|
1
|
Maina RM, Rader C, Kypa J, Asahngwa C, Jasmin HM, Zalamea NN, Nelson JS, Altomar JL, Owens MB, Muenyi CS, Foretia DA. Chemotherapy-associated pneumoperitoneum in cancer patients: a scoping review. Ann Med Surg (Lond) 2024; 86:2828-2835. [PMID: 38694333 PMCID: PMC11060304 DOI: 10.1097/ms9.0000000000001998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/14/2024] [Indexed: 05/04/2024] Open
Abstract
Background The presence of air in the peritoneal cavity (pneumoperitoneum) is often secondary to perforated viscus. Emergent operative intervention is typically warranted in non-cancer patients. Cancer patients present a unique challenge as they have an increased risk of pneumoperitoneum due to local tumour invasion, radiation therapy, and frequent endoscopic procedures. There is a paucity of literature on the management of patients undergoing chemotherapy who present with pneumoperitoneum. The authors conducted a scoping review to identify and synthesize preliminary evidence on the presentation, management, and outcomes of this patient population. Materials and methods A scoping review of cases of pneumoperitoneum in cancer patients from 1990 to 2022 was conducted using the Arksey and O'Malley five-stage approach. Inclusion criteria were a known diagnosis of cancer, chemotherapy within 6 months of presentation, and imaging confirmation of pneumoperitoneum. The authors' exclusion criteria were cancer diagnosis at the time of presentation, perforation secondary to local cancer invasion, and last chemotherapy session greater than 6 months prior to presentation. Results Thirty-four cases (8 paediatric, 26 adults) were identified. The median time from the last chemotherapy treatment to presentation with pneumoperitoneum was 14 days. Twenty-one patients were managed operatively, and 13 were managed non-operatively. The most common source of perforation was multiple sites along the bowel. Thirty-day mortality was 33.3% for the operative cohort and 23.1% for the non-operative group. Conclusions Pneumoperitoneum in cancer patients remains a highly morbid condition with a mortality rate of approximately 30%, regardless of the treatment approach. Non-operative management should be pursued whenever possible.
Collapse
Affiliation(s)
| | | | | | - Constantine Asahngwa
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| | | | - Nia N. Zalamea
- Department of Surgery
- General Surgery Research Group
- Global Surgery Institute, University of Tennessee Health Science Center, Memphis, TN
| | | | | | | | | | - Denis A. Foretia
- Department of Surgery
- General Surgery Research Group
- Global Surgery Institute, University of Tennessee Health Science Center, Memphis, TN
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| |
Collapse
|
|
2
|
Yu Z, Zhu H, Chen H, Zhu L, Liao X. Gastrointestinal perforation associated with novel antineoplastic agents: A real-world study based on the FDA Adverse Event Reporting System. JOURNAL OF PHARMACY & PHARMACEUTICAL SCIENCES : A PUBLICATION OF THE CANADIAN SOCIETY FOR PHARMACEUTICAL SCIENCES, SOCIETE CANADIENNE DES SCIENCES PHARMACEUTIQUES 2023; 26:11235. [PMID: 36942297 PMCID: PMC9990630 DOI: 10.3389/jpps.2023.11235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
Purpose: Gastrointestinal perforation (GIP) is a fatal adverse event (AE). The AE of GIP induced by novel antineoplastic agents has attracted attention recently. We aimed to explore the AE signals of GIP related to novel antineoplastic agents comprehensively based on the FDA Adverse Event Reporting System (FAERS). Methods: The FAERS database containing 71 quarters of records was used for analysis. Reporting odds ratio (ROR), information component (IC), and empirical Bayesian geometric mean (EBGM) were utilized to evaluate the signals of GIP associated with novel antineoplastic drugs. Standardization of drug names was by employing MedEx-UIMA software and Python. Data analysis and visualization were performed using MySQL Workbench and R software. Results: After cleaning and handling the data, 5226 GIP cases were identified that were associated with new antineoplastic medications, where these agents were the main suspected contributors. A total of 37 novel antineoplastic drugs were detected with signals of GIP for ROR and IC. Only 22 drugs showed statistically significant signals for EBGM. We found the GIP signals of 22 novel antineoplastic drugs overlapped for the 3 indicators, including anti-vascular endothelial growth factor/vascular endothelial growth factor receptor, anti-endothelial growth factor receptor, immune checkpoint inhibitors, and so on. Conclusion: The potential risk of GIP associated with several novel antineoplastic agents was identified through data mining, which provided valuable information on the safety risks associated with GIP among these drugs. The potential threat of GIP should be recognized and managed properly when using these novel antineoplastic agents.
Collapse
|
|
3
|
Hamdeh S, Micic D, Hanauer S. Review article: drug-induced small bowel injury. Aliment Pharmacol Ther 2021; 54:1370-1388. [PMID: 34668591 DOI: 10.1111/apt.16642] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/05/2021] [Accepted: 09/29/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Drug-induced gastrointestinal injury has been increasingly reported, but its exact incidence is not known. The small and large intestines represent the most affected sites of injury, accounting for 20%-40% of all gastrointestinal side effects. AIM To provide an updated literature review detailing medications linked to the development of small bowel injury. METHODS We conducted a literature search on PubMed from its inception to May 1, 2021. We included English-language original studies, meta-analyses, systematic reviews, review articles and case reports. RESULTS Drug-induced enteropathy can range from asymptomatic histological changes resulting in a subtle, self-limited disease to a chronic inflammatory condition mimicking inflammatory bowel disease, or bowel perforation. Endoscopy can demonstrate erythema, mucosal friability, oedema, erosions, ulcers or strictures in severe cases. Histology may include mucosal erosions and ulcerations, focal active enteritis, villous atrophy, epithelial apoptosis or necrotising enteritis. A well-established association has been found with the use of nonsteroidal anti-inflammatory drugs, immunosuppressants, chemotherapeutic agents, antibiotics, immunotherapies, etanercept and olmesartan. Possible associations have been reported with other biologic agents, medications used for glycemic control, antihypertensives, cholinesterase inhibitors, potassium and iron supplements, with conflicting data regarding contraceptives/hormonal therapy and isotretinoin. CONCLUSION Physicians should be aware of the manifestations of drug-induced enteropathy as early recognition can lead to prompt discontinuation of the offending therapy and, therefore, a reduced risk of future complications.
Collapse
Affiliation(s)
- Shadi Hamdeh
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Motility, University of Kansas, Lawrence, KS, USA
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, IL, USA
| | - Stephen Hanauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
|
4
|
Valamparampil JJ, Palaniappan K, Vij M, Shanmugam N, Ramachandran P, Ramachandran B, Rela M. Recurrent Intestinal Perforation After Cessation of Immunosuppression in Posttransplant Lymphoproliferative Disease in Pediatric Liver Transplant Recipient. J Gastrointest Cancer 2021; 52:1165-1168. [PMID: 33751328 DOI: 10.1007/s12029-021-00627-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 11/24/2022]
Abstract
Posttransplant lymphoproliferative disease (PTLD) is the most common malignant complication after solid organ transplantation. Gastrointestinal involvement as the presentation in early PTLD can occur in 25-30% of pediatric liver transplant recipients and can be the only system involved in 20%. Recurrent gastrointestinal perforation due to resolution of PTLD is an extremely rare complication. We report a 13-month-old male child diagnosed with PTLD, treatment of which lead to recurrent intestinal perforations. The child presented with gastrointestinal bleed 5 months after living donor liver transplantation for biliary atresia. Evaluation was suggestive of PTLD and biopsy confirmed diffuse large B-cell lymphoma. Positron emission tomography scan showed diffuse involvement of small intestine and ileum. Tacrolimus was withdrawn abruptly following diagnosis of PTLD as there was associated renal impairment. Child developed six episodes of small intestinal perforations over 3 weeks which required multiple laparotomies with closure of perforation and/or small bowel resection. Complete remission was achieved six months after diagnosis with cessation of immunosuppression alone and child is alive at 48 months follow-up without any recurrence. To avoid bowel perforation and complications related to tumor necrosis, immunosuppression reduction in PTLD should be gradual while carefully monitoring Epstein-Barr virus levels, tumor response, graft function, and general health status of the patient.
Collapse
Affiliation(s)
- Joseph J Valamparampil
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India.
| | - Kumar Palaniappan
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Mukul Vij
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Naresh Shanmugam
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Priya Ramachandran
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| | - Bala Ramachandran
- Paediatric Intensive Care Unit, Kanchi Kamakoti Childs Trust Hospital, Chennai, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharat Institute of Higher Education & Research, Chennai, India
| |
Collapse
|
|
5
|
Small S, Barnea Slonim L, Williams C, Karmali R. B Cell Lymphomas of the GI Tract. Curr Gastroenterol Rep 2021; 23:9. [PMID: 33963950 DOI: 10.1007/s11894-021-00811-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 06/12/2023]
Abstract
PURPOSE OF THE REVIEW Primary GI lymphomas of B cell origin are a diverse group of lymphomas. In this article, we provide an overview of the diagnosis, pathologic and molecular features, and management of these varied lymphomas. RECENT FINDINGS The most common primary GI lymphomas are diffuse large B cell lymphoma (DLBCL) and marginal zone lymphomas (MZL), but follicular lymphomas (FL), mantle cell lymphomas (MCL), post-transplant lymphoproliferative disorders (PTLD), and Burkitt lymphoma of the GI tract also occur. Many features of these lymphomas are similar to their nodal counterparts, but certain clinical and biological aspects are unique. Diagnostic and treatment strategies for these lymphomas continue to evolve over time. There are ongoing discoveries about the unique pathophysiology, molecular characteristics, and complications of primary B cell GI lymphomas that are already leading to improvements in management of this histologically diverse set of lymphomas.
Collapse
Affiliation(s)
- Sara Small
- Division of Hematology/Oncology, Northwestern University, Chicago, IL, USA
| | | | - Corinne Williams
- Robert H. Lurie Comprehensive Cancer Center, 675 N. St. Clair St.Fl 21 Ste. 100, Chicago, IL, 60611, USA
| | - Reem Karmali
- Division of Hematology/Oncology, Northwestern University, Chicago, IL, USA.
- Robert H. Lurie Comprehensive Cancer Center, 675 N. St. Clair St.Fl 21 Ste. 100, Chicago, IL, 60611, USA.
| |
Collapse
|
|
6
|
Very Severe and Refractory Noninfectious Cystitis in Patients with Systemic Lupus Erythematosus: Potential Role of Rituximab Therapy. Case Rep Rheumatol 2021; 2021:6610111. [PMID: 33728086 PMCID: PMC7936892 DOI: 10.1155/2021/6610111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/02/2021] [Accepted: 02/24/2021] [Indexed: 11/21/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease with various clinical manifestations, including, rarely, a form of interstitial cystitis (lupus cystitis, LC). LC can be asymptomatic and usually has discrete symptoms that improve with conventional therapies available for SLE and/or typical interstitial cystitis. A very severe and refractory form is rarely described. In this study, we present four patients with SLE and a very severe form of noninfectious cystitis refractory to the different forms of treatment described. The clinical descriptions of the cases, demographic factors, manifestations associated with SLE, and clinical and paraclinical manifestations related to cystitis, treatments, and outcomes are provided. A proposal for the pathogenesis of this condition is based on the common findings of these patients, including the fact that three were in SLE remission and all four receiving rituximab as induction and/or maintenance therapy.
Collapse
|
|
7
|
Haji HA, Corwin DS, So JY, Reed RM. Lymphoproliferative disorder in a lung transplant recipient. BMJ Case Rep 2020; 13:13/3/e234532. [PMID: 32234858 DOI: 10.1136/bcr-2020-234532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Post-transplantation lymphoproliferative disorder (PTLD) is uncommon following solid organ transplantation. We present a case of PTLD presenting as hematochezia and abdominal pain in a 66-year-old man, who had undergone bilateral lung transplantation with alemtuzumab induction 7 months prior to presentation. The transplant serologic status was "high-risk" for the presence of both Epstein-Barr virus (EBV) serologies in the donor and negative serologies in the recipient. Biopsies taken during colonoscopy stained strongly positive for EBV-encoded RNA. Mediastinal lymph node biopsies also showed atypical, EBV-positive lymphohistiocytic infiltration with focal necrosis. The patient's hospital course was complicated by treatment side effects, most notably bowel perforation following rituximab. In this case report the topic of PTLD is reviewed and consideration is given to whether alemtuzumab induction may have contributed to the patient's development of PTLD.
Collapse
Affiliation(s)
- Hassan A Haji
- Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Douglas S Corwin
- Pulmonary and Critical Care Medicine, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Jennifer Y So
- Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Robert M Reed
- Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
|
8
|
Gao W, Li X, Huang L. Treatment of obstructive jaundice caused by hepatic artery pseudoaneurysm after liver transplantation: A case report. Medicine (Baltimore) 2019; 98:e18015. [PMID: 31860951 PMCID: PMC6940052 DOI: 10.1097/md.0000000000018015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 09/29/2019] [Accepted: 10/17/2019] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Despite vast improvements in technique, several complications still challenge surgeons and medical practitioners alike, including biliary and vascular complications, acute and chronic rejection, and disease recurrence. PATIENT CONCERNS A 59-year-old man was admitted to hospital on July, 2016. He had hepatitis B cirrhosis related recurrent hepatocellular carcinoma and underwent living donor liver transplantation in our hospital. DIAGNOSIS At the time of admission, the patient's spirit, diet, sleep, normal urine and stool, and weight did not change significantly. The test indicators are as follows: total bilirubin: 100.1 μmol/L, direct bilirubin: 65.0 μmol/L. Emergency CT in the hospital after admission showed that hepatic artery pseudoaneurysm formation after liver transplantation was observed. INTERVENTIONS This patient underwent minimal invasive endovascular treatment. The demographic, clinical, and laboratory data were collected and reviewed. He was treated successfully by endovascular stent grafting and thrombolytic treatment. OUTCOMES The blood concentration of tacrolimus (FK506) was 6.3 ng/mL total bilirubin 19.6 μmol/L before discharge. The changing of total bilirubin and direct bilirubin were investigated (Fig. 1). The patient recovered well and was discharged 2 weeks later. The patient is doing well and regularly followed up. LESSONS Coil embolization of aneurysmal sac or placement of a stent graft is a minimally invasive alternative to surgery and definitively excludes a bleeding hepatic artery pseudoaneurysm. This technique can be considered as an effective treatment option for hepatic artery pseudoaneurysm instead of a difficult surgical repair.
Collapse
MESH Headings
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/etiology
- Aneurysm, False/therapy
- Carcinoma, Hepatocellular/pathology
- Carcinoma, Hepatocellular/surgery
- Carcinoma, Hepatocellular/virology
- Embolization, Therapeutic/methods
- Follow-Up Studies
- Graft Survival
- Hepatic Artery
- Hepatitis B, Chronic/complications
- Hepatitis B, Chronic/diagnosis
- Humans
- Jaundice, Obstructive/etiology
- Jaundice, Obstructive/physiopathology
- Jaundice, Obstructive/therapy
- Liver Cirrhosis/etiology
- Liver Cirrhosis/physiopathology
- Liver Transplantation/adverse effects
- Liver Transplantation/methods
- Male
- Middle Aged
- Postoperative Complications/diagnosis
- Postoperative Complications/therapy
- Risk Assessment
- Treatment Outcome
Collapse
|
|
9
|
Iwabu J, Namikawa T, Kitagawa H, Kanagawa T, Nakashima J, Hanazaki K. Sigmoid colon perforation in the patient with granulomatosis with polyangiitis. Surg Case Rep 2019; 5:87. [PMID: 31147785 PMCID: PMC6542931 DOI: 10.1186/s40792-019-0646-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/20/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) induces respiratory tract and kidney granulomatous inflammation due to small-vessel vasculitis. However, gastrointestinal involvement, and especially colon perforation, is rare. CASE PRESENTATION A 40-year-old man diagnosed with GPA was admitted to our hospital for GPA management. He was started on anti-cluster of differentiation 20 antibody (rituximab) therapy after admission and suffered severe abdominal pain 2 weeks later. A clinical diagnosis of sigmoid colon perforation was made, and we performed sigmoid colon resection with colostomy. Histopathological examination revealed loss of vascular wall and neutrophil infiltration. He was discharged from the hospital after intravenous immune globulin therapy. CONCLUSIONS Although gastrointestinal involvement is rare in GPA, severe complications require surgical intervention. Bowel perforation should be considered an important complication of GPA.
Collapse
Affiliation(s)
- Jun Iwabu
- Department of Surgery, Kochi Medical School, Nankoku, Kochi, 783-8505, Japan
| | - Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Nankoku, Kochi, 783-8505, Japan.
| | - Hiroyuki Kitagawa
- Department of Surgery, Kochi Medical School, Nankoku, Kochi, 783-8505, Japan
| | - Toshichika Kanagawa
- Department of Surgery, Kochi Medical School, Nankoku, Kochi, 783-8505, Japan
| | - Junko Nakashima
- Laboratory of Diagnostic Pathology, Kochi Medical School Hospital, Nankoku, Kochi, Japan
| | - Kazuhiro Hanazaki
- Department of Surgery, Kochi Medical School, Nankoku, Kochi, 783-8505, Japan
| |
Collapse
|
|
10
|
Kallash M, Smoyer WE, Mahan JD. Rituximab Use in the Management of Childhood Nephrotic Syndrome. Front Pediatr 2019; 7:178. [PMID: 31134169 PMCID: PMC6524616 DOI: 10.3389/fped.2019.00178] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/17/2019] [Indexed: 12/19/2022] Open
Abstract
Childhood nephrotic syndrome is a challenging and often persistent renal disorder, and its incidence varies between different ethnicities and regions. Corticosteroids have been the main treatment for decades and are effective in most children with idiopathic NS, although 10-15% of these children become steroid resistant. Furthermore, some initially steroid sensitive children follow a steroid dependent or frequently relapsing course and are therefore at increased risk for developing steroid toxicity. In such children, alternative immunosuppressive medications are used to induce and/or maintain remission of NS. One such drug, rituximab, is a monoclonal antibody directed against the B lymphocyte CD20 marker which induces depletion of B cells, and has shown promising results in the management of NS in children. In this review, we summarize recent studies on the efficacy and safety of rituximab in the different types of childhood nephrotic syndrome, the known and potential mechanisms of action of rituximab, its possible complications and side effects, and the available and potential biomarkers of rituximab activity.
Collapse
Affiliation(s)
- Mahmoud Kallash
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - William E Smoyer
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - John D Mahan
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| |
Collapse
|
|
11
|
Sullivan BJ, Kim GJ, Sara G. Treatment dilemma for survivors of rituximab-induced bowel perforation in the setting of post-transplant lymphoproliferative disorder. BMJ Case Rep 2018; 11:e226666. [PMID: 30567238 PMCID: PMC6301592 DOI: 10.1136/bcr-2018-226666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2018] [Indexed: 12/17/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a recognised complication of solid and haematopoietic stem cell transplant. It consists of a heterogeneous group of lymphoid neoplasms that arises secondary to post-transplant immunosuppression. Although there is no definite standard of care for the optimal treatment for PTLD, rituximab, a monoclonal antibody, with and/or without chemotherapy (usually CHOP=cytoxan, doxorubicin, vincristine, prednisone) has become a routine part of the treatment of any CD20 (+) PTLD, with response rates similar to chemotherapy with decreased toxicity. A rare and often lethal, complication of rituximab therapy for PTLD is bowel perforation secondary to tumour lysis of lymphoma involving the intestine. A small number of cases of bowel perforation have been reported, with very few documented survivors. The risk for recurrent perforation in the setting of ongoing rituximab treatment is unknown. There is sparse data supporting how to best treat the survivors.
Collapse
Affiliation(s)
- Brianne J Sullivan
- Department of Surgery, Mount Sinai Health System, New York, New York, USA
| | - Grace J Kim
- Department of Surgery, Mount Sinai Health System, New York, New York, USA
| | - Gabriel Sara
- Department of Oncology, Mount Sinai Health System, New York, New York, USA
| |
Collapse
|
|
12
|
Drug-Induced Gastrointestinal and Hepatic Disease Associated with Biologics and Nonbiologic Disease-Modifying Antirheumatic Drugs. Rheum Dis Clin North Am 2018; 44:29-43. [DOI: 10.1016/j.rdc.2017.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
|
13
|
Ghrenassia E, Mariotte E, Azoulay E. Rituximab-related Severe Toxicity. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [PMCID: PMC7176228 DOI: 10.1007/978-3-319-73670-9_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
|
14
|
Lin J, Wang J, Yue P, Zhang X, Lang R, Wang Y, Cui C, He Q. Treatment and outcome of intestinal perforation after liver transplant surgery in adults: a single-center experience. Ther Clin Risk Manag 2017; 13:675-678. [PMID: 28615946 PMCID: PMC5460651 DOI: 10.2147/tcrm.s137161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Intestinal perforation is a rare complication after liver transplantation. This study was designed to calculate the incidence and investigate the outcomes of intestinal perforation in adult liver transplant patients. MATERIALS AND METHODS The clinical records of liver transplant recipients between January 2014 and June 2016 were obtained. The incidence of intestinal perforation was calculated, and high risk factors were analyzed. RESULTS The mean operative time was 8.5 h (range: 6-11 h). The mean portal vein occlusion time was 66.5 min (range: 58-72 min), and the mean cold ischemia time was 7.9 h (range: 6.5-9.5 h). Four (2.7%) patients developed intestinal perforation from 9 to 14 days postliver transplant. All perforations were single and repaired by interrupted silk sutures. Two patients uneventfully recovered, but intestinal perforation recurred in two other patients. Simple repair was undertaken in one patient, and terminal ileum resection and ileostomy were performed in the other patient. There were no perioperative deaths. CONCLUSION The incidence of intestinal perforation after liver transplantation is low. Prompt diagnosis and treatment should be carried out to reduce comorbidities and mortality.
Collapse
Affiliation(s)
| | - Jing Wang
- Patient Service Center, The Affiliated Hospital to Capital Medical University, Beijing Chaoyang Hospital
| | - Peng Yue
- School of Nursing, Department of Basic Nursing, Capital Medical University
| | - Xingmao Zhang
- Department of Hepatobiliary Surgery, The Affiliated Hospital to Capital Medical University, Beijing Chaoyang Hospital, Beijing, People’s Republic of China
| | - Ren Lang
- Department of Hepatobiliary Surgery, The Affiliated Hospital to Capital Medical University, Beijing Chaoyang Hospital, Beijing, People’s Republic of China
| | - Yuan Wang
- Department of Hepatobiliary Surgery, The Affiliated Hospital to Capital Medical University, Beijing Chaoyang Hospital, Beijing, People’s Republic of China
| | - Chen Cui
- Department of Hepatobiliary Surgery, The Affiliated Hospital to Capital Medical University, Beijing Chaoyang Hospital, Beijing, People’s Republic of China
| | - Qiang He
- Department of Hepatobiliary Surgery, The Affiliated Hospital to Capital Medical University, Beijing Chaoyang Hospital, Beijing, People’s Republic of China
| |
Collapse
|
|
15
|
Surgical management of perforated gastrointestinal posttransplantation lymphoproliferative disorder after heart transplantation. Int Surg 2016; 100:358-64. [PMID: 25692442 DOI: 10.9738/intsurg-d-13-00270.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Posttransplantation lymphoproliferative disorder (PTLD) is a relatively rare and life-threatening complication after organ transplantation. From 1999 to 2012, 45 adult patients underwent heart transplantation at our hospital. Two of the patients developed PTLD after transplantation and required emergency surgery due to intestinal perforation. These cases were informative regarding the adequate surgical management of such cases. Both cases revealed Epstein-Barr virus-related PTLD. The optimal treatment of PTLD remains controversial, and PTLD with gastrointestinal perforation could be critical because the patients are already debilitated and immunocompromised after transplantation. Therefore, the nonspecific abdominal symptoms can be diagnostic for PTLD, and proper surgical intervention should be performed immediately. We present these two suggestive and rare cases in regard to the management of perforation with PTLD and a review of literature.
Collapse
|
|
16
|
Shakibazad N, Kamali K, Honar N, Bordbar M, Mohazabieh E. Rigler Sign in a Child With Posttransplant Lymphoproliferative Disease: A Sign That Should Not Be Missed. EXP CLIN TRANSPLANT 2016; 16:352-354. [PMID: 27765006 DOI: 10.6002/ect.2016.0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rigler sign is a double wall sign suggesting pneumoperitoneum and intestinal perforation, and it needs emergency surgical treatment. Early diagnosis of intestinal perforation by clinical symptoms, presence of Rigler sign in abdominal radiography, and then early surgical treatment can reduce mortality. Here, we report a patient with Crigler-Najjar syndrome who underwent liver transplant and then developed posttransplant lymphoproliferative disease and received chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab. She was referred to the emergency department due to abdominal distension with positive Rigler sign in abdominal radiography; intraoperative findings revealed intestinal perforation. Pediatricians and surgeons should be aware of Rigler sign so that it is diagnosed early and emergency surgical treatment can be performed.
Collapse
Affiliation(s)
- Nader Shakibazad
- >From the Department of Pediatric Hematology and Oncology, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | | | | |
Collapse
|
|
17
|
Guo YW, Gu HY, Abassa KK, Lin XY, Wei XQ. Successful treatment of ileal ulcers caused by immunosuppressants in two organ transplant recipients. World J Gastroenterol 2016; 22:5616-5622. [PMID: 27350740 PMCID: PMC4917622 DOI: 10.3748/wjg.v22.i24.5616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/10/2016] [Accepted: 04/20/2016] [Indexed: 02/07/2023] Open
Abstract
Although gastroduodenal ulcers are common in solid organ transplant patients, there are few reports on multiple giant ulcers in the distal ileum and ileocecal valve caused by immunosuppressants Herein, we report on a liver transplant recipient and a renal transplant recipient with multiple large ulcers in the distal ileum and ileocecal valve who rapidly achieved ulcer healing upon withdrawal of sirolimus or tacrolimus and administration of thalidomide. In case 1, a 56-year-old man with primary hepatocellular carcinoma had received a liver transplantation. Tacrolimus combined with sirolimus and prednisolone was used as the anti-rejection regimen. Colonoscopy was performed because of severe abdominal pain and diarrhea at post-operative month 10. Multiple giant ulcers were found at the ileocecal valve and distal ileum. The ulcers healed rapidly with withdrawal of sirolimus and treatment with thalidomide. There was no recurrence during 2 years of follow-up. In case 2, a 34-year-old man with end-stage kidney disease received kidney transplantation and was put on tacrolimus combined with mycophenolate mofetil and prednisolone as the anti-rejection regimen. Twelve weeks after the operation, the patient presented with hematochezia and severe anemia. Colonoscopy revealed multiple large ulcers in the ileocecal valve and distal ileum, with massive accumulation of fresh blood. The bleeding ceased after treatment with intravenous somatostatin and oral thalidomide. Tacrolimus was withdrawn at the same time. Colonoscopy at week 4 of follow-up revealed remarkable healing of the ulcers, and there was no recurrence of bleeding during 1 year of follow-up. No lymphoma, tuberculosis, or infection of cytomegalovirus, Epstein-Barr virus, or fungus was found in either patient. In post-transplantation cases with ulcers in the distal ileum and ileocecal valve, sirolimus or tacrolimus should be considered a possible risk factor, and withdrawing them or switching to another immunosuppressant might be effective to treat these ulcers.
Collapse
|
|
18
|
Fang C, Yan S, Liu J, Zheng S. Gastrointestinal perforation after liver transplantation. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Cheng Fang
- Department of Surgery; First Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Sheng Yan
- Department of Surgery; First Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Jianhua Liu
- Department of Surgery; First Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Shusen Zheng
- Department of Surgery; First Affiliated Hospital of Zhejiang University; Hangzhou China
| |
Collapse
|
|
19
|
Fukushima N. Posttransplant Lymphoproliferative Disorder after Cardiac Transplantation in Children: Life Threatening Complications Associated with Chemotherapy Combined with Rituximab. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/683420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Despite the excellent long-term survival currently achieved in pediatric heart transplant recipients, posttransplant lymphoproliferative disorders (PTLDs) are one of the most important causes of morbidity and mortality after heart transplantation (HTx), especially in children. Timely and accurate diagnosis based on histological examination of biopsy tissue is essential for early intervention for PTLD. Chemotherapy is indicated for patients with poor response to reduction of immunosuppressive medication and for highly aggressive monomorphic PTLD. The use of rituximab in combination with chemotherapy is effective to suppress B cell type PTLD (B-PTLD). However, PTLD relapses frequently and the outcome is still poor. Although everolimus (EVL) has been reported to inhibit growth of human Epstein-Barr-virus- (EBV-) transformed B lymphocytes in vitro and in vivo, EVL has several side effects, such as delayed wound healing and an increase in bacterial infection. During combined treatment of chemotherapy and rituximab, B-PTLDs are sometimes associated with life-threatening complications, such as intestinal perforation and cardiogenic shock due to cytokine release syndrome. In HTx children especially treated with EVL, stoma should be made to avoid reoperation or sepsis in case of intestinal perforation. In cases with cardiac graft dysfunction possibly due to cytokine release syndrome by chemotherapy with rituximab for PTLD, plasma exchange is effective to restore cardiac function and to rescue the patients.
Collapse
Affiliation(s)
- Norihide Fukushima
- Department of Therapeutics Strategies for End Organ Dysfunction, Osaka University Graduate School of Medicine, Japan
| |
Collapse
|
|
20
|
Colonic perforation after rituximab treatment for posttransplant lymphoproliferative disorder. J Pediatr Gastroenterol Nutr 2013; 56:e41. [PMID: 22395186 DOI: 10.1097/mpg.0b013e3182519cfc] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
|
21
|
Surgical management of gastrointestinal posttransplant lymphoproliferative disorders in liver transplant recipients. Transplantation 2012; 94:417-23. [PMID: 22820701 DOI: 10.1097/tp.0b013e3182584854] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Posttransplant lymphoproliferative disorder (PTLD) is a well-established complication of immunosuppression. The involvement of the gastrointestinal (GI) tract occurs in 25% of all cases of PTLD. Fortunately, surgical intervention is seldom required. We report our experience of surgical treatment of complicated GI-PTLD after liver transplantation (LTx). METHODS A retrospective analysis of 5677 adult patients who underwent LTx between 1983 and 2009 was conducted. RESULTS Thirty-six patients presented with GI-PTLD. Sixteen patients presented with complications associated with GI-PTLD requiring emergency surgery. The average (SD) time from LTx to GI surgery was 7.9 (5.8) years (range, 4 months to 17 years). Indications for surgical intervention were small bowel obstruction (seven cases), perforation (six cases), and GI bleeding (three cases). Most GI-PTLD occurred in the small bowel or right colon (81%). In addition to the surgery, treatment of PTLD consisted of reduction of immunosuppression, use of rituximab (n=10), and systemic chemotherapy (n=7). Overall mortality was 69%, with most of the deaths occurring within 8 months after emergency laparotomy. GI bleeding and perforation were associated with higher mortality (>66%). Despite higher early mortality in the surgical group, no differences on long-term outcome were observed between patients with GI-PTLD who required surgery and those who did not (P=0.371). CONCLUSIONS In summary, GI-PTLD requiring surgical intervention is an extremely rare condition with high early mortality. Most of the cases are monoclonal, present a late onset, and involve the lower GI tract. Intestinal obstruction is the main indication for surgical intervention and is associated with better prognosis.
Collapse
|
|
22
|
Rubbert-Roth A. Assessing the safety of biologic agents in patients with rheumatoid arthritis. Rheumatology (Oxford) 2012; 51 Suppl 5:v38-47. [PMID: 22718926 DOI: 10.1093/rheumatology/kes114] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Biologic treatments--including five TNF-α inhibitors, the IL-1 receptor antagonist anakinra, the IL-6 receptor inhibitor tocilizumab, the selective inhibitor of T-cell co-stimulation abatacept and the B-cell-directed mAb rituximab--have provided effective therapeutic options for patients with RA with inadequate response to conventional DMARDs. However, the fact that these agents are immune modulators has raised safety concerns, prompting careful evaluation in clinical trials and intensive post-marketing surveillance. Serious infections may arise, and diagnosis may be delayed by an atypical spectrum of signs and symptoms. Patients may experience reactivation of latent tuberculosis, hepatitis B or C or opportunistic infections. RA is a risk factor for cancer, and biologic therapy may modestly increase the risk of lymphoma and some solid tumours beyond background. During biologic therapy, demyelinating disorders of the CNS have been noted, and pre-existing disease manifestations may be aggravated. Hepatic transaminase levels may increase, although these elevations are usually mild to moderate, transient and without clinical consequence. Hyperlipidaemia, which is responsive to lipid-lowering therapy, may develop, and patients with congestive heart failure may experience symptom exacerbation. Safe use of biologic agents requires thorough risk assessment of potential candidates for treatment and careful monitoring during and after therapy.
Collapse
Affiliation(s)
- Andrea Rubbert-Roth
- Department of Internal Medicine I, University of Cologne, Josef-Stelzmann-Strasse 9, 50924 Cologne, Germany.
| |
Collapse
|
|
23
|
Kasi PM, Tawbi HA, Oddis CV, Kulkarni HS. Clinical review: Serious adverse events associated with the use of rituximab - a critical care perspective. Crit Care 2012; 16:231. [PMID: 22967460 PMCID: PMC3580676 DOI: 10.1186/cc11304] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The advent of biologic agents has provided a more specific and targeted approach to the treatment of various hematological malignancies and other autoimmune disorders. Such biologic agents have been relatively well tolerated with fewer adverse events reported as compared with many other chemotherapeutic agents. Rituximab is a monoclonal antibody to the B-cell marker CD20 and is a common biologic agent widely used for the treatment of B-cell lymphoma, lymphoproliferative disorders, and inflammatory conditions that are refractory to conventional treatment, including rheumatoid arthritis and some vasculitides. However, through randomized controlled trials and post-marketing surveillance, an increasing number of serious adverse events are being associated with the use of rituximab, often leading to or complicating an intensive care unit admission. The purpose of this review is to focus on the severe complications that are associated with the use of rituximab and that require critical care. Management and prevention strategies for the most common complications along with some examples of its uses within the critical care setting are also discussed.
Collapse
|