INTRODUCTION: “Intussusception” is a term initially used by the Scottish surgeon, Dr. John Hunter in 1789 which means invaginating or telescoping. It is caused by any condition that disrupts the normal physiological mechanism of intestinal peristalsis. Intussusception in adults is rare with incidence of 2-3 cases per population of 1000000 annually. The most common cause of intussusception in adults is neoplasms. CASE DESCRIPTION/METHODS: 22-year-old female, with multiple past episodes of abdominal pain and vomiting, presented with one day duration of sudden onset worsening abdominal pain, vomiting and diarrhea. The stools were black but without tarry clots or frank blood. She also had four episodes of non-bilious and non-bloody emesis. Of note, she had more than one year history of extensive marijuana use. Upon presentation, her vitals were unremarkable. Physical exam was pertinent for diffuse abdominal tenderness without guarding or rebound. Initial labs were unremarkable except for an elevated lactic acid level (4.6 Mmol/L). Pregnancy test was negative. Patient received anti-emetics, proton pump inhibitor and IV fluids. She then underwent a CT scan of the abdomen and pelvis which revealed a small bowel intussusception in the left hemiabdomen. She was made NPO and subsequently underwent both upper endoscopy and colonoscopy which were normal. She was treated conservatively with bowel rest, anti-emetics and IV fluids. She gradually improved with resolution of symptoms on day four of hospital stay. Her intussusception had resolved on a follow up small bowel series. She was discharged home with outpatient Gastroenterology follow up. DISCUSSION: There is enough evidence to support that cannabis acts on several segments of the bowel. It has been demonstrated that interaction through inhibition of intrinsic cholinergic mechanisms can result in cannabis-induced inhibition of gastrointestinal motility. Fernández-Atutxa et al. and Olga et al. presented a 3 patient case series and a case report respectively with clinical presentation similar to our patient. These patients were diagnosed with intussusception with no apparent organic cause but had a history of extensive marijuana use. Our case presentation is intended to pay attention to adverse effects of cannabis in light of increasing legalization and increasing therapeutic use of cannabis and its derivatives.

INTRODUCTION: Dronedarone is frequently employed for rhythm control in patients with atrial fibrillation (AF). Chronic therapy with Dronedarone has been associated with mild liver enzymes elevations in up to 12% of patients. There are also several reports of dronedarone induced Acute Renal Failure (ARF) on Adverse Drug Reaction reporting databases worldwide. CASE DESCRIPTION/METHODS: An 86-year-old male with past history of AF, COPD, CKD and HTN presented with 1 day duration of dyspnea and palpitations. He was found to be in AF with rapid ventricular response with a heart rate of 127. Vitals were otherwise stable. He was also suspected to have acute on chronic diastolic CHF likely precipitated by atrial fibrillation. Initial labs were pertinent for creatinine of 2.02 (baseline-1.60). Patient was initially started on Diltiazem drip in the ED which was later discontinued due to an IV site reaction. Upon transfer to the medical floor, Cardiology was consulted who recommended Dronedarone for rhythm control. Patient received a total of 3 doses of Dronedarone but did not cardiovert, therefore electrical cardioversion was performed. He developed fatigue few hours after the cardioversion. Liver function tests (LFTs) one day after the last dose of dronedarone and post cardioversion showed elevated ALT (3155), AST (3930), Alkaline Phosphatase (144), total (2.4) and direct (1.0) bilirubin levels. INR was also high (6.1). Viral hepatitis testing was negative. The patient's course was further complicated by acute renal failure (ARF) with creatinine rising to 5.38. Dronedarone mediated hepatic and renal injury was suspected. Dronedarone was discontinued and supportive measures were initiated. Patient's LFTs and creatinine trended down with improvement of symptoms four days following discontinuation of Dronedarone. Patient was discharged home with complete resolution of hepatic and renal failure noted during outpatient follow up. DISCUSSION: Dronedarone mediated acute liver toxicity is rare. Almost none of the cases involved rapid onset of liver injury after drug initiation, which resolved quickly after cessation of the agent. The onset of injury in reported cases ranged from 2 to 11 months. Besides reports on pharmacovigilance databases, two cases of dronedarone-associated ARF have also been published, one of which required hemodialysis. Only one of these cases reported a combined hepatic and renal failure. Our case is unique due to its early onset and severe features with concurrent involvement of both organ systems.

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