Lenox Hill Hospital, Northwell Health New York, NY
Berta Shamuilova, DO, David Kadosh, MD, Daniel Hogan, DO, Elena Ivanina, DO; Lenox Hill Hospital, Northwell Health, New York, NY
Introduction: Bupropion is a common antidepressant that works by inhibiting the reuptake of norepinephrine and dopamine. The gastrointestinal tract rapidly absorbs bupropion and known side effects include abdominal pain, constipation, nausea, and vomiting. Rare effects include hemorrhage, intestinal perforation, and colonic ischemia.
Methods: A 26-year-old female presented to the ED after taking an unknown amount of Bupropion. She was hemodynamically stable and asymptomatic. After consultation with poison control she was given activated charcoal, GoLytely, and 1L of saline. She then became tachycardic and tachypneic with altered mental status, oral automatisms, and nystagmus. An EKG revealed new QTc prolongation. She was given Magnesium Sulfate and Ativan before being intubated for airway protection. Within 24 hours she had abdominal distension and decreased bowel sounds. An abdominal x-ray (figure 1) showed a markedly dilated colon. A follow-up CT abdomen (figure 2) revealed distended bowel with portal venous gas and pneumatosis intestinalis of the ascending colon. Surgery and GI both advised supportive care and broad-spectrum antibiotics. The patient’s mental status returned to baseline and she was extubated. Serial EKGs showed a return to normal QTc. Her abdominal distention decreased, serial abdominal x-rays showed improvement, and her diet was slowly advanced until she was safe for discharge home. Discussion: The CT finding of pneumatosis intestinalis can reflect both benign and life-threatening etiologies. Right colon ischemia carries a worse prognosis and may be a herald of mesenteric insufficiency or occlusion. Gas in the bowel wall may occur via mechanical force or bacterial invasion through breaks in the mucosa which can occur in ischemic injury. Patients with peritonitis or hemodynamic instability, acidosis, high lactate, or portal venous gas should be evaluated by an exploratory laparotomy. Those with isolated right colon ischemia should be evaluated for mesenteric insufficiency or occlusion. Given our patient’s benign exam and stable laboratory findings, conservative management was pursued. The constipating effects of Bupropion likely contributed to increasing gaseous pressure, leading to pneumatosis via a combination mechanical force and ischemia from decreased blood flow. Through supportive care and relief of fecal impaction, the patient improved and her imaging findings resolved. This case highlights the use of sound clinical judgement when following diagnostic algorithms.
Figure 1: Abdominal x-ray on admission (left) showing a nonspecific gas pattern with increased stool burden. On day 2 of admission, an abdominal x-ray (right) showing markedly dilated loops of bowel extending from the small bowel into the ascending colon.
Figure 2: A non-contrast CT abdomen and pelvis performed on admission showing dilated fluid-filled small bowel loops. There is evidence of portal venous air and ascending colonic pneumatosis.
Disclosures: Berta Shamuilova indicated no relevant financial relationships. David Kadosh indicated no relevant financial relationships. Daniel Hogan indicated no relevant financial relationships. Elena Ivanina indicated no relevant financial relationships.