Small-intestinal necrosis due to non-occlusive mesenteric ischemia with diabetic ketoacidosis after quetiapine treatment

Abstract

We report a 66-year-old male who developed diabetic ketoacidosis (DKA) and necrosis of the small intestine due to nonocclusive mesenteric ischemia (NOMI), 3 months after starting quetiapine treatment. He was transferred to our hospital and diagnosed as diabetic for the first time, associated with DKA. Despite improvement in DKA, abdominal pain worsened gradually 10 h after hospitalization. Computed tomography (CT) revealed bowel emphysema, and gas out of the gut wall, in the mesenteric veins and the intrahepatic portal vein, suggesting intestinal necrosis. He survived because of resection of necrotic small-intestinal tissue and he finally required no diabetes treatment. Mesenteric arteries were patent with good palpitation without occlusion or thrombosis, and pathological findings showed ischemic enteritis, which is consistent with NOMI. DKA is a rare but serious side effect of second-generation antipsychotic medications (SGAMs) such as quetiapine, which can result in NOMI: a life-threatening complication. We must keep in mind that the plasma glucose concentration may increase in patients taking SGAMs, or that NOMI may occur concurrently if DKA develops.

Nonocclusive mesenteric ischemia associated with a hyperosmolar hyperglycemic state: Hepatic portal venous gas as an indicator of mesenteric ischemia

“…However, we found no report on NOMI associated with HHS published in English after a thorough search of PubMed using the following keywords: hyperosmotic hyperglycemic nonketotic state, hyperosmolar hyperglycemic state, diabetic ketoacidosis, diabetes, and nonocclusive mesenteric ischemia. In this search, NOMI associated with DKA was also rare, as we only found four case reports 6–9 . The rarity of published works on NOMI with HHS could be explained as follows.…”

“…In this search, NOMI associated with DKA was also rare, as we only found four case reports. [6][7][8][9] The rarity of published works on NOMI with HHS could be explained as follows. First, according to the National Diabetes Statistics Report (2020) by the Centers for Disease Control and Prevention, it was reported that the frequency of HHS patients admitted to the emergency department was much lower than in DKA patients (HHS, 0.9/1,000 adults with diabetes versus DKA, 8.8/1,000 adults with diabetes).…”

Recurrent bowel necrosis from non-occlusive mesenteric ischemia induced by diabetes ketoacidosis in an adult patient causing mortality: a rare cause of mortality associated with poorly controlled diabetes in adults

“…Signs of dehydration, hypotension, tachycardia and tachypnoea are the typical findings of physical examination. 3 Abdominal pain can present in 40-75% of DKA cases due to various reasons, and the prevalence of abdominal pain rises with acidosis in the blood. 3 Non-occlusive mesenteric ischemia (NOMI) is a known rare complication of DKA that can present with severe abdominal pain, which can cause necrosis of the small bowel and large bowel due to sudden volume depletion, causing severe morbidity and mortality.…”

“…3 Abdominal pain can present in 40-75% of DKA cases due to various reasons, and the prevalence of abdominal pain rises with acidosis in the blood. 3 Non-occlusive mesenteric ischemia (NOMI) is a known rare complication of DKA that can present with severe abdominal pain, which can cause necrosis of the small bowel and large bowel due to sudden volume depletion, causing severe morbidity and mortality. 3,4 Literature suggests DKA with NOMI is common in children with T1DM, and they have a good prognosis after the treatment.…”

“…3 Non-occlusive mesenteric ischemia (NOMI) is a known rare complication of DKA that can present with severe abdominal pain, which can cause necrosis of the small bowel and large bowel due to sudden volume depletion, causing severe morbidity and mortality. 3,4 Literature suggests DKA with NOMI is common in children with T1DM, and they have a good prognosis after the treatment. [4][5][6] We present a case of recurrent bowel necrosis with NOMI from DKA in an adult with poorly controlled insulin-dependent T2DM causing mortality.…”