Abdominal Crises

Several reasons for the occurrence of this symptom have been discussed. A rapid increase in size of liver and spleen precipitated by fatty meals or otherwise may be one possible cause of the abdominal colics resulting in stretching of the capsule of these organs. In Holt s case, 8 gm per 100 ml appeared to be a critical level for serum lipids with values above this level abdominal crises occurred frequently. An alternative explanation for these acute episodes would be the occurrence of recurrent pancreatitis as has been discussed repeatedly in the literature. This aspect will be considered below. A third possible cause in some cases may be impaired oxygen supply to the intestines as has been postulated by Kuo et al. (1959) and others for the myocardium, resulting in a kind of intermittent claudication of the bowel. 

However, when transient lipemia occurs during the course of acute pancreatitis, as documented by Brunner (1935) and Marcus (1937), and abdominal episodes far precede hyperlipemia (Joel 1924), it appears proper to consider such hyperlipemia secondary to pancreatitis (Thannhauser 1950). This concept is supported by the animal experiments of Binet and Brocq (1929) and others. For further discussion of experimental aspects of the subject we refer to Schettler (1955, Handbuch pg. 724—725). 

At present it appears best to evaluate both possibilities at the bedside of each case of hyperlipemia with abdominal symptoms, and support the diagnosis of either EHL or pancreatitis as the primary disease with data from personal history, family history and by observation of the course of hyperglyceridemia. 

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In spite of differences in pathogenesis of the various forms of EHL it is possible to consider their clinical manifestations together since the majority of signs and symptoms seem to vary only in a quantitative manner between syndromes. This, as well as the frequency of asymptomatic cases of EHL, indicates that at least the manifestations of lipemia retinalis, xanthomatosis and probably hepatospleno-megaly and abdominal crises are the results of the lipid elevation rather than primary expressions of the underlying pathogenetic mechanisms. Other evidence for the non-specificity of eruptive xanthomas and lipemia retinalis is their occurrence in secondary hyperlipemias (e.g. diabetic ketoacidosis). 

The clinical picture typically features the appearance of xanthomas (eruptive and/or tuberous) and occasionally abdominal crises which may be mistaken for acute surgical emergencies. On the other hand, asymptomatic cases are not rare. 

Acute adrenal hemorrhage, either unilateral (17) or bilateral (18), has been observed repeatedly after corticotropin administration, and causes an acute abdominal crisis. Although it is usually seen in children, hemorrhage can also occur in adults (SEDA-17, 451). 

Overdose may result in cholinergic crisis, characterized by severe nausea, increased salivation, diaphoresis, bradycardia, hypotension, flushed skin, abdominal pain, respiratory depression, seizures, and cardiorespiratory collapse, increasing muscle weakness may result in death if respiratory muscles are involved. The antidote is 1 -2 mg IV atropine sulfate with subsequent doses based on therapeutic response. 

Overdose produces a cholinergic crisis manifested as abdominal discomfort or cramps, nausea, vomiting, diarrhea, flushing, facial warmth, excessive salivation, diaphoresis, lacrimation, pallor, bradycardia or tachycardia, hypotension, bron-chospasm, urinary urgency, blurred vision, miosis, and fasciculation (involuntary muscular contractions visible under the skin). 

These patients may also exhibit symptoms of excessive stimulation of muscarinic receptors (abdominal cramps, diarrhea, increased salivation, excessive bronchial secretions, miosis, bradycardia). Small doses of edrophonium (1-2 mg intravenously) will produce no relief or even worsen weakness if the patient is receiving excessive cholinesterase inhibitor therapy. On the other hand, if the patient improves with edrophonium, an increase in cholinesterase inhibitor dosage may be indicated. Clinical situations in which severe myasthenia (myasthenic crisis) must be distinguished from excessive drug therapy (cholinergic crisis) usually occur in very ill myasthenic patients and must be managed in hospital with adequate emergency support systems (eg, mechanical ventilators) available. 

An 87-year-old woman received intra-articular betamethasone (Diprophos) 7 mg on three occasions for painful knee joints over 6 months. Six weeks after the last injection she developed diffuse pain and contractures in the legs, fatigue, nausea, abdominal pain, and weight loss of 6 kg. Both knee joints were tender but there was no effusion. Her serum sodium concentration was 123 mmol/1, serum osmolality 254 mosmol/kg, urine sodium 136 mmol/1, and urinary osmolality 373 mosmol/kg. The syndrome of inappropriate antidiuretic hormone secretion was diagnosed, but despite treatment she remained drowsy and hyponatremic. About a week later, she developed hypotension and symptoms of an acute abdomen. Further investigations showed that her basal cortisol concentration was low (36 nmol/1) but it increased to 481 nmol/1 after a short tetracosactide test, consistent with acute adrenal crisis. She recovered rapidly after treatment with oral hydrocortisone, but still required glucocorticoid substitution several months later. 

A 62-year-old hypertensive man with renal artery stenosis, an adrenal adenoma, peripheral artery disease, and an abdominal aortic aneurysm developed a hypertensive crisis with chest pain. He was treated with nitrates, heparin, aspirin, and nicardipine, which were afterwards replaced by diltiazem 200 mg/day, because of persistent chest pain. He developed atrioventricular block 2 hours after the second dose of diltiazem, and was successfully treated with a pacemaker. 

Cholelithiasis is a common occurrence in the SCD patient. It is the result of the chronic hemolysis that results in increased bilirubin production, leading to biliary sludge and/or stone formation. Cholecystitis, exemplified by pain in the right iliac fossa, can be confused with abdominal pain crisis. ... 

Bethanechol (see structure above), the carbamate analogue of methacholine, is selective tor muscarinic receptors and exhibits almost no activity at nicotinic receptors, it is used to treat postsurgical and postpartum urinary retention and abdominal distention. Bethanechol is administered orally, because there is danger of a cholinergic crisis if it is given by intravenous or intramuscular injection. 

Acute intermittent porphyria was first described in Sweden by Waldenstrom. The disease manifests itself in the form of a crisis during which the patient has porphyria, acute abdominal pains, and a complex neurological syndrome. The attacks are precipitated... 

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