Severe abdominal pain, blood in the stool many times, did not expect the real murderer to be this common medicine?

It is only for medical professionals to read for reference.
There are too many causes of abdominal pain! I hope that through the study of today’s case, patients who encounter sudden abdominal pain and blood in the stool of unknown cause in clinical practice, don’t forget to ask for medication history
.

Severe abdominal pain, three analgesic injections, the patient still screamed in pain? At the morning shift, the doctor on duty told me with a sad face that the newly admitted patient had severe abdominal pain, and three painkillers last night did not solve the problem
.

The head nurse also said that the patient was yelling in pain, so I hurry up and have a look
.

The patient is a middle-aged woman, usually in good health, without a history of gastrointestinal disease, and had abdominal pain and blood in the stool 2 days ago without any obvious cause
.

This time, the onset was very acute, with severe abdominal pain, and the pain was located around the belly button.
There was no obvious positive sign on physical examination
.

The patient had blood in the stool several times after abdominal pain, all of which were dark red bloody stools, without adhesion of mucus and pus
.

Is it abdominal pain and blood in the stool caused by ischemic bowel disease? However, this patient does not have high blood pressure, coronary heart disease, diabetes and constipation and other basic diseases that are likely to cause ischemic bowel disease, and abdominal CT showed that the patient’s ascending colon and transverse colon were diffusely thickened and swollen, which is not the result of ischemic bowel disease.
Prevalent site
.

Enhanced CT of the abdomen also ruled out mesenteric vascular thrombosis or embolic disease
.

2021-01-02 Abdominal CT scan scans the ascending colon and transverse colon diffusely thickened and swelled, the proximal bowel is not significantly expanded, and the surrounding fat gap is not an ischemic disease.
Why is there such severe colon swelling and blood in the stool? Is it an infection? Why are there no obvious abnormalities in the blood routine and C-reactive protein indicators that reflect inflammation at the onset? How to diagnose the cause of abdominal pain? In order to clarify the diagnosis of the patient, we carefully asked the medical history and learned that the patient took amoxicillin on his own due to pharyngeal discomfort one week before the onset.
The abdominal pain this time appeared 3 days after the drug was stopped
.

After 3 days of stopping amoxicillin, abdominal pain and blood in the stool occurred, and the lesions mainly involved the right colon.
Is it related to the application of amoxicillin? 2021-01-02 Abdominal CT plain scan MPR antibiotic-associated hemorrhagic enteritis is a rare disease.
It has been reported in foreign literature as early as the 1970s and 1980s, but it is rarely reported in China
.

Antibiotic-related hemorrhagic enteritis is mainly caused by oral amoxicillin and penicillin derivatives.
It may be a specific toxic reaction caused by penicillin components, or it may be related to the high sensitivity of the intestinal mucosa to drugs
.

Amoxicillin, or amoxicillin, is an oral broad-spectrum antibiotic.
Common adverse reactions are allergic reactions, skin rashes and gastrointestinal reactions such as nausea, vomiting, abdominal distension and diarrhea
.

Hemorrhagic colitis caused by amoxicillin is a rare complication of amoxicillin.
The clinical manifestations are bloody diarrhea with or without abdominal cramps
.

After 2021-01-07 treatment, Chinese scholars have found that the common feature of patients with amoxicillin-related hemorrhagic enteritis is the rapid onset of the disease, but the rapid recovery of the disease
.

Most patients develop symptoms about 2-3 days (maximum 5 days) after using amoxicillin.
After 3-5 days, the colonoscopy can completely return to normal.
Most of the patients' lesions are mainly right hemicolon lesions
.

Our patient had an acute onset, which appeared after 3 days of amoxicillin, and the lesions were mainly right hemicolon lesions
.

No infection of Clostridium difficile was found in stool culture, only a small amount of Candida albicans was cultivated, but flora imbalance was found
.

Without special treatment, just 3 days after the combined use of the two probiotics, the patient’s symptoms disappeared completely.
A re-examination of the abdominal CT showed that the inflammation of the colon was significantly improved
.

Unfortunately, although we tried our best to mobilize patients to undergo colonoscopy, patients did not accept it
.

The stool culture report does not have a specific diagnostic method for amoxicillin-related hemorrhagic enteritis.
It is necessary to rule out infectious diarrhea, necrotizing enteritis, ischemic colitis, inflammatory bowel disease, allergic purpura and other diseases.
Early colonoscopy is helpful To assist in diagnosis
.

However, some scholars believe that the disease has various manifestations, and early enteroscopy and barium enema are not necessary diagnostic methods.
If symptoms do not relieve 2-3 days after stopping the drug, invasive examination should be performed
.

Although our patient does not undergo colonoscopy, he can clearly diagnose amoxicillin-related hemorrhagic enteritis through typical symptoms and medication history, the disappearance of symptoms 3 days after stopping the medication, the characteristics of imaging recovery, and the results of stool culture
.

For elderly patients, amoxicillin-related hemorrhagic enteritis and ischemic enteritis must be distinguished
.

Professor Liu Yulan, a well-known digestive expert in China, summarized the main points of differentiation between amoxicillin-related hemorrhagic enteritis and ischemic enteritis, which is very helpful in the diagnosis of these two diseases
.

Table: Differentiation of amoxicillin-associated hemorrhagic enteritis from ischemic enteritis In general, the common characteristics of amoxicillin-associated hemorrhagic enteritis patients are rapid onset and rapid recovery
.

Clinically, if you encounter sudden abdominal pain and bloody stools of unknown cause, you should ask for medication history, especially the history of antibiotic use, so as to avoid missed diagnosis of amoxicillin-related hemorrhagic enteritis
.

Reference materials: [1]CGC 2020|Professor Liu Yulan: Pay attention to the cause of hemorrhagic enteritis-amoxicillin
.

Yimaitong Gastroenterology, 2020-11-11.
[2] Hamada Y, Tanaka K, Yamada R, Takei Y.
Hemorrhagic Colitis Induced by Second-line Helicobacter pylori Eradication.
Intern Med.
2020;59(2):301- 302.
[3] Wang Xuemei, Liu Yulan, Zhang Guoyan, Xiao Wenbin.
Clinical and endoscopic characteristics of antibiotic-associated hemorrhagic enteritis.
China Journal of Endoscopy, 2004,10(1):1-4.
[4]Moulis H, Vender RJ .
Antibiotic-associated hemorrhagic colitis.
J Clin Gastroenterol, 1994, 18: 227-231.
[5] Liu Ensheng, Li Yuzhen, Yang Shiwei.
Two cases of amoxicillin-induced hemorrhagic colitis.
Journal of Adverse Drug Reactions, 2002,4(5): 334-335.