuing peritonitis is to be avoided.
Supported in part by NI NDS Grant 05378
Stuart Weiss, MD, called our attention to 1 of the described cases.
The neuropathological study i n the first patient was done by
William Schlaepfer, MD.
References
1. Adams JT: Adynamic ileus o f the colon: an indication for
cecostomy. Arch Surg 109:503-507, 1974
2. Ogilvie H: Large-intestine colic due to sympathetic deprivarioti:
a new clinical syndrome. Br Med J 2:671-673, 1948
3. MacFarlane JA, Kay SK: Ogilvie’s syndrome of false rolonic
obstruction: is it a new clinical entity? Br Med J 2:1267-1269,
1949
4. Wanebo H, Mathewson C, Conolly B: Pseudo-obstruction of
the colon. Surg Gynecol Obstet 133:44-48, 1971
Fits, Faints, and
the IUD
To the Editor:
While syncope is an infrequenr hut recognized coniplication
ofintrauterine itevice (IUD)insertion [ l ,21, the occurrence
of corivulsions following IUD placement has not often been
observed. Conrad et a1 [ 11, in the only report documenting
the association, described 3 patients who developed fits i n
relation to I U D insertion. Although the frequency of convulsions in Conrad’s series was less than 1 in 2,000, we have
seen 3 such patients during a six-month period.
Each of our patients had generalizecl c h i c movements
lasting 10 to 30 seconds during the insertion of an IUD
305
without local anesthesia. None of the patients had a previous history of seizures, but all had a prominent history of
fainting that occurred in relation to painful o r emotional
stimuli and was suggestive of vasodepressor syncope. All
our patients underwent polygraph recording with simultaneous monitoring of the electroencephalogram and electrocardiogram. In evaluating these patients, ocular compression, the Valsalva maneuver, and carotid sinus massage
were used (as previously described in patients with syncope
[31). No significant EEG or EKG changes were found in any
of the recordings.
The mechanism of the fits in these patients is probably
diminished cerebral blood flow. It is well known that
convulsions may be seen with cerebral hypoperfusion and
that the EEG concomitants of such fits differ significantly
from those ofepilepsy 131. Support for such a mechanism in
these patients comes from a study by Acker et a1 [21, who
evaluated EKG changes during I U D placement and found
both tachyarrhythmias and bradyarrhythmias. O n e of their
patients developed prolonged asystole, and this was associated with a “major motor” seizure.
It seems unlikely that the “seizures”in these patients represent a form of evoked epilepsy. While EEG changes have
been reported following vaginal stimulation in several anithese consist primarily of cortical spindling;
mal species [4],
behavioral evidence of seizure activity has not been described. Moreover, notie of o u r patients had a history of
convulsions associated with either coitus or a gynecological
examination, and all had normal EEGs.
It is of interest that 2 of Conrad’s patients and each of our
patients had a history offainting suggestive of vasodepressor
syncope. Such a history should alert the gynecologist to the
possibility of syncope, convulsions, or both as a complication of the IUD procedure. Because this procedure is
painful, and pain can trigger vasodepressor syncope, the use
of local anesthesia may prevent this complication. All our
patients have done well on follow-up without specific treatment.
Alan Faden, M D
Jean-Paul Spire, M D
Ruth Faden, PhD
Department of Medical Neurosciences
Walter Reed Army Institute of Research
Walter Reed Army Medical Center
Washington, D C 20012
Rderences
1. Conrad CC, Ghazi M, Kitdy DZ: Acute neurovascular sequelae
of incraucerine device insertion or removal. J Reprod Mrd
11:211-212, 1973
2. Acker D, Boehm FH, Askew DE. et al: Electrocardiogram
changes with intrauterine contraception device insertion. Am J
Obstet Gynecol 1153458-461, I973
3. Gastaut H, Fischer-Williams EM: Electroencephalographic
scudy of syncope: its differenriation from epilepsy. Lancer
2:1018-1025, 1957
4 . Sutin J, Michael RP: Changes i n brain elecrrical activity following vaginal stimulation in estrous and anescrous cats. Physiol
Behav 5:1043~-1951,1970
306 Annals of Neurology Vol 1 N o 3 March 1977
Clonazepam and
Branchial Myoclonus
To the Editor:
The use of clonazepam in various types of seizure has
recently been reviewed [ l ] ,and there have been a number
of reports of its value in the treatment of generalized
myoclonus [2-4].It is of interest that 1 of the parients
reported by Goldberg and Dorman [41had dysphagia and
severe dysarthria that improved with clonazepam therapy.
Furthermore, none of their 5 patients could write before
introduction of this drug, but all could write when treated.
W e have successfully used clonazepam in the management
of a patient with disabling hranchial myoclonus. In order to
maintain control, the dosage was increased to 22 mg per day,
without serious side-effects. T h e underlying pathological
mechanism is not known but may be related to mammary
carcinoma.
A 63-year-old woman was admitted to the National Hospital, under the care of Prof Roger Gilliatt, with a two-week
history of involuntary movements of the face that had
quickly spread to involve the jaw, tongue, neck, and right
arm. In addition, she had noted difficulty with speech and
swallowing. There was no past history of cerebral hypoxia or
epilepsy, but five years previously the patient had undergone simple mastectomy for carcinoma of the breast.
O n examination, continuous myoclonic movements were
present at rest involving the face, jaw, floor of the mouth,
tongue, and palate. These movements increased on volition
and resulted in severe dysarthria and dysphagia. T h e
movements also involved the right arm, in which there was
an intention tremor and impaired rapid alternating
movements. H e r handwriting was severely affected (Figure,
a).
A CAT scan with contrast enhancement was normal. Lumbar cerebrospinal fluid showed a total protein of 52 mg/dl
(IgG, 3.8?;), normal glucose, and 8 mononuclear cells per
cubic millimeter.
Prior to admission, treatment with phenobarbital together with diphenylhydantoin had been ineffective and was
therefore withdrawn. Clonazepam was introduced at a dosage of 2 mg per day. Within 24 hours there was a marked
reduction in the frequency and amplitude of the myoclonus,
la) Attempt to write name before treatment:
blClonazepam 2mg /day.
$-
2 weeks after
start of treatment:
/
c) Clonazepam 22mg /day
start of treatment
18 weeks after
As ,vmz ,)W
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