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.
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
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
Pneumoperitoneum, secondary to bowel perforation.
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.
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.
- 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
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