Serotonin Syndrome in a Patient on Trazodone and Duloxetine Who Received Fentanyl following a Percutaneous Liver Biopsy.

Serotonin syndrome is a rare but potentially life-threatening adverse drug reaction resulting from the use or overuse of serotonergic medications alone or in combination. Mild symptoms, overlapping features with similar conditions and clinician lack of awareness are the major reasons for an often missed diagnosis. Not surprisingly, this condition is significantly underreported as a potential complication of endoscopy if serotonergic medications are used periprocedurally for sedation and analgesia. Here we report the case of a patient with relapsed chronic hepatitis C on antidepressant medications who developed signs and symptoms of serotonin syndrome after a percutaneous liver biopsy. Review of the patient's medication list suggested a possible interaction between her home antidepressants and the post-procedure use of fentanyl for abdominal pain. The patient required monitoring in the medical intensive care unit and stabilized after the administration of benzodiazepines and temporary discontinuation of her home medications. We propose that clinicians need to be aware of the increased risk of serotonin syndrome in the outpatient endoscopy setting, particularly with the wider use of serotonergic antidepressants now available and the repeated number of liver biopsies being performed for management of patients with chronic liver disease.

Endoscopic and radiographic evaluation of the small bowel in 2012.

Traditionally, the diagnosis of small bowel disorders has been challenging secondary to the small intestine's length, tortuosity, and anatomic location. Recent technologic advancements in the field of enteroscopy and radiographic imaging have facilitated a more thorough endoscopic evaluation of patients with small bowel disease ranging from obscure gastrointestinal bleeding to inflammatory bowel disease and small bowel tumors. Such developments have made it possible to avoid invasive surgical procedures in certain clinical scenarios where they were previously the gold standard. In this review, we report an update on the diagnostic and management approach to patients with small bowel disease, emphasizing the advantages and limitations of the latest modalities now available to primary care physicians and gastroenterologists for evaluating patients with presumed disease of the small intestine.

Splenic Injury and ERCP: A Possible Risk for Patients with Advanced Chronic Pancreatitis.

Splenic injury is a rare but potentially life-threatening complication of endoscopy, with very few cases of endoscopic retrograde cholangiopancreatography (ERCP)-induced injury reported in the literature. Here we report a patient with chronic alcoholic pancreatitis who was diagnosed with a sub-capsular splenic laceration nearly 6 days after an ERCP. Clinicians should be alerted to the potential post-procedure complications associated with ERCP, particularly as this procedure is being utilized more frequently for the management of patients with complex hepatobiliary and pancreatic conditions.