S1685 Cocaine-Associated Ischemic Colitis: A Rare Form of Lower Gastrointestinal Bleeding

Abstract

INTRODUCTION: Cocaine is a commonly abused stimulant drug. It causes vasoconstriction through stimulation of alpha-adrenergic receptors. The majority of adverse effects are cardiovascular. Gastrointestinal complications occur less frequently – but include ischemia, ulceration, gangrene and perforation. CASE DESCRIPTION/METHODS: A 37-year-old Hispanic woman with history of post-traumatic stress disorder presented with two days of crampy LLQ abdominal pain. She also reported non-bloody diarrhea followed by episodes of hematochezia and a fever of 103 degrees F. She admitted using cocaine the day prior to symptom onset. She denied use of oral contraceptives. On examination, she had LLQ tenderness but no guarding or rigidity. Laboratory studies revealed WBC 11.9 (×103/uL), ESR 29 mm/hr, CRP 3.99 mg/dL. Urine toxicology was positive for cocaine. CT abdomen showed circumferential thickening of the transverse and sigmoid colon (Figure 1). MR Venogram showed no acute mesenteric thrombosis. Stool studies including Clostridium Difficile toxin were negative. A subsequent colonoscopy located moderate inflammation characterized by congestion, erythema and linear ulcerations in the transverse colon (Figure 2). Biopsies revealed acute inflammation. Given the clinical presentation, the patient was diagnosed with acute ischemic colitis (IC) due to cocaine use. She was treated with intravenous hydration and antibiotics (ciprofloxacin and metronidazole). Her gastrointestinal bleeding and abdominal pain resolved after two days, with no recurrence of symptoms. DISCUSSION: We present a case of IC related to cocaine use. IC occurs more commonly in the elderly due to risk factors including atherosclerosis. However it can occur in younger populations due to intestinal arteriolar vasospasm related to cocaine use. Cocaine related gastrointestinal complications are rare. The interval from drug ingestion to symptom onset varies from 2 hours to upto 2 days. Patients can present with fever, nausea, vomiting, severe abdominal pain and hematochezia. The majority of cases reported in the literature have shown ischemia of the small bowel, with large bowel involvement less common. Physicians should have an index of suspicion for cocaine associated IC in younger populations, especially those with a history of substance abuse. It is important to rule out hypercoagulable states and thrombo-embolic events. A thorough history together with contrast imaging and colonoscopy can aid in diagnosis and prognostication.Figure 1.: Computerized tomography (CT) of the abdomen showed circumferential thickening of the transverse colon consistent with colitis.Figure 2.: Colonoscopy revealed moderate inflammation characterized by congestion, erythema and linear ulcerations in the transverse colon. Biopsies revealed acute inflammation on pathology.