Multiple spontaneous small bowel perforations due to clozapine-Case report.

INTRODUCTION: Spontaneous free perforation of the small bowel is unusual. There are many causes of spontaneous small bowel free perforation such as: immune-mediated or inflammatory, infections, drugs and biological agents, congenital, metabolic, vascular and neoplasm. A severe adverse effect of antipsychotic drugs is intestinal ischemia, which could lead to perforation. CASE PRESENTATION: The authors report the clinical case of a 42-year-old schizophrenic patient, smoker, medicated with clozapine 600 mg per day, admitted to the emergency room with diffuse abdominal pain. On physical examination the patient presented abdominal rebound tenderness and peritoneal sign with raised inflammation markers and the abdominal tomography revealed pneumoperitoneum. An emergency laparotomy revealed multiple jejunal and ileal perforations. The patient was subject to small bowel resection complicated with anastomosis dehiscence, respiratory tract infection and intra-abdominal abscess. Histologic specimens showed nonspecific inflammatory findings with ischemia. The main infectious, inflammatory, congenital, auto-immune and vascular causes of spontaneous perforations were excluded. DISCUSSION: Spontaneous free perforation of the small bowel is uncommon. An intestinal ischemia might be a rare adverse effect of antipsychotics. However, only colon perforations due to ischemic colitis are described in the literature. While diagnosis of the precise cause might be challenging, and after excluding other causes, these perforations may be attributed to an adverse effect of clozapine. CONCLUSION: The cause was attributed to clozapine as the other etiologies were excluded. The clozapine's reintroduction is controversial. In this case the clozapine dose was reduced successfully.

Surgical clips as a nidus for stone formation in the common bile duct.

We report the case of a 40-year-old woman who presented with symptomatic gallbladder stones. A laparoscopic cholecystectomy was performed using metallic clips. Three years later, she underwent a endoscopic retrograde cholangiopancreatography (ERCP) for interscapular and right upper quadrant pain, jaundice, and fever. This examination revealed a stone and clips in the common bile duct (CBD). A sphinteroctomy was undertaken, but the stone could not be extracted despite multiple attempts. Ultimately, a Kocher incision was required to achieve choledocotomy and extraction of the stone and the clips.