Bowel ischemia and perforation after cocaine use.

Abstract

A 30-year-old woman was admitted because of pain in the lower abdomen localized to the right lower quadrant. The pain was crampy and associated with bloody diarrhea. The abdomen was diffusely tender with involuntary muscle rigidity. No fever or hypotension were found. She used cocaine regularly and had smoked crack cocaine heavily approximately 24 hr before the onset of the symptoms. Acute appendicitis or pelvic inflammatory disease was the suspected diagnosis. Findings on sonography of the pelvis were normal. However, abdominal sonography showed marked thickening of the walls of the large bowel from the transverse colon to the cecum (Figs. 1 A and 1B). No peristalsis was observed. Peritoneal fluid was seen surrounding the abnormal walls of the colon. CT confirmed the sonographic findings (Fig. 1 C). Gastrografin enema performed to exclude perforation showed marked edema and lack of distensibility of the colon from the splenic flexure to the cecum (Fig. 1 D). No perforation was detected. Two days later, colonoscopy and biopsy were performed. The colonoscopy showed marked submucosal edema and hemorrhages in the transverse and ascending colon. Biopsy of the ascending colon showed ulcerations and necrosis. The patient was treated symptomatically with IV fluids, pain medications, and suctioning via a nasogastric tube. The pain disappeared after 5 days. The patient was discharged with no medications and was to have follow-up in the gastrointestinal clinic.