Hypermagnesemia is a well-known cause of hypotension and cardiac dysfunction but not well recognized is the induction of paralytic ileus. This report details the second and third adult patients reported with hypermagnesemia-induced paralytic ileus. The first patient was a 65-year-old white woman with normal renal function, who had consumed large amounts of magnesium citrate and milk of magnesia. As magnesium blood level fell from 5.1 mg/dl on admission to 2.4 mg/dl on day 3, the vomiting, obstipation, and abdominal distension resolved. The second patient was a 67-year-old woman with mild renal insufficiency, who consumed a large amount of Epsom salts containing magnesium sulfate to treat her constipation. Magnesium levels of 8.1 mg/dl on admission fell to below 3.1 mg/dl on the third hospital day and the paralytic ileus resolved. Mechanical obstruction was ruled out by colonoscopy, gastrographin enema, and barium small bowel series in both patients. Although the clinical findings of muscle weakness, flaccid paralysis, respiratory muscle paralysis or cardiac arrest due to hypermagnesemia are well described in the literature, intestinal smooth muscle dysfunction leading to paralytic ileus has only been reported in one other adult patient. The laboratory and clinical course of these two patients strongly suggest a causal relationship between hypermagnesemia and paralytic ileus.
In the past 10 years, 163 patients with documented gastric ulcers were treated at Vanderbilt University and Metropolitan Nashville General Hospitals. One hundred thirty-five were initially managed medically. Medical therapy was successful in 58 patients (43%) in this group. Twenty-eight (17%) patients required surgical treatment initially. An additional 77 patients (57%) became candidates for surgical management when their medical management failed. Of this group, 40 now have been surgically treated and 37 still have symptoms while on medical treatment. Three patients being treated for benign ulcers, two for as long as six years each, were found to have carcinoma of the stomach diagnosed by subsequent endoscopy and biopsy in one and by laparotomy with gastrectomy to include the ulcer in two. We consider subtotal gastrectomy or surgical resection of the antrum, including the ulcer site, to be the preferred surgical treatment for gastric ulcers, and this was done in 50 cases. Vagotomy was done in addition to the antrectomy in 31 of these, and in addition to the subtotal resection in 11. Two patients who had vagotomy and resection subsequently developed a marginal ulcer. One of these who had a subtotal resection and vagotomy healed with medical treatment. The one who had a vagotomy and antrectomy required a second vagotomy for a missed vagus nerve. Gastrointestinal endoscopy in the past 10 years has improved to the point that very few malignant ulcers are missed by endoscopic biopsy. Large ulcers, those that perforate or continue to bleed, and those that fail to heal on medical treatment for a maximum of 2 to 3 months should be submitted to an antrectomy that includes the ulcer. Vagotomy should be added in selected cases.
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