Clozapine-induced acute gastrointestinal necrosis: a case report

Mark T Osterman,Isaac Matthias,Caitlin Foley

doi:10.1186/s13256-017-1447-4

Mark T Osterman, Isaac Matthias + Show 1 more

Open Access

https://doi.org/10.1186/s13256-017-1447-4

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Abstract

BackgroundClozapine is known to cause fecal impaction and ileus with resultant colonic necrosis due to compression of colonic mucosa. There are rare reports of clozapine causing necrosis of other portions of the gastrointestinal tract unrelated to constipation. We describe a case of acute necrosis of the upper gastrointestinal tract and small bowel to due to clozapine and quetiapine.Case presentationA 66-year-old white man with a past medical history of schizophrenia, maintained on clozapine and quetiapine, presented with hypoxic respiratory failure caused by aspiration of feculent emesis due to impacted stool throughout his colon. His constipation resolved with discontinuation of clozapine and quetiapine, and his clinical condition improved. These medicines were restarted after 2 weeks, resulting in acute gastrointestinal necrosis from the mid esophagus through his entire small bowel. He died due to septic shock with Gram-negative rod bacteremia.ConclusionsClozapine may cause acute gastrointestinal necrosis.

Highlights

Clozapine is known to cause fecal impaction and ileus with resultant colonic necrosis due to compression of colonic mucosa
Constipation due to antipsychotics can progress to severe pathology such as ileus, fecal impaction, aspiration of feculent emesis, and colonic ischemia due to compression of colonic mucosa [2]
We present a case of a patient who developed acute necrosis of the esophagus, stomach, and small bowel shortly after clozapine re-initiation

Summary

Background

Constipation is a common side effect of antipsychotic medicines, and is attributed to their anticholinergic properties [1]. Case presentation A 66-year-old white man with a history of schizophrenia presented to our emergency department with acute altered mental status and feculent emesis His abdomen was distended but not tender. Clozapine and quetiapine, were held, and after manual disimpaction and enemas he had copious bowel movements and resolution of abdominal distension. An urgent esophagogastroduodenoscopy (EGD) was performed, showing transition from normal mucosa in the proximal esophagus to severe diffuse ulceration beginning in the mid esophagus (Fig. 2a), with continued severe ulceration throughout the distal esophagus (Fig. 2b), stomach (Fig. 2c), and duodenum (Fig. 2d) He developed progressive septic shock, and blood cultures grew Escherichia coli and Klebsiella oxytoca.

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