LETTERS
Moderately Severe Acute Pancreatitis Associated With Riluzole To the Editor: Compared with other causes, drugs represent a relatively less common cause of acute pancreatitis. However, >500 different drugs have been described by the WHO as able to induce acute pancreatitis as a side effect.1 Riluzole, a tetrodotoxin-sensitive sodium channel blocker, is the only medication approved by the Food and Drug Administration for the treatment of amyotrophic lateral sclerosis (ALS), showing a reduction of mortality in patients affected. Common side effects are nausea, epigastric pain, diarrhea or constipation, and an increase in the level of liver enzymes.2 Riluzole has only been associated with mild acute pancreatic damage in a few studies.3,4 Herein, we report a case of moderately severe acute pancreatitis associated with riluzole treatment. A 79-year-old man was admitted to our hospital because of severe upper abdominal pain and vomiting. He had no history of alcohol consumption, biliary stones, diabetes, trauma, hypercalcemia, hyperlipidemia, previous acute pancreatitis (AP), chronic pancreatitis, or familiarity for pancreatic diseases. He was being treated for years with irbesartan because of arterial hypertension. Three months before the patient started treatment with riluzole (50 mg tid) because of a diagnosis of ALS. On physical examination, he showed a normal body weight (body mass index = 22.1), with no signs of jaundice. Body temperature was 97.341F, heart rate was 76 bpm, and the blood pressure was 152/94 mm Hg. The abdomen was tender, although with no signs of peritoneal irritability. Laboratory analyses showed a deep increase in serum amylase (1298 U/L, normal r100 U/L) and lipase levels (1650 U/L, normal range 13 to 63 U/L), moderate leukocytosis
Editor’s note: The Board feels this is very important information that should be published but with the caveat that the Board notes the authors had strong suspicion of cause but did not challenge and so the cause was not absolutely established. The authors declare that they have nothing to disclose.
J Clin Gastroenterol
TO THE
EDITOR
(15.750/mm3), mild anemia (hemoglobin 12.5 g/dL), and a mild respiratory alkalosis. AP was therefore diagnosed. Total and direct bilirubin, c-glutamyl transpeptidase, alkaline phosphatase, as well as serum lipids and calcium levels, were all within the normal range. Screening for autoantibodies and infectious diseases was negative. Acute Physiology and Chronic Health Evaluation (APACHE II) Score was 9. A computed tomography scan performed 72 hours from the onset of the symptoms showed a mild swelling of the pancreatic body and tail and a focal necrotic area in the distal portion of the tail. AP was classified as moderately severe, according to the revised Atlanta Classification.5 Riluzole treatment was stopped, and symptoms disappeared rapidly. The patient was treated by fasting, parenteral nutrition, carbapenems, and proton pump inhibitors. After 7 days, serum pancreatic enzymes returned to within normal range, as well as peripheral white cell count. According to the Naranjo probability scale, AP was classified as probably caused by riluzole (Naranjo Score 7/13).6 rbesartan has also been described as able to induce pancreatitis approximately 2 weeks after its first administration,7 but the patient had been taking this drug for years before and ameliorated without stopping it. We did not attempt a rechallenge with riluzole; therefore, so the definite evidence for its association with AP is not available. To our knowledge, this is the first described case of moderately severe AP associated with riluzole treatment. As AP can be a life-threatening disease, the possibility of such a side effect, although rare, should be considered in patients treated with riluzole, although this is the main therapeutic option for ALS. Therefore, the management of such cases may be challenging, requiring a close multidisciplinary collaboration between neurologists and gastroenterologists. Gianluca Ianiro, Giovanni Cammarota, Alessandro Milani, Marco Mettimano, Antonio Gasbarrini,
MD MD MD MD MD
Gastroenterology Unit, Catholic University of Sacred Heart, “A. Gemelli” University Hospital, Largo Gemelli, Rome, Italy
2. Miller RG, Mitchell JD, Moore DH. Riluzole for amyotrophic lateral sclerosis (ALS)/motor neuron disease (MND). Cochrane Database Syst Rev. 2012;3:CD001447. 3. Rodrigo L, Moreno M, Calleja S, et al. Riluzole-induced acute pancreatitis. Am J Gastroenterol. 2001;96:2268–2269. 4. Drory VE, Sidi I, Korczyn AD. Riluzoleinduced pancreatitis. Neurology. 1999;52: 892–893. 5. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–111. 6. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30:239–245. 7. Famularo G, Minisola G, Nicotra GC, et al. Acute pancreatitis associated with irbesartan therapy. Pancreas. 2005;31: 294–295.
Gastrohepatic Fistula as a Complication of Laparoscopic Radiofrequency Liver Ablation in a Patient With Intrahepatic Cholangiocarcinoma To the Editor: Cholangiocarcinoma is a rare malignancy that arises from mutated epithelial cells of the intrahepatic bile duct, extrahepatic bile duct, or hilar bifurcation. Cholangiocarcinoma has a very poor prognosis, and operative treatment remains the only option for a potential cure. Intrahepatic cholangiocarcinoma is generally treated by hepatic resection. Without surgery, a major complication of cholangiocarcinoma is fistula formation into adjacent hollow viscera. There have been several previous reports of extrahepatic cholangiocarcinoma fistula formation involving the stomach,1 duodenum,2 and pancreas3 and one report of extrahepatic cholangiocarcinoma fistula involving the liver.4 Herein, we report what we believe is to be the first reported case of gastrohepatic fistula as a complication of radiofrequency liver ablation for cholangiocarcinoma and only the second
REFERENCES 1. Nitsche C, Maertin S, Scheiber J, et al. Drug-induced pancreatitis. Curr Gastroenterol Rep. 2012;14:131–138.
Volume 48, Number 6, July 2014
The authors declare that they have nothing to disclose.
www.jcge.com |
563
Moderately Severe Acute Pancreatitis Associated With Riluzole To the Editor: Compared with other causes, drugs represent a relatively less common cause of acute pancreatitis. However, >500 different drugs have been described by the WHO as able to induce acute pancreatitis as a side effect.1 Riluzole, a tetrodotoxin-sensitive sodium channel blocker, is the only medication approved by the Food and Drug Administration for the treatment of amyotrophic lateral sclerosis (ALS), showing a reduction of mortality in patients affected. Common side effects are nausea, epigastric pain, diarrhea or constipation, and an increase in the level of liver enzymes.2 Riluzole has only been associated with mild acute pancreatic damage in a few studies.3,4 Herein, we report a case of moderately severe acute pancreatitis associated with riluzole treatment. A 79-year-old man was admitted to our hospital because of severe upper abdominal pain and vomiting. He had no history of alcohol consumption, biliary stones, diabetes, trauma, hypercalcemia, hyperlipidemia, previous acute pancreatitis (AP), chronic pancreatitis, or familiarity for pancreatic diseases. He was being treated for years with irbesartan because of arterial hypertension. Three months before the patient started treatment with riluzole (50 mg tid) because of a diagnosis of ALS. On physical examination, he showed a normal body weight (body mass index = 22.1), with no signs of jaundice. Body temperature was 97.341F, heart rate was 76 bpm, and the blood pressure was 152/94 mm Hg. The abdomen was tender, although with no signs of peritoneal irritability. Laboratory analyses showed a deep increase in serum amylase (1298 U/L, normal r100 U/L) and lipase levels (1650 U/L, normal range 13 to 63 U/L), moderate leukocytosis
Editor’s note: The Board feels this is very important information that should be published but with the caveat that the Board notes the authors had strong suspicion of cause but did not challenge and so the cause was not absolutely established. The authors declare that they have nothing to disclose.
J Clin Gastroenterol
TO THE
EDITOR
(15.750/mm3), mild anemia (hemoglobin 12.5 g/dL), and a mild respiratory alkalosis. AP was therefore diagnosed. Total and direct bilirubin, c-glutamyl transpeptidase, alkaline phosphatase, as well as serum lipids and calcium levels, were all within the normal range. Screening for autoantibodies and infectious diseases was negative. Acute Physiology and Chronic Health Evaluation (APACHE II) Score was 9. A computed tomography scan performed 72 hours from the onset of the symptoms showed a mild swelling of the pancreatic body and tail and a focal necrotic area in the distal portion of the tail. AP was classified as moderately severe, according to the revised Atlanta Classification.5 Riluzole treatment was stopped, and symptoms disappeared rapidly. The patient was treated by fasting, parenteral nutrition, carbapenems, and proton pump inhibitors. After 7 days, serum pancreatic enzymes returned to within normal range, as well as peripheral white cell count. According to the Naranjo probability scale, AP was classified as probably caused by riluzole (Naranjo Score 7/13).6 rbesartan has also been described as able to induce pancreatitis approximately 2 weeks after its first administration,7 but the patient had been taking this drug for years before and ameliorated without stopping it. We did not attempt a rechallenge with riluzole; therefore, so the definite evidence for its association with AP is not available. To our knowledge, this is the first described case of moderately severe AP associated with riluzole treatment. As AP can be a life-threatening disease, the possibility of such a side effect, although rare, should be considered in patients treated with riluzole, although this is the main therapeutic option for ALS. Therefore, the management of such cases may be challenging, requiring a close multidisciplinary collaboration between neurologists and gastroenterologists. Gianluca Ianiro, Giovanni Cammarota, Alessandro Milani, Marco Mettimano, Antonio Gasbarrini,
MD MD MD MD MD
Gastroenterology Unit, Catholic University of Sacred Heart, “A. Gemelli” University Hospital, Largo Gemelli, Rome, Italy
2. Miller RG, Mitchell JD, Moore DH. Riluzole for amyotrophic lateral sclerosis (ALS)/motor neuron disease (MND). Cochrane Database Syst Rev. 2012;3:CD001447. 3. Rodrigo L, Moreno M, Calleja S, et al. Riluzole-induced acute pancreatitis. Am J Gastroenterol. 2001;96:2268–2269. 4. Drory VE, Sidi I, Korczyn AD. Riluzoleinduced pancreatitis. Neurology. 1999;52: 892–893. 5. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–111. 6. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30:239–245. 7. Famularo G, Minisola G, Nicotra GC, et al. Acute pancreatitis associated with irbesartan therapy. Pancreas. 2005;31: 294–295.
Gastrohepatic Fistula as a Complication of Laparoscopic Radiofrequency Liver Ablation in a Patient With Intrahepatic Cholangiocarcinoma To the Editor: Cholangiocarcinoma is a rare malignancy that arises from mutated epithelial cells of the intrahepatic bile duct, extrahepatic bile duct, or hilar bifurcation. Cholangiocarcinoma has a very poor prognosis, and operative treatment remains the only option for a potential cure. Intrahepatic cholangiocarcinoma is generally treated by hepatic resection. Without surgery, a major complication of cholangiocarcinoma is fistula formation into adjacent hollow viscera. There have been several previous reports of extrahepatic cholangiocarcinoma fistula formation involving the stomach,1 duodenum,2 and pancreas3 and one report of extrahepatic cholangiocarcinoma fistula involving the liver.4 Herein, we report what we believe is to be the first reported case of gastrohepatic fistula as a complication of radiofrequency liver ablation for cholangiocarcinoma and only the second
REFERENCES 1. Nitsche C, Maertin S, Scheiber J, et al. Drug-induced pancreatitis. Curr Gastroenterol Rep. 2012;14:131–138.
Volume 48, Number 6, July 2014
The authors declare that they have nothing to disclose.
www.jcge.com |
563
