P0649 - Lactulose-Induced Bowel Perforation

Award: Presidential Poster Award

Anandita Kishore, MD¹, Peter Lymberopoulos, MD², Dinesh Nirmal, MD³, Udit Dey, MD³, Shruthi Sivakumar, MBBS³, Asher Gorantla, MD³, Suzette Graham-Hill, MD^3
1Sisters of Charity Hospital, University of Buffalo, Buffalo, NY; ²SUNY Downstate Medical Center, Brooklyn, NY; ³SUNY Downstate Health Sciences University, Brooklyn, NY

Introduction: Hepatic encephalopathy (HE) is a commonly encountered clinical entity and is effectively treated with lactulose, although rare, when higher doses of lactulose are required to induce stools, it can result in fatal bowel perforation. We describe one patient with HE being treated with lactulose developing bowel perforation requiring emergent exploratory laparotomy.

Case Description/Methods: 75 year old man with past medical history of atrial fibrillation on anticoagulation, prostate cancer treated with radiation, human immunodeficiency virus (HIV) on highly active antiretroviral therapy (CD4 count greater than 200), diabetes mellitus, hypertension, congestive heart failure, alcohol liver disease admitted for altered mental status. Due to the high likelihood of hepatic encephalopathy, he was started on a lactulose regimen titrated to achieve 2 soft bowel movements per day. After 2 doses of 30 grams of lactulose were administered 3 hours apart, patient decompensated with acute abdomen, found to have pneumoperitoneum [Fig.1, 2 on the x-ray]. He was immediately taken to the operating room for an emergency exploratory laparotomy and found to have multiple foci of large bowel perforations requiring right hemicolectomy and transverse colectomy. He was transferred to the surgical intensive care unit where, despite aggressive resuscitative measures over the following days, the patient passed away.

Discussion: Lactulose is the first line approach in the treatment of hepatic encephalopathy. Dosing is usually titrated based on the number of bowel movements and the side effects are usually minimal but rarely when higher doses are required, there is a potential risk for bowel perforation which is fatal. Through this case report, we emphasize the need to Include bowel perforation in the side effect profile of lactulose therapy.



Disclosures:


Anandita Kishore, MD¹, Peter Lymberopoulos, MD², Dinesh Nirmal, MD³, Udit Dey, MD³, Shruthi Sivakumar, MBBS³, Asher Gorantla, MD³, Suzette Graham-Hill, MD³. P0649 - Lactulose-Induced Bowel Perforation, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.