Cocaine-Associated Ischemic Colitis

Jeffrey D. Linder, MD, Klaus E. Mönkemüller, MD, Birmingham, Ala; Isaac Raijman, MD, Houston, Tex; Lawrence Johnson, MD, Audrey J. Lazenby, MD, C. Mel Wilcox, MD, Department of Medicine, Division of Gastroenterology and Hepatology, and the Department of Pathology, University of Alabama at Birmingham; and the Division of Gastrointestinal Oncology, University of Texas-M. D. Anderson Cancer Center, Houston.

South Med J. 2000;93(9) 

In This Article

Case Reports

Case 1. A 26-year-old white man had bloody diarrhea, cramp-like periumbilical abdominal pain, and nausea for 6 hours. He denied vomiting, melena, or hematemesis. He reported no previous medical problems and denied taking any prescription drugs, over-the-counter medications, or nonsteroidal anti-inflammatory drugs (NSAIDs). He had smoked 20 cigarettes daily for the last 5 years and reported drinking 4 or 5 beers during the weekends. He initially denied drug use, but he later admitted to smoking a large quantity of cocaine approximately 8 hours before the onset of symptoms.

On physical examination, the patient was afebrile and in no distress. Blood pressure was 127/78 mm Hg without orthostasis, pulse rate was 75/min, and respiratory rate was 16/min. The abdomen was mildly distended with normal bowel sounds. There was diffuse tenderness on abdominal palpation and no peritoneal signs. Rectal examination revealed bright red blood and no stool in the rectal vault.

Laboratory data showed a white blood cell (WBC) count of 12,200/mm3 with 69% neutrophils and 1% band cells, hemoglobin level of 15 g/dL, and hematocrit of 49%. Electrolytes, liver enzymes, creatinine value, and coagulation studies were normal. A urine drug screen was positive for cocaine and marijuana. A plain film of the abdomen showed a nonspecific gas pattern. Computed tomography (CT) of the abdomen with contrast medium showed mucosal thickening of the descending colon (Fig 1). Flexible sigmoidoscopy showed abnormalities in the left colon. The mucosa in the rectum and proximal descending colon appeared normal endoscopically. The colitis was characterized by patchy mucosal edema, erythema, and submucosal hemorrhages, interspersed with areas of normal appearing mucosa (Fig 2). Biopsies showed inflammation, submucosal hemorrhages, and edema consistent with ischemic colitis (Fig 3).

Figure 1.

Computed tomography of abdomen with intravenous contrast reveals thickening of sigmoid and descending colon walls.

Figure 2.

Colonoscopy showing patchy mucosal edema, erythema, submucosal hemorrhages, interspaced by areas of normal-appearing mucosa in sigmoid colon.

Figure 3.

Tissue sections from colonic biopsies show lesions associated with acute cocaine-induced ischemic colitis. Edema, congestion, hemorrhage, and inflammatory cellular infiltrate in lamina propria can be seen. (Hematoxylin and eosin stain)

The patient was treated conservatively. The bloody diarrhea and abdominal pain subsided gradually over 48 hours, and he was discharged home 72 hours after hospital admission.

Case 2. A 41-year-old black woman came to the Emergency Department with a 3-day history of intermittent, severe, cramp-like pain in the lower left quadrant of the abdomen associated with nausea and vomiting. Two days earlier, bloody diarrhea had also developed. The episodes of abdominal pain occurred several hours after smoking crack cocaine over a 3-day period. The most recent crack cocaine use had been about 12 hours before the patient sought medical attention. Her medical history was significant for breast cancer (T1, N1, M0) treated with a right modified radical mastectomy and adjuvant chemotherapy (agents used unknown) 4 years previously. She was taking hydrochlorothiazide for hypertension. She denied a significant history of gastrointestinal problems or use of NSAIDs or estrogen-containing medications such as birth control pills. She admitted to smoking crack cocaine daily for many years. She also admitted to occasional alcohol and tobacco use for the past 20 years.

On physical examination the patient was in mild distress. She was afebrile. Blood pressure was 125/73 mm Hg without orthostatic changes, pulse rate was 111/min, and respiratory rate was 17/min. The abdomen was not distended, with hypoactive bowel sounds and tenderness in the left lower quadrant without rebound. The stool was liquid brown and bloody.

Laboratory studies showed a total WBC count of 10,100/mm3 with 43% neutrophils and 4% band cells, and hemoglobin level of 15.9 g/dL. Blood chemistries, liver tests, prothrombin time (PT), and partial thromboplastin time were within reference ranges. Urine drug screen was positive for cocaine. A plain abdominal film appeared normal. Abdominal CT showed mucosal thickening of the sigmoid colon and cecum. Chest CT, bone scan, and mammogram were negative for breast cancer metastasis. A colonoscopy showed a patchy colitis with areas of normal mucosa in the sigmoid and distal descending colon (Fig 4). The colitis was characterized by a friable erythematous mucosa, subepithelial hemorrhages, and erosions covered by a yellowish exudate. Both the rectum and the proximal colon were normal endoscopically. Biopsies showed loss of goblet cells with regeneration, acute inflammatory cells in the lamina propria, and submucosal hemorrhage consistent with ischemic colitis. Special immunohistochemical stains were negative for cytomegalovirus and herpes simplex virus. Clostridium difficile toxin was not present and stool cultures for Campylobacter, Shigella, and Salmonella were negative, as well.

Figure 4.

Colonoscopy showing patchy colitis with areas of normal mucosa in sigmoid and distal descending colon.

The patient's clinical course was uncomplicated with the exception of an ileus that resolved with the use of intravenous fluids, electrolyte replacement, and intermittent nasogastric tube suction. She was discharged on day 7 of hospitalization. She had no recurrence of symptoms and has not used cocaine for the past 24 months.

Case 3. A 43-year-old black man was brought to the hospital after losing consciousness at home. The family members stated that he had been drinking alcohol and smoking crack cocaine for several days. No other clinical history was available. While in the emergency room his condition rapidly deteriorated, and he required endotracheal intubation to protect his airway.

On physical examination the patient was agitated, distressed, and uncooperative. Blood pressure was 110/60 mm Hg, pulse rate was 110/min, and respiratory rate was 28/min. The abdomen was distended, tympanitic, and diffusely tender. Bowel sounds were hyperactive. Laboratory data revealed a total WBC count of 18,000/mm3 with 78% segmented neutrophils and 12% band cells. Creatinine level was 4.3 mg/dL, aspartate aminotransferase was 78 IU/L, alanine aminotransferase 56 IU/L, lactate dehydrogenase 236 U/L, creatine kinase 78 mg/dL, PT 16 seconds, a lactate level was 2.5 mg/dL. A CT scan of the abdomen and pelvis revealed diffuse thickening of the colonic wall.

A flexible sigmoidoscopy revealed diffuse colitis with edema, erythema, submucosal hemorrhages, and serpiginous ulcers, covered by blood and a whitish-yellow exudate

Figure 5.

Flexible sigmoidoscopy revealing diffuse colitis with edema, erythema, submucosal hemorrhages, and serpiginous ulcers, covered by blood and whitish-yellow exudate.

(Fig 5). Areas of normal colonic mucosa were present. Biopsies revealed an acute inflammatory infiltrate in the lamina propria and submucosal hemorrhage consistent with ischemic colitis. The patient had progressive clinical deterioration, the development of multiple organ system failure, gram-negative bacterial sepsis, and Candida albicans sepsis. He had exploratory laparotomy on day 3 of hospitalization. On entering the peritoneal cavity, 2 L of clear, yellow ascites was present. The liver was diffusely micronodular, consistent with cirrhosis. All areas of the colon were noted to be viable without any transmural necrosis or gangrene. The small bowel was viable from the ligament of Treitz to the ileocecal valve. Two ampules of fluorescein were given intravenously, and the Wood's lamp was used to illuminate the peritoneal cavity. All the areas of the small intestine and large intestine appeared viable without any evidence of patchiness; therefore the intestines were not resected. Despite maximum ventilatory and hemodynamic support, the patient died 2 weeks after initial examination. Autopsy could not be obtained.

 

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