Recurrent clozapine-induced adynamic bowel obstruction requiring two laparotomies: A case report

• CIGH can rapidly progress to life-threatening adynamic obstruction and ischemia. • Recurrent obstruction required two laparotomies despite timely surgical intervention. • Clozapine withdrawal triggered severe manic–psychotic relapse needing ECT. • Early recognition and bowel surveillance are crucial for preventing fatal outcomes. • Multidisciplinary psychiatric–surgical care enabled stabilization and survival. CIGH is a potentially life-threatening adverse effect that may progress from constipation to adynamic obstruction, ischemia, sepsis, and death. Its early recognition is often delayed due to impaired symptom reporting, polypharmacy, and clozapine’s anticholinergic and anti-serotonergic effects, making vigilance essential in clinical practice. We report a 35-year-old man with a chronic psychotic illness on long-term clozapine who presented with acute abdominal pain, distension, bilious vomiting, and five days of constipation. Emergency laparotomy revealed 110 cm of pregangrenous small bowel, necessitating resection and double-barrel ileostomy. Three months later, following ileostomy reversal, he developed recurrent ileus requiring a second laparotomy, which demonstrated adynamic obstruction without mechanical cause, consistent with CIGH. His postoperative course was complicated by severe manic–psychotic relapse requiring antipsychotic re-initiation and electroconvulsive therapy. Multidisciplinary care enabled stabilization, and he was discharged with plans for delayed re-anastomosis once psychiatric control is optimized. This case exemplifies the severe and recurrent nature of CIGH and parallels the broad clinical spectrum reported in the literature, ranging from reversible ileus to fatal gastrointestinal necrosis. Timeliness of diagnosis and intervention determines outcome, as seen in comparable cases where delayed recognition resulted in fulminant ischemia and mortality, whereas early management enabled full recovery. CIGH should be considered a medical emergency. Routine bowel monitoring, proactive laxative protocols, and a low threshold for imaging or surgical consultation are crucial. Integrated medical–psychiatric management is essential to prevent catastrophic complications and ensure safe continuation of antipsychotic therapy.