A Woman Couldn’t Sleep For 9 Days. This Is What Happened To Her Colon.


A Woman Couldn’t Sleep for 9 Days. The medicine she used to help her sleep was
less than optimal. This Is What Happened To Her Colon. JD is a 27 year old woman, presenting to the
emergency room, unconscious. Her boyfriend Jeff tells the admitting nurse
at admission that she had been awake for the last 48 hours before complaining of severe
nausea. You see, JD had been experiencing a strange
insomnia over the past 7 months. Some nights she would lay in bed, tossing
and turning while hearing the morning traffic build up in her window. Some mornings, she would dreadfully watch the
sun rise. Without sleep, her quality of life began to
rapidly deteriorate. She was an attorney, and her job performance
began to suffer, as she would have trouble making court dates. She began losing interest in her hobbies and
her relationship began to suffer as she blamed Jeff for the insomnia, but even after his
absence, her sleep trouble worsened. 10 years ago, JD was diagnosed with a mild
depression. She was started on a low dose of quetiapine,
with good results and never missed a dose nor had any complaints about it. About 3 months ago, JD began trying supplements
to help her sleep. Some nights, she’d sleep great, and others,
she’d be wide awake for 2 consecutive nights, exhausted by the third day. Some supplements, became many supplements. She’d mix and match, and take much more
than she needed until finally, nothing worked. She consulted a neurologist for her problems,
who prescribed her cognitive behavioral therapy, but in it, she found limited success. She finally moved on to over the counter medication. She started taking the PM branding of a drug
named diphenhydramine, which helps with allergies but also makes one drowsy. It helped her sleep every night for a whole
week, but she noticed that the medicine would give her not only stomach pain, but also constipation. Sometimes, she’d sit for 30 minutes, with
limited movement, but finally being able to sleep gave her new life. Inevitably, the insomnia came back. JD began to escalate the dose each night until
she would take 4 to 5 times the recommended dose each night to sleep just a few hours,
before waking up unrefreshed and exhausted. One evening, she was at dinner with Jeff. She barely ate. She told him that she hadn’t had a bowel
movement nor slept more than just a few hours for 9 days. He stayed with her over night to make sure
she’d be ok. Her skin became pale as she started complaining
of nausea and stomach pain. Jeff fell asleep but as he woke up, he found
her laying on her side, in a pool of cold sweat, huddled up and unresponsive. In a panic, he called 911 and she was brought
to the emergency room where we are now. Given this history of present illness, there
are several clues as to what’s happening. At physical examination, JD was immediately
identified to be in shock. Her blood pressure was low and her heart,
to compensate for this hypotension, was beating at 150 beats per minute, 3 times that of average. And she was completely unresponsive. An abdominal CT scan finds that JD has Acute
Megacolon. Mega meaning enlargement and referring to
the dilatation of the colon, or the large intestines Acute meaning that there are no underlying
pathophysiologic conditions that are leading to this problem except for the massive doses
of diphenhydramine JD consumed for her sleep, which leads us to the first clue. Diphenhydramine is an allergy medicine. In most parts of the body, it blocks the chemical
named histamine which is responsible for most common allergic reactions, like itching from
mosquito bites, and sneezing from pollen. But in the brain, diphenhydramine blocks a
different chemical that transmits signals. This means that small amounts leads to mild
sedation, helping with sleep, but by affecting the brain and its nerves, diphenhydramine
also slows down the digestive system, which receives signals from the brain. Large amounts of diphenhydramine can lead
to an almost complete stoppage of the digestive system which brings us back to the name of
JD’s condition Acute Megacolon. If she had no bowel movements for 9 days,
and CT scan did not reveal any mechanical obstructions in her colon, then it means nothing
was specifically blocking the way in her intestines. But if that’s the case, then why is her
colon dilated? Why is it megacolon? Well, there’s a few things to be known here. First, the stomach and intestines form their
own set of nerves called the enteric nervous system, sometimes called the second brain. This “second brain,” controls the muscles of
your bowel and cannot be actively controlled by you, meaning you can’t force your stomach
to contract at will like you can your biceps. But if the first brain in the head and the
second brain in the gut both use the same chemicals to transmit signals along the nerves,
and JD’s sleep medicine diphenhydramine blocks the chemicals from transmitting signals
in those nerves, then it means that high doses of JD’s sleep medicine were slowing down
her gut to a high degree. Inside the colon, because the digestive system
is a giant tube from your mouth to the other end, the pressure stays constant within, meaning
that if one part is dilated, the pressure has more or less, stayed the same and hasn’t
dropped. This means that the tension at the wall of
the dilated segment is elevated, and as the colon keeps slowing down from high doses of
diphenhydramine, and as tension keeps building up, then blood can’t flow through it, meaning
those blood vessels will begin to crush up against the sides of the wall, starving the
tissue of oxygen as it slowly begins to necrose, or quite literally die. This necrotic tissue begins to lose it’s
muscular integrity, and as time continued through JD’s abdominal pain and distention
starting from several days ago, the walls of her colon began to weaken so much, that
they finally perforated, spilling her intestinal contents into her peritoneal cavity, causing
bacteria from the gut to spill into her blood stream, as they begin to flow freely, all
throughout her body. Just like how when you get an infection on
your skin it becomes swollen, red and warm, an infection that spreads into your blood
causes your entire body to become “swollen,” which translates to the body sending white
blood cells systemically, promoting inflammation. Because JD’s situation isn’t self-limiting,
meaning it isn’t containing itself, her blood vessels have begun to vasodilate, causing
her blood pressure to drop. Her heart detects this and begins to beat
faster in order to compensate for the loss in pressure so that her organs can still receive
blood, but as her brain starts to lose oxygen, JD loses consciousness. This dramatic escalation in signs and symptoms
due to colonic perforation is known as septic shock and means almost imminent death in JD’s
case, if treatment isn’t initiated within the next few minutes. The notion of motor dysfunction in the gastrointestinal
system is a persistent underlying theme that has far reaching implications when it comes
to seemingly unrelated causes of disease in humans. Opioids for pain control in the hospital can
often cause gastric hypomotility. This is a time when constipation becomes a
common occurrence leading to fecal impaction. If the patient is elderly and doesn’t receive
a stool softener, then it means they will have to strain to pass a movement. If they strain hard enough, their heart will
temporarily stop and they can rupture blood vessels in the brain causing a stroke, which
leads to cerebral vasospasm days later, which can starve the brain of oxygen leading to brain damage. In the case of gastroesophageal reflux disease,
stomach acid commonly splashes into the esophagus, which isn’t equipped to handle the low pH. While laying down, this acid can enter the
bronchioles of the lungs and trigger asthma as well as damage the larynx and erode the
enamel of the teeth. The integrity of the esophageal mucus membrane
is disrupted and the cells are damaged, leading to Barrett’s Esophagus which predisposes
the patient to esophageal cancer, which can then undergo a malignant transformation and then spread
all throughout the body. A common inflammatory bowel disease known
as Crohn’s Disease affects any part of the digestive tract, at all layers of the bowel
walls. This is a state of mucosal inflammation that
can seep into the smooth muscle of the colon, paralyzing it, causing it to dilate. The deep ulcerated parts of the intestines
begin to degenerate and necrose as white blood cells begin to swell into the tissue, causing
it to rupture, giving way to toxic megacolon, a more chronic condition with an underlying
pathophysiology compared to JD’s acute megacolon. Her history of present illness all point to
this. The prior stomach pain. The nausea. The high doses of diphenhydramine in a desperate
attempt to finally fall asleep. Since the onset of shock appears to be relatively
recent, it may not yet be too late for her, she could still be resuscitated. The first line of treatment is to remove the
source of bacteria spreading into her blood. She is admitted immediately to surgery and
at laparotomy, or incision into the abdominal cavity, massive colonic distention was found
with evidence of perforation. Her small intestines, and distal parts of
her rectum were found to be viable and her entire colon was removed. Admission into the intensive care unit led
to immediate initiation of antibiotics and early goal-directed resuscitation as her condition
began to stabilize over the following days. The final thing to note here, is that JD’s
condition sould have been easily caught by any health care provider, at any point. Diphenhydramine as a medicine is a well known
anti-cholinergic. If a cholinergic does things like promote
smooth muscle movement in the digestive system and promote a “rest and digest” state
of the body, then an anti-cholinergic prevents digestive system movement. Do you remember that quetiapine that JD was
taking for her depression? Well, quetiapine is also a well known anti-cholinergic,
meaning the dangerous dual blockade of diphenhydramine in large, prohibited doses in combination
with quetiapine, which also exhibits anti-dopaminergic and anti-serotonergic activity, both important
neurotransmitters in “both” brains, virtually stopped her digestive system from moving completely,
and caused her colon to swell, crushing the blood vessels, starving it of oxygen and causing
the walls to perforate, leaking enteric contents including gut bacteria into her blood. JD’s anticholinergic excess, produced from
a drug interaction that should have been caught by physicians, nurses and the pharmacist at
the store where she bought the medicine, caused this set of symptoms. Luckily for her, it wasn’t too late to begin
early goal directed resuscitation in the intensive care unit, and over a few weeks, her septic
shock was resolved as she regained consciousness, and her gut was surgically anastomosed, or
rejoined together, without her colon. And upon arriving home, a good nights sleep
in her own bed, was waiting for her. Thank you so much for watching. Take care of yourself. And Be well.

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