嘔吐 Angioedema ACEI

THINK LIKE A DOCTOR NOVEMBER 7, 2013, 8:00 AM 307 Comments

Think Like a Doctor: Gut Feeling

Think Like a Doctor: Gut Feeling http://nyti.ms/17GGGPC

By LISA SANDERS, M.D

The red line indicates the amount of swelling in the colon.

這是一個困難的病例，一位47歲的女性患者，高血壓、糖尿病，近2年來一直為偶發性的嚴重的嘔吐所擾，遍尋名醫，也找不出為什麼，後來找出答案了，把這病史貼在New York Times 網站考一下大家（美國的大眾真是強？）不過答對的人，大多是醫療背景者，有些是住院醫師等。

突發嚴重嘔吐，白血球稍高，胃鏡無異常，後來做到腹部的CT和大腸鏡，看到腸道水腫（還被疑是Crohn's disease），外科醫師做了剖腹探查（negative！真是白痛了）。治療上，給予抗生素和點滴，感覺和台灣也是一樣。

在一次的再度住院時會診，腸胃科fellow（是fellow沒錯！）建議再做一次abdominal CT with contrast（上次做是36小時前在ER做的，若是在台灣健保下，36小時後，再做另一次abdominal CT，這個腸胃科醫師真是有GUTS）。

為什麼要立即再F/U abdominal CT？因為患者住院後1天後，症狀立即改善了，GI man想了解腸道是否有變化（水腫消失了嗎？），結果，如上二張CT圖比較，右圖後來F/U的，腸道水腫快速消失。

原因？是她拿來治高血壓的藥，lisinopril所引起的angioedema。

以下原文，讓大家參考這個不常見的名詞angioedema，但是我想，有這些症狀的患者，應該也在台灣存在，會不會被當作精神病患者或是情勢障礙啊？

The correct diagnosis is…

Intestinal angioedema, triggered by lisinopril, the ACE inhibitor the patient took for her high blood pressure.

The Diagnosis:

Angioedema is a localized type of swelling usually involving the mouth, tongue or upper airways. It can be part of a typical allergic reaction, with hives and itching, or it can be isolated, with swelling as the only notable finding. While there is an inherited form of this disease, most cases are acquired. And medications are the most common cause of this form of the syndrome.

The class of high blood pressure drugs known as ACE inhibitors is the most common medication linked to angioedema. This patient was taking lisinopril, one of the most widely prescribed drugs of these drugs. Although angioedema usually arises when the medication is first started, it can occur at any point during a patient’s treatment.

African Americans are at a particularly high risk of this strange drug reaction. Up to one in 30 African Americans who take an ACE inhibitor will develop angioedema at some point. Women are also at somewhat higher risk than men.

And it’s not just this class of medication. Painkillers such as ibuprofen and certain antibiotics are also listed as relatively frequent causes of angioedema. Indeed, there’s a whole long list of drugs that have been linked to this unusual reaction.

A Rare Gut Problem:

Usually the swelling of angioedema is seen in the face: the lips, tongue or throat. And the swelling can be quite dramatic, occasionally completely blocking the upper airways.

However, this patient had a rare form of the problem that arose not in the face but in the intestine. When swelling occurs in the gut, it can block off the intestinal lumen and bring digestion to a screeching halt, causing the terrible pain and vomiting this patient experienced.

Remarkably, no matter where in the body the swelling occurs, or how severe it gets, it always resolves quickly – often within hours – even if the patient continues to take the medication.

When the angioedema happens in the G.I. tract, the diagnosis can be delayed for months or years because so many doctors don’t know that this kind of reaction is even possible. When the medication is stopped, the episodic reaction also finally stops.

How the Diagnosis Was Made:

It was both the rapid resolution of the patient’s symptoms and CT scan abnormalities that provided the essential clue in this case. Dr. Ajaypal Singh was the G.I. fellow who was consulted to help figure out the cause of the patient’s pain. Once he saw the repeat CT scan, which — much to his astonishment — was nearly normal, the diagnosis was rapid. There are simply not very many diseases that will turn around this fast.

Dr. Singh immediately called Dr. Poonam Merai, the resident on call that day at the University of Chicago Medical Center, and told her that he thought this was a reaction to the patient’s blood pressure medication.

He also recommended that the patient be tested for the inherited version of the disease. If the patient had this unusual genetic disorder, stopping the medications would not prevent the attacks of pain and vomiting. Those tests were normal.

The patient was amazed to hear that this pill she’d been taking for years was the cause of her pain. Once the doctors explained it to her, though, a light went off and the intermittent nature of her attacks suddenly made sense.

You see, one thing she hadn’t told any of her doctors was that she often stopped that medication when her blood pressure seemed O.K. She had a blood pressure cuff at home and monitored it closely. She exercised regularly — she knew that brought her blood pressure down. And she tried to follow a low sodium, high potassium diet. When she did both, her blood pressure was usually well under the 140/90 measurement she knew was her target.

And she always restarted the drug when her blood pressure started to go up. That was usually predictable, occurring when she “fell off the wagon” and stopped her exercise and diet routine. Now that she thought about it, most of these episodes arose weeks after restarting her lisinopril.

How the Patient Is Doing:

The patient was given an alternative blood pressure medication and happily stopped taking her lisinopril forever. It has been six months now, and so far, so good. She is keeping her fingers crossed, but at this point it looks like a remarkably simple solution to a terribly painful problem.