Psychotic Woman With Painful Abdominal Distension

[Ann Emerg Med. 2009;54:756.]

A 46-year-old psychotic woman presented to our emergency department with a 4-day history of abdominal pain and protracted vomiting. She reported no previous surgeries, and her treatment consisted of high doses of 2 neuroleptics (chlorpromazine and loxapine) and a combination of 2 anticholinergic drugs (trihexyphenidyl and tropatepine). Physical findings included a painful distended abdomen with hypertympanic percussion and rapid shallow breathing. Chest radiograph and computed tomography (CT) of the abdomen revealed an enormous gaseous distension of the stomach and the whole intestinal tract, with hepatodiaphragmatic interposition of the large bowel (Chilaiditi sign) (Figure 1, Figure 2, and Figure 3). Laboratory testing showed no electrolyte imbalance. A few hours later, she was transferred to the operating room for circulatory shock, with acute renal failure and abdominal compartment syndrome, attested to by a high intra-abdominal pressure reaching 36 cm H2O. Surgical decompression by “blow hole” cecostomy and segmental colonic resection of the infarcted intestinal loops (Figure 4) were performed. No evidence of mechanical bowel obstruction was found during surgery.

Figure 1. Chest radiograph showing an enormous gaseous dilation of the stomach and the large bowel.

Figure 2. CT of the abdomen showing the hepatodiaphragmatic interposition of the large bowel (Chilaiditi sign).

Figure 3. Acute colonic pseudo-obstruction with massive distension of the whole bowel.

Figure 4. Typical bluish aspect of the infarcted intestinal loops that had to be removed during the open surgical procedure. Used with permission of Malcolm Lemyze, MD, Department of Emergency and Critical Care Medicine, Broussais Hospital, St Malo, France.

Diagnosis 

Life-threatening psychotropic drug–induced gastrointestinal hypomotility. Antipsychotics can affect the entire gastrointestinal system, from esophagus to rectum, and may cause bowel obstruction, colonic distension, ischemia, perforation, and aspiration. The mechanism is likely to be anticholinergic and antiserotonergic. The fatality rate of acute colonic pseudo-obstruction is high, especially if surgery is delayed and in cases of abdominal compartment syndrome associated with multiple organ failure.1 Althought many cases of fatal neuroleptic-induced constipation have been previously reported, this life-threatening adverse effect of psychotropic drugs remains unknown by most emergency care practitioners who may be in charge of such psychotic patients in the medical-surgical setting.2, 3