Much caution does no harm! Organophosphate poisoning often causes pancreatitis
Tóm tắt
Organophosphate poisoning (OP) results in various poisoning symptoms due to its strong inhibitory effect on cholinesterase. One of the occasional complications of OP is pancreatitis. A 62-year-old woman drank alcohol and went home at midnight. After she quarreled with her husband and drank 100 ml of malathion, a parasympathomimetic organophosphate that binds irreversibly to cholinesterase, she was transported to our hospital in an ambulance. On admission, activated charcoal, magnesium citrate, and pralidoxime methiodide (PAM) were used for decontamination after gastric lavage. Abdominal computed tomography detected edema of the small intestine and colon with doubtful bowel ischemia, and acute pancreatitis was suspected. Arterial blood gas analysis revealed severe lactic acidosis. The Ranson score was 6 and the APACHE II (Acute Physiology and Chronic Health Evaluation) score was 14. Based on these findings, severe acute pancreatitis was diagnosed. One day after admission, hemodiafiltration (HDF) was started for the treatment of acute pancreatitis. On the third hospital day, OP symptoms were exacerbated, with muscarinic manifestations including bradycardia and hypersalivation and decreased plasma cholinesterase activity. Atropine was given and the symptoms improved. The patient’s general condition including hemodynamic status improved. Pancreatitis was attenuated by 5 days of HDF. Ultimately, it took 14 days for acute pancreatitis to improve, and the patient discharged on hospital day 32. Generally, acute pancreatitis associated with OP is mild. In fact, one previous report showed that the influence of organophosphates on the pancreas disappears in approximately 72 hours, and complicated acute pancreatitis often improves in 4–5 days. However, it was necessary to treat pancreatitis for more than 2 weeks in this case. Therefore, organophosphate-associated pancreatitis due to malathion is more severe. Although OP sometime causes severe necrotic pancreatitis or pancreatic pseudocysts, it was thought that the present patient had a good clinical course without these complications due to the appropriate intensive care including nafamostat, antibiotics, fluid resuscitation, and HDF. In conclusion, OP-associated pancreatitis requires careful assessment because it may be aggravated, as in this case.
Tài liệu tham khảo
Dressel TD, Goodale Jr RL, Arneson MA, Borner JW. Pancreatitis as a complication of anticholinesterase insecticide intoxication. Ann Surg. 1979;189(2):199–204.
Dagli AJ, Shaikh WA. Pancreatic involvement in malathion–anticholinesterase insecticide intoxication. A study of 75 cases. Br J Clin Pract. 1983;37(7–8):270–2.
Weizman Z, Sofer S. Acute pancreatitis in children with anticholinesterase insecticide intoxication. Pediatrics. 1992;90(2 Pt 1):204–6.
Sahin I, Onbasi K, Sahin H, Karakaya C, Ustun Y, Noyan T. The prevalence of pancreatitis in organophosphate poisonings. Hum Exp Toxicol. 2002;21(4):175–7.
Moore PG, James OF. Acute pancreatitis induced by acute organophosphate poisoning. Postgrad Med J. 1981;57(672):660–2.
Lee WC, Yang CC, Deng JF, Wu ML, Ger J, Lin HC, et al. The clinical significance of hyperamylasemia in organophosphate poisoning. J Toxicol Clin Toxicol. 1998;36(7):673–81.
Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974;139(1):69–81.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818–29.
Edwards D. “Reregistration Eligibility Decision for Malathion”. US Environmental Protection Agency - Prevention, Pesticides and Toxic Substances EPA 738-R-06-030 journal: 9. 2006.
Marsh WH, Vukov GA, Conradi EC. Acute pancreatitis after cutaneous exposure to an organophosphate insecticide. Am J Gastroenterol. 1988;83(10):1158–60.
Panieri E, Krige JE, Bornman PC, Linton DM. Severe necrotizing pancreatitis caused by organophosphate poisoning. J Clin Gastroenterol. 1997;25(2):463–5.
Kawabe K, Ito T, Arita Y, Sadamoto Y, Harada N, Yamaguchi K, et al. Pancreatic pseudocyst after acute organophosphate poisoning. Fukuoka Igaku Zasshi. 2006;97(4):123–9.
Zamir DL, Novis BN. Organophosphate poisoning and necrotizing pancreatitis. Isr J Med Sci. 1994;30(11):855–6.
Makrides C, Koukouvas M, Achillews G, Tsikkos S, Vounou E, Symeonides M, et al. Methomyl-induced severe acute pancreatitis: possible etiological association. JOP. 2005;6(2):166–71.
Lambert H. Electrocardiographic changes in acute pancreatitis. Cardiologia. 1966;48(4):387–90.
Challan Belval A, Cheron A, Floccard B, Lienhart AS, Allaouchiche B. Acute pancreatitis and bradycardia. Ann Fr Anesth Reanim. 2010;29(2):159–61. doi:10.1016/j.annfar.2009.10.020.