Methamphetamine-Induced Colonic Ischemia

Abstract

Introduction: Methamphetamines are sympathomimetic compounds that can trigger arterial vasospasm, leading to increased risk of ischemic events in watershed areas in colon. Case presentation: We present a case of a 51-year-old man who was brought to the emergency department for acute delirium. On physical examinations, he had tenderness without peritoneal signs in both lower quadrants and frank hematochezia on rectal examination. Laboratory findings revealed white blood cell count 17,000/μL, hematocrit 44.3%, sodium 165 mMol/L, BUN 70mg/dL, and creatinine 4.1mg/dL. CT abdomen showed diffuse wall thickening of descending and sigmoid colon, consistent with colitis (Figure 1). Urine toxicology was positive for cannabinoids and amphetamines. His mental status improved with appropriate correction of hypernatremia. He continued to have left lower quadrant abdominal pain and bloody diarrhea. Further history revealed extensive crystal methamphetamine use prior to admission. Colonoscopy revealed hyperemia, superficial erosions and sloughing of the necrotic mucosa in the proximal rectum, sigmoid and descending colon with evidence of shallow ulcerations (Figure 2). Biopsy showed superficial mucosal necrosis with sparing of the deeper colonic crypts (Figure 3). Diagnosis of methamphetamine-induced colonic ischemia was made and patient's symptoms subsequently improved with conservative management.Figure 1Figure 2Figure 3Discussion: Colonic ischemia is commonly reported in elderly or patients with comorbid cardiovascular disease. In our patient, there was no evidence of thromboembolic event or appreciable arteriosclerotic disease of the mesenteric vasculature. An important but commonly overlooked etiology is drug induced colonic ischemia. Common drugs include antibiotics, decongestants, and infrequently illicit drugs. To our knowledge, there are only a few reported cases of methamphetamine-induced colonic ischemia. The diagnosis is made on the basis of clinical, endoscopic and pathologic findings, with imaging aiding the assessment of distribution of colitis. The vasoconstrictor properties of amphetamine lead to alterations in splanchnic blood flow. Susceptible areas are splenic flexure (Griffith point) and sigmoid colon (Sudeck point). Cessation of amphetamine use and supportive care help in resolution of symptoms. In summary, this case highlights the importance of social history and to consider methamphetamine as a causation etiology patients suspected to have colonic ischemia.