1457 Cocaine-Induced Colonic Ischemia

• Published in: The American journal of gastroenterology Vol. 114; no. 1; p. S808
• Main Authors: Abdo, Michael, Kozacek, Kyler S., Oroian, Tudor, Mank, Victoria M., Hudspath, Caleb, Manibusan, Pedro
• Format: Journal Article
• Language: English
• Published: 01.10.2019
• DOI: 10.14309/01.ajg.0000595356.69677.0d
• ISSN: 0002-9270

INTRODUCTION: Cocaine use is associated with arterial vasoconstriction and enhanced thrombus formation. Rarely, these effects on the intestinal blood supply result in intestinal ischemia. Cocaine-induced ischemic colitis is a relatively poorly-defined variant of this phenomenon, but some studies suggest it may be associated with higher morbidity and mortality than other etiologies. Therefore, timing is critical in both diagnosis and initiating treatments to prevent poor outcomes. We present a case of a middle-aged patient who had an unusual presentation for ischemic colitis due to cocaine abuse. CASE DESCRIPTION/METHODS: A 49-year-old male with a history remarkable only for alcohol and cocaine use disorders presented with a two day history of hematemesis with syncope and severe abdominal pain. Urine drug screen was positive for cocaine on admission, and initial workup with EGD was grossly unremarkable. An abdominal CT scan showed extensive circumferential submucosal fat but without colonic wall thickening or other signs of acute process, and a mesenteric angiography was similarly unrevealing. However, his clinical condition continued to deteriorate over the next 48 hours with worsening abdominal pain, and he began passing large melanic stools with occasional frank red blood. He subsequently became septic; due to concern for ischemic bowel, a colonoscopy was emergently performed. Diffuse severe ischemic changes with deep cratered ulcers in the descending, transverse, and ascending colon were noted. Emergent laparotomy was performed for a near-total colectomy, after which the patient began to stabilize. DISCUSSION: Long-term cocaine abuse is associated with multiple vascular morbidities, including bowel ischemia. Our patient presented in extremis due to bowel ischemia of both SMA and IMA territories requiring intensive care and emergent colectomy. Interestingly, despite the widespread vascular compromise, initial symptoms were nonspecific without blood per rectum and imaging was unremarkable, including CT and angiography. This illustrates the importance of maintaining clinical suspicion and the utility of colonoscopy in diagnosis, as his unusually diffuse disease eventually necessitated a colectomy in this middle-aged man with otherwise unremarkable medical history.