Cocaine-induced mesenteric ischaemia requiring small bowel resection

Abstract

Cocaine use causes profound vasoconstriction leading to various systemic complications. Gastrointestinal complications such as mesenteric ischaemia are difficult to recognise and may result in serious consequences if not treated promptly. We report on the case of a 47-year-old man presenting with mesenteric ischaemia on a background of acute on chronic cocaine consumption, where diagnosis was not evident until second presentation. He underwent an emergency laparotomy with small bowel resection and jejunostomy formation and made a good recovery with eventual reversal surgery. The literature on cocaine-induced bowel ischaemia shows significant variability in presentation and outcome. Laboratory investigations are non-specific, and early recognition is vital. Given the increasing recreational use of cocaine in the UK, it is imperative to have a high clinical index of suspicion for mesenteric ischaemia in patients presenting with non-specific abdominal pain, and to ensure a detailed social history covering recreational drug use is not forgotten.

Keywords: emergency medicine; general surgery; poisoning; small intestine; toxicology.

Figure 1

Coronal cross-section of contrast CT showing dilated small bowel loops and intramural gas suggestive of small bowel ischaemia. Intramural gas is seen within a small bowel loop in the left upper quadrant.

Figure 2

Histomicrographs stained with H&E, at a magnification of ×20 (A), ×40 (B) and ×100 (C), respectively. (A) The microscopic features seen include loss of villi and atrophy of the muscularis propria. (B) Submucosal oedema is shown, while (C) significant mucosal and submucosal inflammations are highlighted. Blood vessel congestion, haemorrhage and ulceration are evident in all images.