Cocaine Use and Incarceration: A Rare Cause of Bowel Ischemia, Perforation, and Gastrointestinal Hemorrhage

Abstract

Cocaine use is rising in persons ≥50 years old and in black and socioeconomically disadvantaged communities. Cocaine-induced bowel ischemia and gastrointestinal injury are deadly findings that have been previously described in the literature. In this report, we present a case of small bowel ischemia, perforation, and upper gastrointestinal hemorrhage co-occurring in a 62-year-old incarcerated male with a 15-year history of cocaine use. The patient presented from jail, peritonitic in septic shock, and was promptly taken for emergent surgical exploration. He was found to have massive fecal peritonitis secondary to full-thickness ischemia and perforation of the jejunum and ileum. Immediately postoperatively, the patient developed a large volume of hemorrhage from multiple gastric and duodenal ulcers refractory to endoscopic intervention, ultimately requiring emergent embolization of the gastroduodenal artery. His course was further complicated by severe septic shock with a blunted response to catecholamine vasopressors. Early recognition and aggressive treatment of the gastrointestinal complications and the unique critical care challenges associated with cocaine use facilitated this patient's eventual full recovery.

Keywords: bowel ischemia; crack-cocaine; gastrointestinal hemorrhage; perforation; trauma.

Figure 1. KUB demonstrating dilated small bowel loops suggestive of ileus or obstruction. This imaging does not provide definitive evidence of perforation.

KUB: kidney, ureter, and bladder study.

Figure 2. EGD image revealing nonbleeding cratered ulcer in the duodenal bulb.

EGD: esophagogastroduodenoscopy.

Figure 3. EGD image exposing severe stenosis of the first portion of the duodenum.

EGD: esophagogastroduodenoscopy.

Figure 4. Digital subtraction angiography demonstrating embolization of the gastroduodenal artery using a series of 0.035 inch metallic coils.

Figure 5. Abdomen/pelvis CT demonstrating pneumatosis of the small bowel, suggestive of ischemia (arrows).

Figure 6. Abdomen/pelvis CT revealing hyperdense fluid in the stomach and OG tube in place, consistent with upper GI bleed (arrows).