Clozapine-induced acute gastrointestinal necrosis: a case report

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.

Diagnosis and management of acute esophageal necrosis

“…This hemodynamic state may be aggravated by the presence of disseminated infection, since there are cases of AEN associated with positive blood cultures, including bacteremia from Escherichia coli [24,62], Klebsiella oxytoca [62], Staphylococcus aureus [60], or fungemia from Candida glabrata [8].…”

“…Several drugs have also been implicated in the pathogenesis of AEN, including non-steroidal anti-inflammatory drugs (NSAID) [10], antihypertensive agents [36], bismuth subsalicylate [88], terlipressin [79], cocaine [89], cefazolin [60], alendronate [90], haloperidol [91], clozapine [62,92], olanzapine [92], and afatinib [77]. The association between these drugs and black esophagus may be related to several mechanisms.…”

Atypical Presentation of Acquired Hypoganglionosis in a Patient Taking Clozapine

“…Despite a large body of literature on clozapine-related ileus, there is a scarcity of data describing the histopathology of this disease [16]. ere are numerous reports of fatal clozapine-related ileus in the literature [17]. It is thought that clozapine significantly reduces gastrointestinal motility primarily by affecting the peripheral muscarinic anticholinergic activity via the M3 receptors in the gut wall [7].…”

“…There are numerous reports of fatal clozapine-related ileus in the literature [ 17 ]. It is thought that clozapine significantly reduces gastrointestinal motility primarily by affecting the peripheral muscarinic anticholinergic activity via the M3 receptors in the gut wall [ 7 ].…”

Comprehensive review of acute oesophageal necrosis

“…Of these cases, we managed to extract data from 79 articles having 105 cases of AON (online supplementary table 1). 5–82 Data could not be extracted from (n=13) of the articles containing a total of (n=20) cases 4 83–95. The most common reasons for these were unavailability of complete data or the language being other than English.…”