{"id":1989,"date":"2020-05-05T17:50:03","date_gmt":"2020-05-05T15:50:03","guid":{"rendered":"https:\/\/www.newslab.sk\/ileus-pri-farmakoterapii-chronickej-hnacky\/"},"modified":"2020-05-05T17:58:09","modified_gmt":"2020-05-05T15:58:09","slug":"ileus-in-chronic-diarrhoea-drug-therapy-case-report","status":"publish","type":"post","link":"https:\/\/www.newslab.sk\/en\/ileus-in-chronic-diarrhoea-drug-therapy-case-report\/","title":{"rendered":"Ileus in chronic diarrhoea drug therapy (case report)"},"content":{"rendered":"

*<\/strong>All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf attachment at the end of the paper.<\/strong><\/span><\/p>\n

 <\/p>\n

\u00davod<\/strong><\/p>\n

Ileus je stav \u010drevnej nepriechodnosti, pri ktorom je naru\u0161en\u00e1 pas\u00e1\u017e \u010drevn\u00e9ho obsahu fyziologick\u00fdmi peristaltick\u00fdmi vlnami abor\u00e1lnym smerom, n\u00e1sledkom \u010doho vznik\u00e1 stagn\u00e1cia a hromadenie \u010drevn\u00e9ho obsahu a plynu nad postihnut\u00fdm miestom. Jeho pr\u00ed\u010diny sa daj\u00fa rozdeli\u0165 na mechanick\u00e9 a funk\u010dn\u00e9. Pri mechanickom ileu je pr\u00edtomn\u00fd patologick\u00fd proces, ktor\u00fd fyzicky zabra\u0148uje posunu obsahu \u010drevom, naj\u010dastej\u0161ie ide o poopera\u010dn\u00e9 intraabdomin\u00e1lne zrasty, r\u00f4zne z\u00e1palov\u00e9 procesy v bru\u0161nej dutine a panve, hernie, divertikul\u00f3zu, volvulus, \u010drevn\u00e9 a in\u00e9 bru\u0161n\u00e9 n\u00e1dory, k menej \u010dast\u00fdm pr\u00ed\u010din\u00e1m patria cudzie teles\u00e1, parazity, koprolity, intususcepcia(1). Pri funk\u010dnom ileu (niekedy naz\u00fdvanom paralytick\u00fd ileus) nie je identifikovate\u013en\u00e1 mechanick\u00e1 pr\u00ed\u010dina nepriechodnosti, podkladom je naru\u0161en\u00e1 \u010dinnos\u0165 svaloviny, napr\u00edklad v d\u00f4sledku metabolick\u00fdch por\u00fach (hypokali\u00e9mia), hypoperf\u00fazie \u010dreva, u\u017e\u00edvania liekov (po celkovej opera\u010dnej anest\u00e9zii, niektor\u00e9 antipsychotik\u00e1, opioidy)(1,2).<\/p>\n

Pri v\u0161etk\u00fdch typoch ilea doch\u00e1dza k postupn\u00e9mu hromadeniu obsahu, zvy\u0161ovaniu intralumin\u00e1lneho tlaku, ku kolekcii vo\u013enej tekutiny vn\u00fatri \u010dreva, v pr\u00edpade progresie stavu k postupn\u00e9mu opuchu a ischemiz\u00e1cii steny \u010dreva. To m\u00e1 za n\u00e1sledok syst\u00e9mov\u00fa poruchu acidob\u00e1zy a elektrolytov, dehydrat\u00e1ciu a\u017e hypovol\u00e9miu. Naru\u0161en\u00e1 \u010drevn\u00e1 bari\u00e9rov\u00e1 funkcia m\u00f4\u017ee sp\u00f4sobi\u0165 septick\u00fd stav vzh\u013eadom na prestup \u010drevn\u00fdch bakt\u00e9ri\u00ed do cievneho rie\u010diska. Ob\u00e1vanou komplik\u00e1ciou je rupt\u00fara \u010dreva (pre nadmern\u00fa dilat\u00e1ciu, isch\u00e9miu, v pr\u00edpade mechanick\u00e9ho ilea pre hyperperistaltiku) s n\u00e1slednou perito- nit\u00eddou, ktor\u00e1 m\u00e1va napriek v\u010dasn\u00e9mu opera\u010dn\u00e9mu rie\u0161eniu \u010dasto vysok\u00fa mortalitu(1,3).<\/p>\n

Ku klinick\u00fdm pr\u00edznakom ilea patr\u00ed abdomin\u00e1lny diskomfort, boles\u0165 brucha, meteorizmus s hyperson\u00f3rnym poklopom, nauzea a vracanie, zastavenie odchodu vetrov a stolice, a\u017e \u0161okov\u00fd stav. Auskulta\u010dne je pri paralytickom ileu takmer kompletne vymiznut\u00e1 peristaltika, pri mechanickom ileu je typick\u00e1 hyperperistaltika pre snahu \u010dreva pretla\u010di\u0165 obsah cez miesto ob\u0161trukcie. V diagnostike s\u00fa okrem fyzik\u00e1lneho vy\u0161etrenia u\u017eito\u010dn\u00e9 zobrazovacie met\u00f3dy (nat\u00edvna sn\u00edmka brucha, ultrasonografia, po\u010d\u00edta\u010dov\u00e1 tomografia \u2013 CT), ktor\u00e9 pom\u00e1haj\u00fa potvrdi\u0165 ile\u00f3zny stav (typick\u00e1 je dilat\u00e1cia \u010drev- n\u00fdch k\u013eu\u010diek s ve\u013ek\u00fdm mno\u017estvom plynu a tvorbou hladiniek) a m\u00f4\u017eu odhali\u0165 pr\u00ed\u010dinu mechanickej nepriechodnosti(4).<\/p>\n

 <\/p>\n

Pr\u00edpadov\u00e1 \u0161t\u00fadia<\/strong><\/p>\n

60-ro\u010dn\u00e1 pacientka s anamn\u00e9zou inkontinencie stolice s hna\u010dkami, trvaj\u00facej viac ako 6 mesiacov bola prijat\u00e1 na intern\u00e9 oddelenie pre ak\u00fatne, opakovan\u00e9 vracanie hnedozelen\u00e9ho obsahu s dlhodobo trvaj\u00facimi boles\u0165ami brucha a \u017eal\u00fadka. Ud\u00e1vala, \u017ee v stolici nepozorovala zn\u00e1mky krv\u00e1cania alebo \u010dierneho obsahu, v \u010dase pred hospitaliz\u00e1ciou m\u00e1vala iba mal\u00e9 mno\u017estvo stolice nepravidelne. Pacientka dlhodobo neu\u017e\u00edvala \u017eiadne lieky, iba liek Imodium s \u00fa\u010dinnou l\u00e1tkou loperamid na hna\u010dku a inkontinenciu stolice. Pri \u00favodnom fyzik\u00e1lnom vy\u0161etren\u00ed bola pacientka obehovo stabilizovan\u00e1, afebriln\u00e1, brucho mala v niveau hrudn\u00edka, priehmatn\u00e9, bez zn\u00e1mok peritone\u00e1lneho dr\u00e1\u017edenia, spo\u010diatku s bolestivos\u0165ou\u00a0 v epigastriu, s norm\u00e1lnym poklopom a auskulta\u010dne pr\u00edtomnou peristaltikou, t\u00e1 dokonca bola vidite\u013en\u00e1 cez bru\u0161n\u00fa stenu, per rectum so zvy\u0161kami riedkej stolice, na nat\u00edvnej sn\u00edmke brucha bez zn\u00e1mok pneumoperitonea a hladiniek. Pri pr\u00edjme bol vysaden\u00fd liek u\u017e\u00edvan\u00fd na hna\u010dku. V priebehu hospitaliz\u00e1cie sa brucho dostalo nad niveau hrudn\u00edka, stalo sa dif\u00fazne palpa\u010dne citliv\u00fdm, bez hmatnej rezistencie, st\u00e1le bez zn\u00e1mok peritone\u00e1lneho dr\u00e1\u017edenia, no v\u00fdrazne meteoristick\u00e9, u\u017e bez auskulta\u010dne pr\u00edtomnej peristaltickej \u010dinnosti, per rectum bo- la hned\u00e1 tuh\u0161ia stolica, ktor\u00e1 bola \u010diasto\u010dne manu\u00e1lne eva- kuovan\u00e1. CT vy\u0161etren\u00edm brucha sa zobrazil extr\u00e9mne objem- n\u00fd obsah abor\u00e1lnej \u010dasti hrub\u00e9ho \u010dreva, ktor\u00fd komprimoval ostatn\u00e9 org\u00e1ny brucha, peror\u00e1lne podan\u00e1 kontrastn\u00e1 l\u00e1tka zostala v \u017eal\u00fadku a hornej \u010dasti \u010driev. V laborat\u00f3rnych parametroch mala pacientka leukocyt\u00f3zu, retenciu dus\u00edkat\u00fdch l\u00e1tok, hyponatri\u00e9miu, hypokali\u00e9miu, hypochlor\u00e9miu. Napriek komplexnej terapii o p\u00e1r dn\u00ed pacientka exitovala.<\/p>\n

Pri pitve sa na\u0161li mas\u00edvne mno\u017estv\u00e1 tuhej kompaktnej stolice hnedej farby, vyp\u013a\u0148aj\u00face priestor od rekta a\u017e po abor\u00e1lnu \u0161tvrtinu colon descendens, s v\u00fdraznou dilat\u00e1ciou tejto \u010dasti \u010dreva (obvod 30 cm), ostatn\u00e9 \u00faseky hrub\u00e9ho a tenk\u00e9ho \u010dreva boli zna\u010dne dilatovan\u00e9 a vyplnen\u00e9 plynom a v\u00e4\u010d\u0161\u00edm mno\u017e- stvom hnedozelen\u00e9ho plegick\u00e9ho tekut\u00e9ho obsahu. Nena\u0161li sa zn\u00e1mky naru\u0161enia integrity \u010driev alebo in\u00fdch \u010dast\u00ed gastrointestin\u00e1lneho traktu, bez zn\u00e1mok ak\u00fatneho peritone\u00e1lneho z\u00e1palov\u00e9ho procesu, bez ascitu a krv\u00e1cania do bru\u0161nej dutiny alebo l\u00famenu \u010dreva, bez n\u00e1lezu in\u00fdch mechanick\u00fdch pr\u00ed\u010din ob\u0161trukcie gastrointestin\u00e1lneho traktu. Z ostatn\u00e9ho n\u00e1lezu bola identifikovan\u00e1 pokro\u010dil\u00e1 ateroskler\u00f3za aorty a jej vetiev v \u0161t\u00e1diu kalcifika\u010dn\u00fdch zmien s lo\u017eiskovou ob\u0161trukciou do 50 %, chronick\u00e1 pyelonefrit\u00edda obojstranne s ak\u00fatnou exacerb\u00e1ciou a bronchopneum\u00f3nia jedn\u00e9ho laloka p\u013e\u00fac.<\/p>\n

 <\/p>\n

Diskusia<\/h2>\n

Vo\u013enopredajn\u00e9 lie\u010divo loperamid patr\u00ed do skupiny antidiaro\u00edk ur\u010den\u00fdch na symptomatick\u00fa lie\u010dbu ak\u00fatnej a chronickej hna\u010dky. Via\u017ee sa na opioidn\u00e9 receptory plexus myentericus \u010dreva, spoma\u013euje uvo\u013e\u0148ovanie acetylchol\u00ednu a prostagland\u00ednov, \u010d\u00edm zni\u017euje propulzn\u00fa peristaltiku, predl\u017euje pas\u00e1\u017e obsahu \u010drevom a zvy\u0161uje tonus an\u00e1lneho sfinktra(5). K \u010dast\u00fdm ne\u017eiaducim \u00fa\u010dinkom zo strany gastrointestin\u00e1lneho traktu pri u\u017e\u00edvan\u00ed loperamidu patr\u00ed z\u00e1pcha, nauzea, flatulencia, menej \u010dasto boles\u0165 brucha, abdomin\u00e1lny diskomfort, s frekvenciou \u2265 1\/10 000 a\u017e < 1\/1 000 ileus, megakolon, abdomin\u00e1lna dystenzia. Pri v\u00fdskyte ne\u017eiaducich \u00fa\u010dinkov aj pri pred\u00e1vkovan\u00ed je nutn\u00e9 liek vysadi\u0165, pr\u00edpadne opakovane poda\u0165 antidotum nalox\u00f3n(5). Napriek tomu, \u017ee ide o vysoko\u00fa\u010dinn\u00fd a relat\u00edvne bezpe\u010dn\u00fd liek, z\u00e1va\u017en\u00e9 a\u017e let\u00e1lne ne\u017eiaduce \u00fa\u010dinky loperamidu vr\u00e1tane paralytick\u00e9ho ilea boli pozorovan\u00e9 a publikovan\u00e9 u\u017e pred vy\u0161e p\u00e4\u0165desiatimi rokmi naprie\u010d r\u00f4znymi vekov\u00fdmi kateg\u00f3riami, od pediatrickej a\u017e po geriatrick\u00fa popul\u00e1ciu. Vznik ilea bol pozorovan\u00fd pri pred\u00e1vkovan\u00ed, no aj pri be\u017en\u00fdch terapeutick\u00fdch d\u00e1vkach(6,7). V minulosti bol op\u00edsan\u00fd pr\u00edpad star\u0161ej pacientky, u ktorej sa pri lie\u010dbe ak\u00fatnej hna\u010dky, pravdepodobne v d\u00f4sledku pred\u00e1vkovania loperamidom, rozvinuli ak\u00fatne pr\u00edznaky \u010drevnej nepriechodnosti ve\u013emi podobn\u00e9 op\u00edsanej kazuistike. Po vysaden\u00ed lieku a primerane intenz\u00edvnej, no najm\u00e4 v\u010dasnej konzervat\u00edvnej terapii sa pacientkin stav kompletne upravil(7).<\/p>\n

V pr\u00edpade pacientky z tejto kazuistiky nie s\u00fa k dispoz\u00edcii \u00fadaje o d\u013a\u017eke u\u017e\u00edvania a d\u00e1vkovan\u00ed lieku. Vzh\u013eadom na \u00fadaj o hna\u010dk\u00e1ch trvaj\u00facich 6 mesiacov, uv\u00e1dzan\u00fd pacientkou, v\u0161ak mo\u017eno predpoklada\u0165, \u017ee lie\u010dba loperamidom trvala dlh\u0161ie. Pr\u00ed\u010dinou \u010drevnej nepriechodnosti u pacientky pravdepodobne nebol priamo paralytick\u00fd ileus, ale napriek ud\u00e1van\u00fdm hna\u010dk\u00e1m paradoxne sk\u00f4r dlhodobo prebiehaj\u00faca obstip\u00e1cia, ktor\u00e1 vy\u00fastila do nahromadenia ve\u013ek\u00e9ho mno\u017estva skyb\u00e1l v colon sigmoideum a colon descendens, \u010doho n\u00e1sledkom bolo mechanick\u00e9 blokovanie l\u00famenu \u010dreva so vznikom mechanick\u00e9ho ilea, resp. kombin\u00e1cia mechanick\u00e9ho a paralytick\u00e9ho ilea s viacfaktorovou etiol\u00f3giou. Podiel na progresii ilea mohla ma\u0165 pokro\u010dil\u00e1 ateroskler\u00f3za aorty a jej vetiev, ktor\u00e1 mohla zhor\u0161ova\u0165 zdravotn\u00fd stav ischemiz\u00e1ciou \u010dreva. Napriek tomu, \u017ee po\u010das hospitaliz\u00e1cie bola pacientka lie\u010den\u00e1 na z\u00e1pchu konzervat\u00edvne a manu\u00e1lnou evaku\u00e1ciou stolice, norm\u00e1lnu pas\u00e1\u017e sa nepodarilo obnovi\u0165 v\u010das. Ile\u00f3zny stav spolu s exacerbovanou chronickou pyelonefrit\u00eddou viedol\u00a0 k fat\u00e1lnej poruche homeost\u00e1zy a \u00famrtiu pacientky.<\/p>\n

 <\/p>\n

Z\u00e1ver<\/h2>\n

Farmakologicky navoden\u00fd ileus je zn\u00e1mym ne\u017eiaducim \u00fa\u010dinkom viacer\u00fdch liekov. Pri v\u010dasnom a adekv\u00e1tne volenom z\u00e1sahu mo\u017eno pas\u00e1\u017e \u010dreva obnovi\u0165 a pacient m\u00f4\u017ee pre\u017ei\u0165 bez zdravotn\u00fdch n\u00e1sledkov(7). Je nutn\u00e9 ma\u0165 na zreteli riziko v\u00fdskytu vz\u00e1cnej\u0161\u00edch ne\u017eiaducich \u00fa\u010dinkov liekov, najm\u00e4 u pacientov s\u00fa\u010dasne u\u017e\u00edvaj\u00facich viacer\u00e9 lieky vr\u00e1tane vo\u013enopredajn\u00fdch liekov, a zoh\u013eadni\u0165 ich pri diferenci\u00e1lnodiagnostick\u00fdch \u00favah\u00e1ch.<\/p>\n

 <\/p>\n

Po\u010fakovanie: <\/em><\/strong>Tento<\/em> \u010dl\u00e1nok vznikol aj v\u010faka podpore v r\u00e1mci OP V\u00fdskum a v\u00fdvoj pre projekt: Centrum v\u00fdskumu z\u00e1va\u017en\u00fdch ochoren\u00ed a ich komplik\u00e1ci\u00ed, ITMS 26240120038, spolufinancovan\u00fd zo zdrojov Eur\u00f3pskeho fondu region\u00e1lneho rozvoja.<\/em><\/p>\n

 <\/p>\n

 <\/p>\n

LITERAT\u00daRU<\/strong><\/p>\n

    \n
  1. Griffiths S, Glancy Intestinal obstruction. Surgery (Oxford) 2017; 35(3): 157-164.<\/li>\n
  2. Vilz TO, Stoffels B, Strassburg C, et al. Ileus in Adults. Dtsch Arztebl Int 2017; 114(29-30): 508-518.<\/li>\n
  3. Bielecki K, Kami\u0144ski P, Klukowski Large bowel perforation: morbidity and mortality. Tech Coloproctol 2002; 6(3): 177-182.<\/li>\n
  4. Jackson PG, Raiji Evaluation and management of intestinal obstruction. Am Fam Physician 2011; 83(2): 159-165.<\/li>\n
  5. ADC port\u00e1l [online]. Bratislava: PharmINFO spol., s. r. o. D\u00e1tum rev\u00edzie textu 07\/2019 [cit. 19. 2. 2020]. Dostupn\u00e9 na: https:\/\/w<\/a>ww.<\/a> adc.sk\/databazy\/produkty\/spc\/imodium-808582.html<\/li>\n
  6. Von M\u00fchlendahl KE, Bunjes R, Krienke Loperamide-induced ileus.Lancet 1980; 1(8161): 209.<\/li>\n
  7. Zaniello B, Phillips-Caesar Over-the-counter medication overuse and bowel obstruction. J Am Geriatr Soc 2014; 62(2): 400-402.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    *All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf attachment at the end of the paper.   \u00davod Ileus je stav \u010drevnej nepriechodnosti, pri ktorom je naru\u0161en\u00e1 pas\u00e1\u017e \u010drevn\u00e9ho obsahu fyziologick\u00fdmi peristaltick\u00fdmi vlnami abor\u00e1lnym smerom, n\u00e1sledkom \u010doho vznik\u00e1 stagn\u00e1cia a hromadenie \u010drevn\u00e9ho obsahu a plynu nad<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_mi_skip_tracking":false,"footnotes":""},"categories":[297],"tags":[1471,1467,1472,1470],"class_list":["post-1989","post","type-post","status-publish","format-standard","hentry","category-pathology","tag-adverse-effects","tag-ileus-en","tag-loperamide","tag-pharmacotherapy-of-chronic-diarrhoea","typ_clanku-casuistry"],"acf":{"abstrakt":"

    In ileus, the normal motility of the intestines is impaired due to various underlying diseases. Among the numer- ous causes, there are mechanical blockage of the lumen, disruption of the intestinal innervation or inadequacy of the blood supply. Together with other surgical diagnoses collectively referred to as \u201eacute abdomen, it often leads to surgery. The prognosis and rate of mortality differ depending on the cause of the obstruction. We describe a case of a 60-year-old female patient who developed ileus during treatment of chronic diarrhoea by lop- eramide. Possible causes of ileus in the patient are discussed.<\/p>\n

    Keywords: <\/strong>ileus, pharmacotherapy of chronic diarrhoea, adverse effects, loperamide<\/p>\n","casopis":[{"ID":1893,"post_author":"7","post_date":"2020-05-05 11:32:54","post_date_gmt":"2020-05-05 09:32:54","post_content":"

      \r\n \t
    • Identification of metabolic pathways in pathogenesis of diabetic retinopathy using exome sequencing \u2013 a pilot study<\/li>\r\n \t
    • Anti-tumour effects of vitamin D<\/li>\r\n \t
    • Molecular detection methods of mutations in the kinase domain of fusion gene bcr-abl1 in patients with chronic myelocyte leukemia<\/li>\r\n \t
    • The case report of toxoplasmic meningoencephalitis with fatal outcome in HIV patient<\/li>\r\n \t
    • Carcinosarcoma-like endometrioid carcinoma of the uterus: case report of rare non-high-grade tumor<\/li>\r\n<\/ul>","post_title":"newsLab","post_excerpt":"","post_status":"publish","comment_status":"closed","ping_status":"closed","post_password":"","post_name":"newslab-4","to_ping":"","pinged":"","post_modified":"2020-05-05 15:13:41","post_modified_gmt":"2020-05-05 13:13:41","post_content_filtered":"","post_parent":0,"guid":"https:\/\/www.newslab.sk\/?post_type=casopis&p=1893","menu_order":0,"post_type":"casopis","post_mime_type":"","comment_count":"0","filter":"raw"}],"strana":"61-62","upload_clanok":{"ID":1987,"id":1987,"title":"NEWSLAB_1-2020_Horak","filename":"NEWSLAB_1-2020_Horak.pdf","filesize":136579,"url":"https:\/\/www.newslab.sk\/wp-content\/uploads\/2020\/05\/NEWSLAB_1-2020_Horak.pdf","link":"https:\/\/www.newslab.sk\/en\/ileus-in-chronic-diarrhoea-drug-therapy-case-report\/newslab_1-2020_horak-2\/","alt":"","author":"7","description":"","caption":"","name":"newslab_1-2020_horak-2","status":"inherit","uploaded_to":1989,"date":"2020-05-05 15:42:21","modified":"2020-05-05 15:42:21","menu_order":0,"mime_type":"application\/pdf","type":"application","subtype":"pdf","icon":"https:\/\/www.newslab.sk\/wp-includes\/images\/media\/document.png"}},"_links":{"self":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts\/1989","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/comments?post=1989"}],"version-history":[{"count":0,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts\/1989\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/media?parent=1989"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/categories?post=1989"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/tags?post=1989"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}