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Query: UMLS:C0030193 (pain)
 261,466 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Ketamine, lidocaine, and mexiletine are potential nonopioid adjuvant medications for the use of refractory cancer-related pain, particularly when opioids are demonstrating limited objective benefit. This is a case report of a single patient admitted to a large academic medical center in the United States. The patient is a 43-year-old woman with a history of Crohn's disease complicated by rectal squamous cell carcinoma and complex, progressive, and intractable pelvic and rectal pain. Over the course of hospitalization, her pain demonstrated limited opioid responsiveness despite marked fluctuations of her oral morphine equivalent doses. She also demonstrates variable responsiveness to ketamine. Lidocaine continuous infusion ultimately proves beneficial, and she is discharged after conversion to oral mexiletine. An overview of the hospital system's protocols for ketamine and lidocaine continuous infusions for pain and considerations for transitioning to mexiletine from lidocaine infusion are included.
J Pain Palliat Care Pharmacother 2018 Mar
PMID:Case Report: Utility of Ketamine, Lidocaine, and Mexiletine as Nonopioid Adjuvants in Complex Cancer-Associated Pain. 2973 33

Seed bezoars are a subcategory of phytobezoars, caused by consumption of indigestible vegetable or fruit seeds. We present the case of a 64-year-old male patient, who presented at the Emergency Department, complaining of constipation, tenesmus and rectal pain. History and digital examination revealed a rectal seed bezoar due to sunflower seeds, impacted in the lower rectum. The patient underwent manual disimpaction under general anaesthesia, after conservative measures failed. Seed bezoars represent a different pathophysiological process compared to fibre bezoars. They are usually found in the rectum of patients without predisposing factors, causing constipation and anorectal pain. History taking and digital rectal examination are the cornerstones of diagnosis, with manual disimpaction under general anaesthesia being the procedure of choice.
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PMID:Rectal seed bezoar due to sunflower seed: a case report and review of the literature. 3106 17

Seed bezoars are a distinct subcategory of phytobezoars, caused by indigestible vegetable or fruit seeds. The aim of our study was to present a comprehensive review on seed bezoars, focusing on epidemiology, symptomatology, diagnosis and treatment options. A systematic review of the English literature (1980-2018) was conducted, using PubMed, Embase and Google Scholar databases. Fifty-two studies fulfilled the inclusion criteria, with a total of 153 patients, the majority of whom (72%) came from countries around the Eastern Mediterranean and the Middle East. Patients complained primarily about constipation (63%), abdominal/rectal pain (19%) or intestinal obstruction (17%). Most seed bezoars were found in the rectum (78%) and the terminal ileum (16%). Risk factors were recognised in 12% of cases. Manual disimpaction under general anaesthesia was the procedure of choice in 69%, while surgery was required in 22% of cases. Seed bezoars appear to represent a different pathophysiological process compared to fibre bezoars. Seeds usually pass through the pylorus and ileocaecal valve, due to their small size, and accumulate gradually in the colon. Seed bezoars are usually found in the rectum of patients without predisposing factors, causing constipation and pain. History and digital rectal examination are the mainstay of diagnosis, with manual extraction under general anaesthesia being the procedure of choice.
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PMID:Gastrointestinal Seed Bezoars: A Systematic Review of Case Reports and Case Series. 3133 15

Background: Malignant rectal pain (MRP) and tenesmus cause significant morbidity for cancer patients at all stages of disease. There is little evidence to guide management of these symptoms. Objective: The objective of this review was to summarize the existing evidence base for palliative management of MRP and tenesmus outside of standard oncologic or surgical management. Design: A systematic review of PubMed and Embase was conducted according to PRISMA guidelines using preselected search terms for publications between 1980 and January 2017. Setting/Subjects: Studies that described management for patients with tenesmoid pain from malignant tumors of the rectum, anus, or perineum were identified. Measurements: The primary outcome was response of pain to treatment. Results: The search produced 1412 titles. Twenty articles met criteria for inclusion in the review, including 11 case series and 9 case reports. A variety of treatments were found with most patients receiving interventional procedures, but overall evidence to support any particular intervention is limited and of poor quality. Conclusions: This review highlights the limited current evidence base for medical and interventional treatments for MRP and tenesmus. Further study is needed to clarify the best approach to managing these challenging symptoms.
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PMID:Management of Malignant Rectal Pain and Tenesmus: A Systematic Review. 3168 88

In this video we present a case of rectal injury, which occurred during laparoscopic mesh removal following sacrocervicopexy. Four years after sub-total hysterectomy with laparoscopic sacrocervicopexy, a 64-year-old patient still suffered from intense proctalgia and pain while sitting. On physical examination, intense pain could be triggered by palpating the left aspect of the levator ani muscle, raising the suspicion of an association with the mesh and leading to the decision for its removal. The left posterior arm of the mesh was removed completely laparoscopically. During this procedure, a rectal lesion was diagnosed and immediately repaired by a double layer of interrupted sutures. There was an immediate and complete resolution of the symptoms after surgery, with no short-term prolapse recurrence or postoperative complications. Laparoscopy appears to be an efficient approach to mesh excision. A high level of alertness to recognize intraoperative injuries is warranted.
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PMID:Rectal injury during laparoscopic mesh removal after sacrocervicopexy. 3179 94

Common anorectal conditions include hemorrhoids, perianal pruritus, anal fissures, functional rectal pain, perianal abscess, condyloma, rectal prolapse, and fecal incontinence. Although these are benign conditions, symptoms can be similar to those of cancer, so malignancy should be considered in the differential diagnosis. History and examination, including anoscopy, are usually sufficient for diagnosing these conditions, although additional testing is needed in some situations. The primary treatment for hemorrhoids is fiber supplementation. Patients who do not improve and those with large high-grade hemorrhoids should be referred for surgery. Acutely thrombosed external hemorrhoids should be excised. Perianal pruritus should be treated with hygienic measures, barrier emollients, and low-dose topical corticosteroids. Capsaicin cream and tacrolimus ointment are effective for recalcitrant cases. Treatment of acute anal fissures with pain and bleeding involves adequate fluid and fiber intake. Chronic anal fissures should be treated with topical nitrates or calcium channel blockers, with surgery for patients who do not respond to medical management. Patients with functional rectal pain should be treated with warm baths, fiber supplementation, and biofeedback. Patients with superficial perianal abscesses not involving the sphincter should undergo office-based drainage; patients with more extensive abscesses or possible fistulas should be referred for surgery. Condylomata can be managed with topical medicines, excision, or destruction. Patients with rectal prolapse should be referred for surgical evaluation. Biofeedback is a first-line treatment for fecal incontinence, but antidiarrheal agents are useful if diarrhea is involved, and fiber and laxatives may be used if impaction is present. Colostomy can help improve quality of life for patients with severe fecal incontinence.
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PMID:Benign Anorectal Conditions: Evaluation and Management. 3189 30

BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a class of antihyperglycemic medications associated with an increased risk of urinary and genital infections due to their glycosuric effects. In 2018, the FDA issued a safety alert warning that multiple cases of Fournier's Gangrene (FG), a severe genital infection, had been reported in patients taking SGLT2 inhibitors. CASE REPORT We present a case of 72-year-old male with type II diabetes mellitus who developed FG while taking the SGLT2 inhibitor canagliflozin. Besides diabetes and canagliflozin use, his other risk factors were his age, gender, and remote history of radiotherapy for prostate cancer. He presented to the Emergency Department (ED) multiple times complaining of rectal pain and was admitted for a possible diagnosis of prostatitis. During his stay, he developed leukocytosis, his pain worsened, and examination of the perianal area was consistent with FG. He was treated with multiple surgical debridement procedures and broad-spectrum antibiotics; the source of infection was determined to be a perianal abscess. He stayed in the hospital for 1 month and was discharged home with outpatient wound care and vacuum dressing changes. Canagliflozin was discontinued during the hospital stay. CONCLUSIONS Due to the possible association of FG with SGLT2 inhibitors, patients who present with signs and symptoms consistent with FG should be examined for possible FG and treated promptly.
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PMID:A Case of Fournier's Gangrene in a Patient Taking Canagliflozin for the Treatment of Type II Diabetes Mellitus. 3208 42


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