We report the case of a 34-year-old woman with severe post-infectious gastroparesis who was transferred from an outside medical facility for a second opinion regarding management. This patient had no prior history of gastrointestinal symptoms. However, in the aftermath of a viral illness, she developed two months of intractable nausea, vomiting, and oral intake intolerance that resulted in numerous hospitalizations for dehydration and electrolyte disturbances. A solid-phase gastric emptying scan had confirmed delayed emptying, confirming gastroparesis. Unfortunately, conventional pro-kinetic agents and numerous anti-emetic drugs provided little or no relief of the patient's symptoms. At our institution, the patient experienced a cessation of vomiting, reported a significant reduction in nausea, and tolerated oral intake shortly after taking mirtazapine. Based on mirtazapine's primary action as a serotonin (5-HT) 1a receptor agonist, we infer that this receptor system mediated the clinical improvement through a combination of peripheral and central neural mechanisms. This report highlights the potential utility of 5-HT1a agonists in the management of nausea and vomiting. We conclude that mirtazapine may be effective in treating symptoms associated with non-diabetic gastroparesis that are refractory to conventional therapies.
The authors report two unusual cases of Bickerstaff encephalitis that presented with encephalopathy and severe agitation. Management with neuroleptics typically used for management of delirium was not effective and worsened agitation. Valproic acid was effective in treatment of agitation and well tolerated.
We are presenting the first documented case of lithium toxicity after vertical sleeve gastrectomy surgery in an 18 year-old female with psychiatric history of bipolar disorder who was treated with lithium. This case illustrates the need for closer monitoring of lithium levels following bariatric surgery. Both psychiatrists and surgeons should be aware of the potential risk of lithium toxicity following bariatric surgery, as well as the need to judiciously monitor lithium level and possibly adjust the dose of some medications.
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