Gastric Ulceration and Bleeding with Hemodynamic Instability Caused by an Intragastric Balloon for Weight Loss

Obesity in the United States is a medical crisis with many people attempting to lose weight with caloric restriction. Some patients choose minimally invasive weight loss solutions, such as intragastric balloon systems. These balloon systems were approved by the Federal Drug Administration (FDA) in 2015–2016 and have been considered safe, with minimal side effects. We report a patient with a two-day history of melena, abdominal pain, hypotension, and syncope which developed five months after placement of an intragastric balloon. Esophagogastroduodenoscopy with balloon removal revealed a small 8-mm gastric ulcer in the incisura. This gastric ulcer probably developed secondary to mechanical compression of the stomach mucosa by the gastric balloon which contained 900 mL of saline. The FDA is now investigating five deaths since 2016 associated with these second-generation balloons. Clinicians should be aware of these complications when evaluating patients with gastrointestinal complications, such as bleeding

Acute respiratory distress syndrome, metabolic acidosis, and respiratory acidosis associated with citalopram overdose

We report a 53-year-old man who ingested 2400 mg of citalopram and presented to the emergency department three hours post-ingestion with altered mental status, somnolence, and a blood pressure of 67/45 mmHg. He failed to respond to three boluses of normal saline (1000 ml each) and required vasopressors. The patient developed serotonin syndrome with hyper-reflexia, rigidity, and ankle myoclonus. He had a tonic-clonic seizure in the ER requiring intravenous lorazepam and phenytoin. An ECG showed QT prolongation. Chest x-ray on presentation was normal. Within 32 hours the patient developed acute respiratory distress, hypoxemia, a wide A-a gradient, PaO2/FiO2< 200, and chest x-ray changes compatible with acute respiratory distress syndrome (ARDS). He had normal central venous pressures, normal cardiac biomarkers, normal systolic and diastolic functions on echocardiography, and no acute ST/T wave changes. His ABG showed a metabolic acidosis and a respiratory acidosis. The patient required intubation and ventilation. Citalopram has been associated with seizures and ECG abnormalities after overdoses. The respiratory complications and metabolic acidosis have been reported only a few times in the literature.  We are reporting the second case of ARDS and the fifth case of metabolic acidosis due to citalopram overdose and suggest that the metabolic acidemia is explained by propionic acid. The respiratory acidosis seen in this patient has not been reported previously

Gastric Ulceration and Bleeding with Hemodynamic Instability Caused by an Intragastric Balloon for Weight Loss

Obesity in the United States is a medical crisis with many people attempting to lose weight with caloric restriction. Some patients choose minimally invasive weight loss solutions, such as intragastric balloon systems. These balloon systems were approved by the Federal Drug Administration (FDA) in 2015–2016 and have been considered safe, with minimal side effects. We report a patient with a two-day history of melena, abdominal pain, hypotension, and syncope which developed five months after placement of an intragastric balloon. Esophagogastroduodenoscopy with balloon removal revealed a small 8-mm gastric ulcer in the incisura. This gastric ulcer probably developed secondary to mechanical compression of the stomach mucosa by the gastric balloon which contained 900 mL of saline. The FDA is now investigating five deaths since 2016 associated with these second-generation balloons. Clinicians should be aware of these complications when evaluating patients with gastrointestinal complications, such as bleeding

The association between blood glucose levels and hospital outcomes in patients admitted with acute exacerbations of chronic obstructive pulmonary disease

Patients with acute exacerbations of chronic obstructive pulmonary disease usually require an escalation in medical management and often require hospitalization.  The outcomes from these episodes depend on the severity of the underlying chronic lung disease, the degree of acute respiratory failure superimposed on the chronic lung disease, comorbidity, and possibly hospital related complications. Hyperglycemia represents an independent risk factor for hospital associated complications and/or mortality in other medical diagnoses, such as stroke and acute myocardial infarction.  Recent studies in patients with acute exacerbations of COPD demonstrate that hyperglycemia is associated with an increased length of hospital stay, failure of noninvasive ventilation, and/or mortality. Acute stress and medications used with an acute flare, such as glucocorticoids and beta agonists, increase blood glucose levels.   The explanation for poor outcomes likely involves an increase in colonization with pathogenic bacteria, acute changes in host defenses, and possibly metabolic disorders related to hyperglycemia and glycosuria.  Patients with acute stress and glucocorticoid related hyperglycemia often have higher blood glucose levels in the afternoon and early evening.  Consequently, this problem may be overlooked if clinicians depend on routine a.m. laboratory tests.  Therefore, patients with acute flares in COPD should have bedside point of care glucose measurements during the early course of their hospitalizations.  Patients with high glucose levels require nutritional management and/or insulin treatment.  We need more prospective studies to determine the degree of hyperglycemia in these patients, the acute consequences, and the best management strategies