<Brief
History>
A 51 y/o man, who denied any systemic disease such
as hypertension or diabetes mellitus, was admitted to
our hospital due to persistent abdominal pain for a few days.
He had been quite well until two weeks before admission, when
he had upper respiratory infection and went to a local clinic
to seek treatment. His body temperature was normal then, but
he was given some Non-steroidal anti-inflammatory drugs
(NSAIDs)including indomethacin (25mg tid) and naproxen (250mg
qhs), which he took for 3 days as prescribed. Six days before
admission, he started to suffer from left lower quadrant
abdominal pain which was persistent and dull in characters.
The pain gradually radiated to his left lower back. Poor
appetite, abdominal fullness and constipation occurred later.
As the symptoms deteriorated, he came to our emergency room
(ER) for further treatment.
At ER, the pain extended to the whole abdomen and he
vomited some greenish colored fluid twice. Physical
examination revealed that the body temperature was 37.9℃, the
pulse rate was 90 per minute, the respiratory rate was 22 per
minute, and the blood pressure was 130 /90 mmHg. Abdominal
examination revealed hyperactive bowel sounds on auscultation,
and diffuse abdominal tenderness without rebounding pain on
palpation.
<Laboratory
Data>
1.CBC + PLT
WBC |
RBC |
HB |
HCT |
MCV |
MCH |
MCHC |
PLT |
K/μL |
M/μL |
g/dL |
% |
fL |
pg |
g/dL |
K/μL |
21.19 |
5.12 |
15.6 |
47.0 |
91.8 |
30.5 |
33.2 |
370.0 | 2. WBC Classification
Blast |
Promyl |
Myelo |
Meta |
Band |
Seg |
Eos. |
Baso. |
% |
% |
% |
% |
% |
% |
% |
% |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
84.4 |
0.0 |
0.1 |
Mono |
Lym |
Aty.Lym. |
Plasma Cell |
% |
% |
% |
% |
5.7 |
9.8 |
0.0 |
0.0 | 3.BCS + electrolytes
UN |
CRE |
Na |
K |
NH3 |
T-BIL |
AST |
mg/dl |
mg/dl |
mmole/l |
mmole/l |
μmole/l |
mg/dl |
U/l |
35.3 |
1.5 |
134 |
4.4 |
20 |
0.94 |
29 | 4.Blood
pH/Gas
PH |
PCO2 |
PO2 |
HCO3 |
Base Excess |
|
mmHg |
mmHg |
mEq/l |
mEq/l |
7.36 |
49.3 |
31.4 |
27.3 |
1.5 | 5. Urinalysis [multistix, random urine]
Appearance |
Sp Gr |
pH |
Protein mg/dL |
Glu g/dL |
Ketones * |
yellowish/clear |
1.006 |
7.0 |
+ |
- |
- |
OB |
Urobil |
Bil |
Nitrite |
WBC |
1+ |
0.1 |
- |
- |
5-10 | 6.Stool
Appearance |
OB |
WBC /HPF |
YB;F |
+ |
- |
7. Chest X-ray
enlarged heart
size,
tortuous aorta,
low lung volume.
8. KUB
- partially obscured left lower psoas
shadow,
- phleboliths in the pelvis.
9. Computed tomography
(abdomen)
- segmental bowel wall thickening at
duodenum and proximal jejunum
- the major mesenteric vessels are patent.
<Course and
Management>
After admission, the patient received enteroscopic
examination. Reflux esophagitis, gastric erosion as well as
multiple duodenal and jejunal ulcers were found. Biopsy of the
duodenal and jejunal ulcers revealed marked ischemic change.
Lactulose (60 ml) was prescribed for his constipation, but he
only passed small amounts of stool. Due to the suspicion of
colonic obstruction, he received colonoscopic examination
which showed mucosal edematous change around the cecum and the
ascending colon, and multiple patches of mucosal hyperemia of
the rectum and the distal sigmoid colon. Erosion at the
sigmoid colon was also observed. Diffuse colitis was
impressed. Biopsy of the colon revealed marked ischemic
change. Stool culture and blood culture were both negative.
Renal echo showed no stone or other abnormality. Bowel rest
was suggested, so the patient was treated with nothing per os
(NPO), intravenous fluid supplement, and oral antacid
administration.
Empirical antibiotic with cefmetazole (Cefmetazon
500mg/vial) 2 vials iv q8h was prescribed because the patient
had fever and high white blood counts (WBC) and c-reactive
protein (CRP) levels. Acetaminophen (Paramol 500mg/tab) 1# q6h
was prescribed to relieve the abdominal pain. Cefmetazole was
changed to cefuroxime axetil (Zinnat 250 mg/tab) 1# q12h po a
few days later when the abdominal pain subsided. Oral intake
was restarted without recurrence of abdominal pain.
Autoimmune profile was checked which showed no evidence of
systemic vasculitis. His fever, abdominal pain, WBC, CRP and
renal function tests gradually improved, and he was discharged
after two weeks of hospitalization and was arranged to be
followed up in the OPD.
<討論>
非類固醇消炎藥 (Non-steroidal anti-inflammatory drugs, 簡稱NSAIDs)
有退燒、止痛和消炎三大作用,因藥效良好,故常被使用於治療喉炎、痛風、扭傷和關節疼痛等疾病。NSAIDs的種類繁多,常用者包括有diclofenac、ibuprofen、indomethacin、ketoprofen、naproxen及sulindac等,作用機轉為透過抑制cyclooxygenase來減少prostaglandins的製造。NSAIDs在胃腸道內很快就被吸收,90%以上與血清蛋白結合,1-15%以原型由腎臟排出。
NSAIDs的副作用很多,在使用上需特別注意。在胃腸方面,NSAIDs可能會引起噁心、嘔吐、腹痛、或胃腸發炎,嚴重者更會造成胃腸潰瘍或出血,因此應在餐後服用並配合制酸劑等胃藥來使用。因NSAIDs也可以引起缺血性大腸炎,故要特別小心大腸潰爛及狹窄等後遺症。在腎臟方面,NSAIDs可能會造成糖尿(glycosuria)、血尿、蛋白尿、白血球尿、急性腎衰竭、腎病症候群、腎小管間質炎、慢性腎衰竭、水腫及鈉和鉀平衡失調等,因此應定期監測病人的腎功能及電解質變化。發生NSAIDs引起急性腎衰竭的高危險群包括有體液不足、肝硬化、心衰竭及本身即有腎功能不良者,在此類病人應避免使用NSAIDs。其他曾被報告過的副作用還有皮疹、嗜睡、頭痛、急性肝炎及急性胰臟炎等。
針對NSAIDs中毒的治療,一般靠支持性療法。因為利尿劑並不會增加NSAIDs的腎臟排出率,而且NSAIDs因與血清蛋白高度結合,故也不能靠血液透析來清除。
目前除了NSAIDs外,還有selective cyclooxygenase-2 inhibitors
(Coxibs)常被用來治療疼痛和發炎。Coxibs對於胃腸道的副作用比NSAIDs輕,但在合併使用aspirin時即失去保護胃腸道的優勢;Coxibs也可能引起急性腎衰竭,同樣應避免與含腎毒性的藥物一起使用。另一方面,Coxibs曾被報告過會引起心血管併發症,例如心肌梗塞,故使用Coxibs不一定比NSAIDs安全。
本病人因感冒服用了三天的NSAIDs,結果引發了嚴重的併發症,包括發燒、胃炎、十二小腸炎、缺血性大腸炎、急性腎功能受損及尿液檢查異常(血尿、蛋白尿、白血球尿)等,在禁食及給予胃藥和輸液補充後,病人的發燒與腹痛漸漸改善,可見停止使用NSAIDs並給予支持性療法為治療NSAIDs急性副作用的重要法則。至於在因NSAIDs引起急性腎小管間質炎的患者,是否可使用類固醇來治療急性腎衰竭仍有爭議。本病人的症狀應為NSAIDs引起,不需使用抗生素治療,但因無法排除有腸炎造成的次發性細菌感染,故使用抗生素治療也屬合理。此病人在短期使用NSAIDs下引發如此嚴重的併發症,可能是因為NSAIDs的藥量過重、同時使用兩種NSAIDs或病人本身有特異體質所致,因此必須建議病人以後不要使用NSAIDs,或在使用時必須非常小心。 |