SESSION TYPE: Critical Care Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Insulin deficiency or resistance in diabetes mellitus leads to an increased circulating triglyceride (TG) levels which can be responsible for precipitating acute pancreatitis (1). There have been few reported cases of severe hypertriglyceridemia (defined as TG level > 2,000 mg/dL) in diabetic ketoacidosis accompanied by acute pancreatitis in Korea, but none from the United States.

CASE PRESENTATION:

30-year-old male with a history of insulin dependent diabetes mellitus, non compliance presented with complaint of abdominal pain described as constant, sharp, 10/10 in severity, located in epigastric region, associated with nausea and vomiting for one day duration. On physical examination, he was afebrile, BP=129/81 mmHg, pulse=89 bpm and had mild tenderness over the epigastric region. Laboratory examination revealed a white blood cell count 14,500 /µL, sodium 125 meq/L, potassium 4.7 meq/L, chloride 97 meq/L, bicarbonate 19 meq/L, BUN 6 mg/dL, creatinine 0.5 mg/dL, an anion gap of 9. Glucose was 543 mg/dL and lipase was 1055 U/L. Urinalysis showed glucose > 1000 mg/dL, ketones > 80 mg/dL. Patient was admitted to the medical floor for managing pancreatitis. Thereafter fasting lipid profile was obtained and triglycerides were 3354mg/dL. Repeat metabolic panel showed an anion gap of 27 and the patient was transferred to the intensive care unit for diabetic ketoacidosis. Patient was continued on intravenous fluid hydration and insulin drip was started. The anion gap closed the following day but the insulin drip was continued to manage hypertriglyceridemia. Subsequent triglyceride levels were 2289, 1340, 769, 396 mg/dL.

DISCUSSION:

The insulin mediated lipoprotein lipase suppression and VLDL production is defective in insulin resistance, leading to increased free fatty acid and VLDL production, which results in increased circulating triglyceride concentrations (2). Lipase in the pancreatic bed breaks the serum triglycerides into toxic free fatty acids which results in pancreatitis (3). Diagnostic clues include lipemic serum; high urine anion gap as compared to normal serum anion gap. Treatment includes insulin therapy with conservative management and rarely some cases require plasma exchange.

CONCLUSIONS:

A case of hypertriglyceridemia resulting in acute pancreatitis and diabetic ketoacidosis, managed with aggressive hydration and a continuous insulin infusion, thus leading to a correction of both the acidosis and hypertriglyceridemia.1) Suk Jae et al. Severe Hypertriglyceridemia in Diabetic Ketoacidosis Accompanied by Acute Pancreatitis. (2010): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2923793/.2) Kronenberg et al. Williams Textbook of Endocrinology. 11. 2007.3) TaYamada et al, Textbook of Gastroenterology. 5th; 2. 2008.DISCLOSURE: The following authors have nothing to disclose: Vibu Varghese, Vipin Mittal, Anery Patel, Muhammad Ali, Mourad IsmailNo Product/Research Disclosure InformationSt. Joseph's Regional Medical Center, Paterson, NJ.

Functional abdominal pain (FAP) is a common complaint among children and adolescents. For many patients, symptoms exacerbate with eating. This review discusses findings concerning the role of diet in FAP. The foods that are discussed are divided into two major groups: (1) Food allergies or intolerances, which focus on milk, gluten, and FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides and polyols), and (2) Functional foods, which hone in on foods that reduce abdominal pain in adolescents such as fiber, peppermint oil, and probiotics. Lastly we discuss the role of eating habits in FAP and how the physics of eating may be the real culprit of symptoms associated with eating.

BACKGROUND:

Constipation-predominant irritable bowel syndrome (IBS-C) is a common functional gastrointestinal (GI) disorder with abdominal pain and decreased motility. Current treatments of IBS-C are insufficient. The aim of this study was to evaluate the potential application of taranabant, a cannabinoid type 1 (CB1) inverse agonist using mouse models mimicking the symptoms of IBS-C.

METHODS:

Changes in intestinal contractile activity were studied in vitro, using isolated mouse ileum and colon and intracellular recordings. In vivo, whole gastrointestinal transit (WGT) and fecal pellet output (FPO) were measured under standard conditions and with pharmacologically delayed GI transit. The antinociceptive effect was evaluated in mustard oil- and acetic acid-induced models of visceral pain. Forced swimming and tail suspension tests were performed and locomotor activity was measured to evaluate potential central side effects. KEY

RESULTS:

In vitro, taranabant (10(-10) -10(-7)  mol L(-1) ) increased contractile responses in mouse ileum and blocked the effect of the CB agonist WIN 55,212-2. Taranabant had no effect on the amplitude of electrical field stimulation (EFS)-evoked junction potentials. In vivo, taranabant (0.1-3 mg kg(-1) , i.p. and 3 mg kg(-1) , p.o.) increased WGT and FPO in mice and reversed experimental constipation. The effect of taranabant was absent in CB1(-/-) mice. Taranabant significantly decreased the number of pain-related behaviors in animal models. At the doses tested, taranabant did not display mood-related adverse side effects typical for CB1 receptor inverse agonists.

CONCLUSIONS

& INFERENCES: Taranabant improved symptoms related to slow GI motility and abdominal pain and may become an attractive template in the development of novel therapeutics targeting IBS-C.

BACKGROUND:

Abdominal pain is common in the community, but only a subset meet diagnostic criteria for irritable bowel syndrome (IBS). Although anxiety and depression have been linked to IBS, the role of mood disturbances in the remainder with symptoms remains unclear. We aimed to study the associations between abdominal pain, anxiety, depression, and quality of life in the general population who were free of organic colonic disease by colonoscopy.

METHODS:

Two hundred and seventy-two randomly selected subjects from the general population, mean age 54 years (27-71), were clinically evaluated, had a colonoscopy and laboratory investigations to exclude organic gastrointestinal (GI) disease. All subjects completed GI symptom diaries for 1 week, the Rome II modular questionnaire, the Hospital Anxiety and Depression Scale, and Short Form 36. KEY

RESULTS:

Twenty-two subjects were excluded due to organic disease; 1532 daily symptom records were available for analysis in the remainder. Thirty-four percent (n = 83) recorded at least one episode of abdominal pain on the diary. Twelve percent fulfilled Rome II criteria for IBS. Both anxiety and depression scores were higher in subjects who reported abdominal pain vs those who did not (P < 0.0005 and P < 0.0005). Anxiety and depression scores independently from IBS diagnosis (Rome II) predicted pain reporting and also correlated positively with pain burden. Quality of life scores were generally lower in subjects with abdominal pain.

CONCLUSIONS

& INFERENCES: Anxiety and depression are linked to functional abdominal pain, not only in subjects with IBS but also in otherwise healthy people with milder, subtle GI symptoms.

Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic angiopathy, which commonly affects the renal and internal carotid arteries. Although rare, FMD has the potential of involving the mesenteric vasculature. Due its low incidence and relatively little knowledge concerning its risk factors and etiology, actual diagnosis of FMD involving the mesenteric vessels requires a very high degree of suspicion. Upon review of the few reported cases of FMD causing mesenteric ischemia, it is clear that therapeutic interventions are rarely discussed and that positive outcomes are even more uncommon. Herein, we present the case of a 47 year-old female with mesenteric ischemia secondary to FMD, which was diagnosed and treated originally with angioplasty, then repeat angioplasty with stent placement, and finally with a bypass graft. Ultimately, the patient had a positive outcome, including eight month follow-up.

Hemophagocytic syndrome (HPS) is an uncommon hematological disorder that manifests as fever, splenomegaly, and jaundice, with hemophagocytosis in the bone marrow and other tissues pathologically. Secondary HPS is associated with malignancy and infection, especially viral infection. The prevalence of cytomegalovirus (CMV) infection in ulcerative colitis (UC) patients is approximately 16%. Nevertheless, HPS in UC superinfected by CMV is very rare. A 52-year-old female visited the hospital complaining of abdominal pain and hematochezia for 6 days. She was diagnosed with UC 3 years earlier and had been treated with sulfasalazine, but had stopped her medication 4 months earlier. On admission, her spleen was enlarged. The peripheral blood count revealed pancytopenia and bone marrow aspiration smears showed hemophagocytosis. Viral studies revealed CMV infection. She was treated successfully with ganciclovir. We report this case with a review of the related literature.

A 7-year-old girl was referred to our hospital for severe abdominal pain and elevated serum levels of amylase and aminotransferase. Radiological examinations revealed choledocholithiasis. EPBD was performed under intravenous anesthesia using midazolam and ketamine chloride. After fluoroscopic confirmation of a bile duct stone, a dilation balloon (30 mm-long, 8 mm-diameter) was passed over the guidewire and placed across the papilla. The balloon was gradually inflated until the notch created by the papillary sphincter disappeared. At 4 atm, the notch disappeared and the pressure was maintained for 15 s. Stone extraction was performed by using a retrieval balloon catheter. Abdominal pain disappeared immediately after EPBD, and she resumed oral intake 2 days after EPBD. In conclusion, EPBD may be a safe and effective technique for the treatment of choledocholithiasis in pediatric patients. EPDB should be selected as a treatment for pediatric choledocholithiasis in view of its advantages of preserving papillary function.

A 25-year-old pregnant woman complained of abdominal pain and diarrhea. Total colonoscopy provided a diagnosis of Crohn's disease (CD) of the large intestine (Crohn's colitis). Because the patient was allergic to mesalazine, adalimumab (ADA) was used as maintenance therapy during pregnancy, following prednisolone as remission induction therapy. Remission of the patient's CD was maintained with ADA, and the patient delivered a baby girl without any difficulties. Remission of the patient's CD continued to be maintained with the administration of ADA after childbirth. We believe that this is the first report of the use of ADA therapy in a pregnant CD patient in Japan.

Endoscopic submucosal dissection (ESD) is not a common treatment for colorectal neoplasms because of its technical difficulties and has a higher incidence of complication. In particular, perforation is one of the severe complications and these patients require surgical intervention. However, whether prophylactic closure after colorectal ESD prevents perforation and other complications is not known. In the present study, we assessed the efficacy and safety of prophylactic closure for a large mucosal defect after colorectal ESD using a conventional clip and over-the-scope clip (OTSC) system. From April 2010 to December 2012, 68 patients with colorectal tumors were treated with ESD. The prohylactic closure was indicated for patients with excessive coagulation in the muscularis propria or larger resection size. The closure group reduced the peritoneal inflammatory reaction and abdominal symptoms without increasing complications. The closure group also had a significantly lower WBC count (post operative day 1), CRP (post operative day 4) and abdominal pain after colorectal ESD compared to the non-closure group. Perforation occurred in 1 case, and postoperative bleeding in 2 cases, with only 1 bleeding case needing an emergency endoscopy in the non-closure group. One perforation case needed emergency surgery because the endoscopic treatment was ineffective. Without increasing adverse effects, the prophylactic closure efficiently reduced the inflammatory reaction and abdominal symptoms of colorectal ESD in patients with large superficial colorectal neoplasms.