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Postgrad Med J: first published as 10.1136/pgmj.58.681.451 on 1 July 1982. Downloaded from

Postgraduate Medical Journal (July 1982) 58, 451-453

Atropine and paralytic ileus NEIL BEATSON M.B., B.S. Department of Surgery, Royal South Hants Hospital, Southampton

Summary Biochemical and haematological investigations were all unremarkable. Plain X-rays of the abdomen A patient who developed paralytic ileus while on showed massive dilatation of stomach and small atropine therapy is described, and this complication intestine (Fig. 1). of atropine-like drugs is reviewed. All drugs were stopped and conservative treatment was commenced with nasogastric aspiration and Introduction intravenous fluid replacement. By the fourth day Drugs are an important cause ofparalytic ileus and after admission the patient was much improved, failure to recognize this may lead to unnecessary taking oral fluids, having a normal bowel action and laparotomy. Atropine is an anti-muscarinic alkaloid much more alert. and its action in decreasing the motility ofintestine is Repeat plain abdominal X-rays showed the bowel well known. to have been decompressed. The patient was recom- menced on his minus the However, paralytic ileus as a complication of previous copyright. atropine therapy has not to my knowledge previously atropine. been reported. Case report Discussion A 77-year-old man was admitted from a nearby George (1980) has recently reviewed drugs causing geriatric unit with a 24-hr history of and intestinal obstruction and mentions that atropine-like epigastric pain. He had previously been well, al- compounds do not usually give rise to problems, though limited by Parkinson's which was except in overdose or when combined with an opiate. http://pmj.bmj.com/ controlled with Sinemet 275 (levodopa and carbi- Indeed, standard textbooks of pharmacology suggest dopa) one tablet daily. that the dosage of atropine necessary to suppress the For the previous 4 months, distressing excessive motility of the is greater than salivation had been successfully treated with 0.6 mg that necessary either to block salivary secretion or atropine sulphate daily given orally. He was also increase the heart rate. taking bendrofluazide 5 mg daily, slow K 2 tablets However, earlier literature suggests that often the and indomethacin 25 twice and the of do not a daily mg daily. dosage length therapy play on September 26, 2021 by guest. Protected He had not demonstrated any signs of excessive significant part in the development of the ileus for activity before his present illness and ganglion blocking drugs (Munster and Milton, 1961) occasionally had needed Lomotil (atropine and or (Milner and Buckler, 1964). The case diphenoxylate) for bouts of loose bowel motions described here would appear to support this view. which were not thought to be significant. Anti-cholinergic activity is a property of many Examination revealed a withdrawn, dehydrated drugs and most notably the tricyclic anti-depressants patient with a slightly distended abdomen and absent have been reported as causing paralytic ileus (Milner bowel sounds. He showed tenderness without guard- and Buckler, 1964; Milner and Hills, 1966). ing in the epigastrium. There were no other demon- Phenothiazines, specifically chlorpromazine, are strable signs of atropine poisoning; his heart rate was also a recognized cause, thought to be due to their regular 56 per min. The pupils were not dilated, the weak atropinic properties (Sriram et al., 1979). skin was of normal temperature and colour and his However, with this latter group of drugs it is thought mental state, although depressed, was thought to be that the development of the ileus is dose related, as it due to the combination ofhis Parkinson's disease and is most often seen in the mentally disturbed patient dehydration. who may be on huge doses of chlorpromazine. 0032-5473/82/0700-0451 $02.00 © 1982 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.58.681.451 on 1 July 1982. Downloaded from

452 Clinical reports

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FIG. 1. supine abdominal X-ray showing dilatation of stomach and small bowel. http://pmj.bmj.com/ , another neuroleptic drug has also been concomitant anti-cholinergic therapy being taken by incriminated (Maltbie et al., 1981). Phenothiazines the patient on admission. may also act to cause ileus via their anti-histaminic Treatment of established anti-cholinergic induced properties. Histamine is thought to act directly or ileus is conservative, as in this case. Little has been indirectly to stimulate gastrointestinal motility published on the effect of the use of anti-cholinester- (George, 1980), although with one exception (Wat- ase drugs such as neostigmine in these patients, son, Knutty and Colclough, the H2 antagonists although Sriram et al. (1979) have had some success 1977) on September 26, 2021 by guest. Protected have not been incriminated. Parkinson's disease itself with these drugs and it would seem sound practice to may cause (Simpson, 1978), and thus institute such therapy. patients receiving anticholinergic therapy for Parkin- son's disease are more prone to ileus by the very nature of their disease (Daggett and Ibrahim, 1976). Acknowledgments Atropinic properties of drugs are therefore an I should like to thank Mr A. D. B. Chant for permission to report important cause of paralytic ileus. This may be an on his patient, Professor C. F. George for his encouragement and idiosyncratic phenomenon as well as dose related, or Mrs S. E. Gough and Miss L. G. Jennings for the typing of the it may occur when in combination with other drugs manuscript. predisposing to bowel immobility, such as opiates. Some drugs, most notably the mono-amine oxidase References inhibitors, prolong the detoxification of anti-cholin- DAGGETT, P. & IBRAHIM, S.Z. (1976) Intestinal obstruction compli- ergic drugs and account should also be taken of this cating orphenadrine treatment. British Medical Journal, 1, 21. (Goodman and Gilman, 1980). GEORGE, C.F. (1980) Drugs causing intestinal obstruction: a review. Postoperatively ileus may be prolonged due to Journal of the Royal Society of Medicine, 73, 200. Postgrad Med J: first published as 10.1136/pgmj.58.681.451 on 1 July 1982. Downloaded from

Clinical reports 453

GEORGE, C.F. (1981) Drugs causing constipation and intestinal MUNSTER, A. & MILTON, G.W. (1961) Paralytic ileus due to obstruction. Prescriber's Journal, 21, 148. ganglion blocking drugs. Medical Journal ofAustralia, 2, 210. GOODMAN, L.S. & GILMAN, A. (1980) The Pharmacological Basis of SIMPSON, J.A. (1978) of the nervous system. Textbook of Therapeutics. 6th edn, MacMillan, London. 1980. Medical Treatment 14th edn (Ed by S. Alstead & R.H. Girdwood), MALTBIE, A.A., VARIA, I.G. & THOMAS, N.U. (1981) Ileus Chapter 19, p. 303. Churchill Livingstone, Edinburgh & London. complicating haloperidol therapy Psychosomatics, 22, 158. SRIRAM, K., SCHUMER, W., EPHRENPREIS, S., COMATY, J.E. & MILNER, G. & BUCKLER, E.G. (1964) Adynamic ileus and amitrip- SHELLER, J. (1979) Phenothiazine effect on gastrointestinal tract tyline: three case reports. Medical Journal ofAustralia, I, 921. function. American Journal of Surgery, 137, 87. MILNER, G. & HILLs,N.H. (1966) Adynamic ileus and nortriptyline. WATSON, W.C., KNUTTY, P.K. & COLCLOUGH, R.G. (1977) Does British Medical Journal, I, 841. cimetidine cause ileus in the burned patient? Lancet, ii, 720. copyright. http://pmj.bmj.com/ on September 26, 2021 by guest. Protected