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SAEM Clinical Image Series: The Cocaine Gut

Posted by Eric M. Beyer, MD on

A sixty-five-year-old male with a medical history of gastroesophageal reflux disease (GERD), hypertension, alcohol dependence, homelessness, and cocaine abuse presents to the emergency department with abdominal pain for three days. The patient describes his abdominal pain as knife-like, 9/10, located diffusely throughout his abdomen, with associated anorexia and nausea. He reports that he had one episode of coffee ground emesis this morning which provoked him to come to the ED. He reports frequent cocaine use with his last use three days ago. He endorses subjective fevers, chills, and no bowel movement for two days. He has had no sick contacts.

Additional Images

Physical Exam

Vitals:

  • Temp 39°C
  • HR 104
  • RR 22
  • BP 120/98
  • SpO2 95% on room air

General: Uncomfortable, weak, unsteady on feet

Cardiovascular: Tachycardia, no murmurs, rubs, or gallops

Pulmonary: Mildly increased work of breathing

Gastrointestinal: Generalized tenderness to palpation, rigid, distended, diminished bowel sounds, and peritonitis

Labs

CBC: WBC 14.0 x 10^9/L

Troponin: 0.06 ng/mL

Creatinine: 5.3 mg/dL

Urine Drug Screen: Positive for cocaine metabolites

Case Question: What finding is demonstrated in the above images? What is the likely diagnosis?

Pneumoperitoneum, secondary to bowel perforation.

Case Question: What is the pathophysiology behind this diagnosis?

Cocaine causes bowel ischemia by blocking norepinephrine reuptake in presynaptic nerve endings, leading to arterial vasospasm or vasoconstriction. This vasoconstriction can lead to complete bowel wall ischemia, leading to perforation.

Cocaine use likely exacerbated underlying peptic ulcer disease. Peptic ulcer disease is largely focused on H. pylori infection and chronic nonsteroidal anti-inflammatory drug (NSAID) use, however, gastric perforation of ulcers is a rare but potentially life-threatening complication of cocaine use.

Case Discussion

This case demonstrates an older male patient with a history of GERD who presents with findings concerning for an acute surgical abdomen. A kidney, ureters, and urinary bladder X-ray (KUB) (as shown above) demonstrates significant pneumoperitoneum, requiring an emergent surgical consult and subsequent laparotomy. During surgery, the perforation was found to be located at the anterior surface of the pylorus. A graham patch was placed, and the patient recovered without any further complications.

Take Home Points

  • Peptic ulcer disease should be considered as a rare but possible cause of abdominal pain in patients with a history of recent cocaine use.
  • The onset of symptoms of cocaine-induced bowel perforation can occur between one and sixty hours after cocaine use.
  • Pneumoperitoneum is managed with an emergent surgical consult or transfer to an outside facility if surgical services are not readily available.

References

  • Chander, B., & Aslanian, H. R. (2010). Gastric perforations associated with the use of crack cocaine. Gastroenterology & hepatology, 6(11), 733–735. PMCID: PMC3033546
  • Kram HB, Hardin E, Clark SR, Shoemaker WC. Perforated ulcers related to smoking “crack” cocaine. The American Surgeon. 1992 May;58(5):293-294. PMID: 1622009
  • Muñiz, A. E., & Evans, T. (2001). Acute gastrointestinal manifestations associated with use of crack. The American Journal of Emergency Medicine, 19(1), 61–63. PMID: 11146022
  • Uzzaman, M. M., Alam, A., Nair, M. S., & Meleagros, L. (2010). Gastric perforation in a cocaine user. Gastroenterology & hepatology, 6(11), 731–733. PMCID: PMC3033545

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2020 SAEM Annual Meeting | Copyrighted by SAEM 2020 – all rights reserved. View other cases from this series on ALiEM.

Author information

Eric M. Beyer, MD

Resident
Department of Emergency Medicine
Emory University School of Medicine

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The post SAEM Clinical Image Series: The Cocaine Gut appeared first on ALiEM.

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