Cocaine-Induced Intestinal Ischemia

cocaineCOCAINE, AN ALKALOID derived from the Erythroxylon coca plant, remains a popular recreational drug. Although its recreational use has decreased, the number of hard-core regular users remains unchanged at 476,000 according to the 1993 National Institute on Drug Abuse Household Survey. Cocaine-related complications are, therefore, of clinical importance. Bowel ischemia due to cocaine use is probably more common than is reported, but it may be overlooked because its presentation is similar to other acute abdominal conditions. A direct causal relationship between cocaine use and bowel ischemia is difficult to prove. Nevertheless, the patients described in published reports so far had been relatively young, had a positive urine toxicology screen for cocaine, and had no previous history of atherosclerosis. We report a case of acute small bowel ischemia in the oldest patient after smoking crack cocaine.

Report of a Case
The patient, a 50-year-old man who smoked ciga-rettes and crack cocaine regularly, presented to the emergency department with a three-day history of abdominal pain, nausea, vomiting, and poor urine output after a binge of alcohol and cocaine use. The abdominal pain was sudden in onset, severe in intensity, and located mainly in the lower abdomen. The pain was made worse by oral intake and had no relieving factors. There was no history of fever, chills, chest pain, back pain, shortness of breath, or seizures. He had been unable to eat or drink for three days because of the pain.

On examination, the patient was awake and alert but looked uncomfortable. Apart from tachycardia (115 beats per minute), he had normal vital signs. He was clinically dehydrated. He had diffuse tenderness in the lower abdomen with guarding in his right lower quadrant, but no rebound was elicited at this stage. Bowel sounds were markedly diminished, and a rectal examination showed occult blood in the stool. Pertinent laboratory data included the following values: a leukocyte count of 30X10^9 per liter (30,000 per ul) with a leftward shift; hemoglobin level, 185 grams per liter (18.5 grams per dl); hematocrit, 0.55 (55%); platelet count, 300X109 per liter (300,000 per ul); serum bicarbonate, 19 mmol per liter; blood urea nitrogen, 16.4 mmol per liter (46 mg per dl); creatinine, 582 umol per liter (6.6 mg per dl); phos¬phate, 3.13 mmol per liter (9.7 mg per dl; normal, 0.80-1.55 mmol per liter); and anion gap, 28. Other lab¬oratory results were a creatine kinase level of greater than 16,000 units per liter (normal, 20-315); lactate dehydrogenase level, 9,282 units per liter (normal, 111-217); aspartate aminotransferase, 1,996 units per liter (normal, 3-26); alanine aminotransferase, 580 units per liter (normal, 5-30); alkaline phosphatase, 144 units per liter (normal, 25-128); amylase, 270 units per liter (normal, 30-120); and lipase, 144 units per liter (normal, 0-200). A urinalysis revealed 1-plus ketones, 3-plus blood and protein, 40 to 50 white blood cells per high-powered field, and few bacteria. The findings of urine microscopy were consistent with acute tubular necrosis. Canadian pharmacy

Abdominal roentgenogram showed only a nonspecific bowel gas pattern. Computed tomography snowed abdominal ascites and fluid collection or inflammatory changes (or both) in the right lower quadrant. The patient was admitted to the intensive care unit and was given fluid resuscitation and antibiotics. After a few hours, the patient became febrile, his abdominal pain worsened, and he had abdominal distension, generalized rebound tenderness, and absent bowel sounds. The patient underwent an exploratory laparotomy that revealed gangrenous dis¬tal small bowel, including the distal ileum. A 75-cm seg-ment of the nonviable bowel was resected, and an end-to-end anastomosis was done. Microscopic examination of the specimen of resected bowel revealed acute ischemic necrosis of the small bowel wall. There was no thrombus, embolus, or atherosclerosis. The patient received hemodialysis, his renal function improved grad¬ually, and he was subsequently discharged.

Discussion
We searched MEDLINE for the literature on cocaine-induced bowel ischemia. The review excluded those who swallowed condom-filled cocaine packets with the intention of smuggling the drug—the so-called body packers. There were 18 cases to date, with most patients in their third or fourth decade of life. Our patient was the oldest at 50 years of age. There was nearly a 2:1 ratio of women to men. No method of administering cocaine is safe. Apart from two patients whose route of administration was unknown, most patients either smoked crack cocaine or injected it intravenously. Most cases involved ischemia of the small rather than the large bowel, and two thirds of the patients recovered, usually with surgical management (Table 1). Canadian Pharmacy prednisone

TABLE 1 —Reported Coses of Cocoine-lnduced Bowel Ischemia*

Reference

Age, у

Sex

Route

Site of Ischemia

Outcome
This report

…. 50

M

Smoked crack

Small bowel

Survived
Sudhakar et al, 1997

…. 35

F

Unknown

Small bowel

Died
Sudhakar et al, 1997

…. 32

F

IV

Small bowel

Survived
Boutros et al, 1997

…. 36

F

Smoked crack

Large bowel

Survived
Myers et al, 1996

…. 29

F

IV, smoked crack

Celiac artery thrombosis, mesenteric ischemia

Survived
Myers et al, 1996

…. 35

F

IV

Distal ileum, cecum

Survived
Jawahar et al, 1995

…. 31

F

Intranasal

Small bowel

Died
Yangetal, 1991

…. 26

F

Smoked crack

Large bowel

Survived
Freudenberger et al, 1990

…. 38

M

IV

Small bowel

Died
Mizrahi et al, 1988

…. 27

M

Intranasal

Small bowel

Survived
Endressetal, 1992

…. 30

F

Smoked crack

Small bowel

Survived
Hazanas et al, 1993

…. 23

F

Oral

Large bowel

Died
Hon et al,1990

…. 37

F

Smoked crack

Small bowel

Survived
Carfiaetal, 1990

…. 24

M

Not specified

Small bowel

Died
Martin, 1991

…. 30

M

Intranasal

Bowel

Survived
Brown et al, 1994

…. 47

M

IV

Large bowel

Survived
Fishel et at, 1985

…. 37

M

Smoked crack

Cecum and ascending colon

Survived
Nalbandian etal, 1985

…. 29

F

Oral

Small bowel

Survived
Nalbandianetal, 1985

…. 26

F

Oral

Distal small bowel and proximal colon

Died

*IV = intravenous injection

In keeping with previously described patients, our patient had no history of predisposing factors that make other causes of bowel ischemia likely. An additional factor may be cigarette smoking, a common finding among those who use cocaine. The combined use of cocaine and smoking has a probable additive effect on coronary artery vasoconstriction. This may be applicable to other vessels elsewhere in the body, including mesenteric vessels. Our patient had been smoking for many years and was a current smoker at the time of his illness. cialis professional

This patient had rhabdomyolysis that resolved with medical treatment. We had expected rhabdomyolysis to be a common complication among patients with bowel ischemia because ischemia is its most frequent cause. Rhabdomyolysis, however, may be rare or underreported because mere is only one reported case linking it to bowel ischemia. We suggest that rhabdomyolysis should be screened for in all these patients because it may cause acute renal failure. cymbalta canadian pharmacy

Cocaine is a well-known central nervous stimulant, local anesthetic, and pyrogenic agent. Several mechanisms have been proposed to explain how cocaine causes bowel ischemia. It potentiates the normal adrenergic response by blocking the reuptake of presynaptic monoamine neurotransmitters. Mesenteric vessels contain many a-adren-ergic receptors. Stimulation of these receptors causes intense vasoconstriction, leading to reduced blood flow and ischemia. Cocaine also has a direct vasoconstrictive effect by enhancing calcium flux across the endothelial membrane. Some investigators have suggested that cocaine has a direct toxic effect on the gut mucosa. Cocaine displaces the transmitter from the axonal mem brane, thereby inducing a sympathomimetic response. Thrombus formation and platelet aggregation are enhanced following cocaine administration. Cocaine also decreases fibrinolytic activity by stimulating plasminogen activator inhibitor activity. Some or all of these effects of cocaine may explain the increased susceptibility of the bowel to ischemia in patients who abuse this drug. canadian generic viagra

This report highlights the importance of including cocaine use in the differential diagnosis of acute abdomen in all patients. That our patient was 50 years old suggests that probably no age barriers to drug abuse exist. Many cases may go unrecognized for different reasons. Some patients may be reluctant to admit to cocaine use, drug testing is not uniform, and dose-related complications are not consistent.

Category: disorders

Tags: Bowel, cocaine, smoking

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