Enterocolitis associated with cocaine use

Upper gastrointestinal bleeding from gastric antral vascular ectasia following cocaine use: case presentation and review of literature

Gastric antral vascular ectasia (GAVE), also known as "Watermelon stomach", is a rare cause of upper gastrointestinal bleeding (UGIB). It is characterized by an endoscopic appearance of flat red blood vessels traveling from the pylorus to the antrum. Patients often present with chronic blood loss resulting in iron deficiency anemia, or, less commonly, with acute gastropathy resulting in massive hemorrhage. The etiology of GAVE is unknown but the disorder has been more commonly observed in patients with cirrhosis, especially with portal hypertension, as well as in those with systemic sclerosis and other connective tissue disease. There is no definitive cure for GAVE, but the condition can be managed with a variety of endoscopic techniques, including heater probes, bipolar probes, plasma coagulators, laser therapy, and radiofrequency ablation. In rare cases, patients also require blood transfusions. Here we present an interesting case of upper GI bleeding resulting in symptomatic anemia in a 69-year-old female patient with GAVE following cocaine use. The patient was initially admitted for fatigue and shortness of breath and required multiple units of pRBCs. She was also found to have a urine drug screen positive for cocaine. Following stabilization, she underwent endoscopy which revealed the characteristic "watermelon stomach" appearance consistent with GAVE syndrome. The patient was discharged on an oral proton-pump inhibitor with instructions to follow-up outpatient with Gastroenterology. This case is presented as an example of a risk factor for acute exacerbation of a rare cause of UGIB. This patient presentation also represents an example of the importance of strict follow-up for those with risk factors for exacerbation of chronic GI conditions.

Non-clostridium difficile induced pseudomembranous colitis

Pseudomembranous colitis is severe inflammation of the inner lining of the colon due to anoxia, ischemia, endothelial damage, and toxin production. The majority of cases of pseudomembranous colitis are due to Clostridium difficile. However, other causative pathogens and agents have been responsible for causing a similar pattern of injury to the bowel with the endoscopic appearance of yellow-white plaques and membranes on the mucosal surface of the colon. Common presenting symptoms and signs include crampy abdominal pain, nausea, watery diarrhea that can progress to bloody diarrhea, fever, leukocytosis, and dehydration. Negative testing for Clostridium difficile or failure to improve on treatment should prompt evaluation for other causes of pseudomembranous colitis. Bacterial infections other than Clostridium difficile, Viruses such as cytomegalovirus, parasitic infections, medications, drugs, chemicals, inflammatory diseases, and ischemia are other differential diagnoses to look out for in pseudomembranous colitis. Complications of pseudomembranous colitis include toxic megacolon, hypotension, colonic perforation with peritonitis, and septic shock with organ failure. Early diagnosis and treatment to prevent progression are important. The central perspective of this paper is to provide a concise review of the various etiologies for pseudomembranous colitis and management per prior literature.

Short- and Long-Term Effects of Cocaine on Enteric Neuronal Functions

Cocaine is one of the most consumed illegal drugs among (young) adults in the European Union and it exerts various acute and chronic negative effects on psychical and physical health. The central mechanism through which cocaine initially leads to improved performance, followed by addictive behavior, has already been intensively studied and includes effects on the homeostasis of the neurotransmitters dopamine, partly mediated via nicotinic acetylcholine receptors, and serotonin. However, effects on the peripheral nervous system, including the enteric nervous system, are much less understood, though a correlation between cocaine consumption and gastrointestinal symptoms has been reported. The aim of the present study was to gain more information on the effects of cocaine on enteric neuronal functions and the underlying mechanisms. For this purpose, functional experiments using an organ bath, Ussing chamber and neuroimaging techniques were conducted on gastrointestinal tissues from guinea pigs. Key results obtained are that cocaine (1) exhibits a stimulating, non-neuronal effect on gastric antrum motility, (2) acutely (but not chronically) diminishes responses of primary cultured enteric neurons to nicotinic and serotonergic stimulation and (3) reversibly attenuates neuronal-mediated intestinal mucosal secretion. It can be concluded that cocaine, among its central effects, also alters enteric neuronal functions, providing potential explanations for the coexistence of cocaine abuse and gastrointestinal complaints.

Histopathology of non-IBD colitis practical recommendations from pathologists of IG-IBD Group

Pathologists are often called upon to diagnose colitides that differ from the two main forms of inflammatory bowel disease (IBD). These non-IBD colitides include infectious colitis, microscopic colitis, ischemic colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation colitis and diversion colitis. The diagnosis of these different disease entities relies on the histopathological examination of endoscopic biopsies of the gastrointestinal tract. This paper reviews the main histomorphological characteristics of the various Non-IBD colitides.

Unusual Case of Ischemic Colitis Caused by Low-Dose Sumatriptan Therapy in a Generally Healthy Patient After Strenuous Physical Activity

Ischemic colitis refers to an inflammatory condition of the large bowel caused by ischemia. It usually presents with an acute onset abdominal pain followed by hematochezia. It can occur as a result of arterial occlusion (embolic or thrombotic), venous thrombosis, or hypoperfusion of mesenteric circulation secondary to dehydration, surgery, or medications. Herein, we present an unusual case of sumatriptan-induced ischemic colitis. Sumatriptan succinate is a selective serotonin (5-hydroxytryptamine-1) receptor agonist that is usually prescribed for refractory migraine headaches. This is a 59-year-old female who presented with acute onset abdominal pain followed by bloody diarrhea after vigorous physical activities. She has a past medical history of non-specific colitis (one time, 15 years ago) and chronic migraine for which she was on low-dose sumatriptan therapy (one tab once or twice a week). On the day of the event, the patient took sumatriptan in the morning and had strenuous activities throughout the day, and overnight she developed abdominal pain. It was followed by bouts of bloody diarrhea. The colonoscopy revealed erythematous mucosa with significant ulceration and necrosis involving the distal transverse colon, splenic flexure, descending colon, and proximal colon, suggestive of ischemic colitis. Unlike previously reported cases, this patient was only on low-dose sumatriptan therapy without frequent dosing. So, her risk of ischemic colitis from triptan therapy could have been accelerated by excessive sweating and strenuous physical activities. The patient was treated with intravenous hydration, bowel rest, intravenous antibiotics, and withdrawal of sumatriptan and her condition improved within the next two to three days.

Cocaine-induced mesenteric ischaemia requiring small bowel resection

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.

Abdominal Imaging Manifestations of Recreational Drug Use

Recreational drug use is a burgeoning health issue worldwide, with a variety of presenting symptoms and complications. These complications can be secondary to the toxic effects of the drug itself, drug impurities, and nonsterile injection. The abdominal radiologist is likely to encounter patients who use drugs recreationally and may be responsible for recognizing and reporting these acute conditions, which in some cases can be life threatening. Because these patients often present with an altered mental state and may deny or withhold information on drug use, the underlying cause may be difficult to determine. The most commonly used drugs worldwide include cocaine, cannabinoids, opioids, and amphetamines and their derivatives. Complications of use of these drugs that can be seen at abdominopelvic CT can involve multiple organ systems, including the soft tissue and gastrointestinal, genitourinary, vascular, and musculoskeletal systems. A diverse range of abdominal complications associated with these drugs can be seen at imaging, including disseminated infections, gastrointestinal ischemia, and visceral infarction. Radiologists should be familiar with the imaging findings of these complications to accurately diagnose these entities and help guide workup and patient treatment. ^©RSNA, 2020.

Review of Drug-induced Injury in Mucosal Biopsies From the Tubular Gastrointestinal Tract

The use of prescription and over-the-counter medications is on the rise in the US population, especially among those aged 65 and over, with over 46% of the population taking at least 1 prescription medication. Given the frequency of medication use, and that the majority of these medications are taken orally, it has become increasingly relevant for pathologist examining endoscopically obtained gastrointestinal tract mucosal biopsies to consider and recognize patterns of mucosal injury associated with various drugs. Reports on injuries associated with certain classes of drugs can be scattered among different sources, making a comprehensive view of various injury patterns and the drugs known to cause them difficult to obtain. Herein, we provide a comprehensive overview of the drugs known to cause mucosal injuries in the tubular gastrointestinal tract organized by the organ involved and the prominent pattern of injury.

Ischemic colitis

Most clinicians associate ischemic colitis with elderly patients who have underlying cardiovascular comorbidities. While the majority of cases probably occur in this population, the disease can present in younger patients as a result of different risk factors, making the diagnosis challenging. While a majority of patients respond to medical management, surgery is required in approximately 20% of the cases and is associated with high morbidity and mortality.

Presumptive cocaine toxicosis in 19 dogs: 2004-2012

OBJECTIVE

To characterize the incidence, signalment, presenting complaint, history, clinical signs, diagnostic test results, complications, treatment, length of hospitalization, and outcome of dogs presenting with presumptive cocaine toxicosis.

DESIGN

Retrospective study from March 1, 2004 to March 1, 2012.

SETTING

Twenty-four hour urban university veterinary teaching hospital.

ANIMALS

Nineteen dogs presenting with clinical signs consistent with cocaine toxicosis and having a positive urine cocaine test.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All dogs had neurological abnormalities including bilateral mydriasis (11/19 [58%]), hyperexcitability/hyperesthesia (10/19 [53%]), ataxia (8/19 [42%]), focal or generalized muscle tremors (8/19 [42%]), reduced mental awareness (6/19 [32%]), and seizures (3/19 [16%]). Other signs included weakness (7/19 [37%]), vomiting (6/19 [32%]), and lethargy (3/19 [16%]). Tachycardia was apparent in 10/19 (53%) dogs, hypertension in 4/19 (21%), and hyperthermia in 5/19 (26%). Sinus tachycardia was the only reported cardiac arrhythmia. Bloodwork findings included hyperglycemia in 4/19 (21%) dogs, and increased plasma lactate concentration in 9/19 (47%). Most dogs (16/19 [84%]) were hospitalized for supportive care, which generally included isotonic crystalloid fluid administration, and treatment with sedative or anxiolytic drugs including diazepam, midazolam, acepromazine, and chlorpromazine. Two dogs required further anticonvulsant therapy (phenobarbital and propofol) and 1 dog was treated with a constant rate infusion of esmolol. All dogs survived to discharge, and the median length of hospitalization was 15 hours (10-30 h).

CONCLUSIONS

Cocaine toxicosis was infrequently suspected. Neurological signs predominated, but cardiovascular alterations were also frequently reported. Hospitalization for monitoring and supportive care is recommended given the potential for life-threatening complications such as seizures, hypertensive crisis, and tachyarrhythmias. The prognosis for survival to hospital discharge can be good with the appropriate supportive care.

Beyond appendicitis: common and uncommon gastrointestinal causes of right lower quadrant abdominal pain at multidetector CT

Right lower quadrant abdominal pain is one of the most common causes of a patient visit to the emergency department. Although appendicitis is the most common condition requiring surgery in patients with abdominal pain, right lower quadrant pain can be indicative of a vast list of differential diagnoses and is thus a challenge for clinicians. Other causes of right lower quadrant pain beyond appendicitis include inflammatory and infectious conditions involving the ileocecal region; diverticulitis; malignancies; conditions affecting the epiploic appendages, omentum, and mesentery; and miscellaneous conditions. Multidetector computed tomography (CT) has emerged as the modality of choice for evaluation of patients with several acute traumatic and nontraumatic conditions causing right lower quadrant pain. Multidetector CT is an extremely useful noninvasive method for diagnosis and management of not only the most common causes such as appendicitis but also less common conditions.

Adverse effects of drugs on small intestine and colon

The small and large intestine are one of the most common sites for the adverse action of drugs, accounting for 20-40% of all drug side effects. The most important factor in the diagnosis of drug-induced intestinal side effect is awareness. The mechanisms of damage are invariably complex, but may be due to topical effects, a known pharmacologic action of the drug on motility (for instance cholinergic/anti-cholinergic effect) and/or secretion, immune suppression and in the case of cytotoxic drug treatment a combination of many actions. The diagnosis of damage may be simple and widely recognised (NSAID-induced enteropathy resulting in bleeding, protein loss and rarely perforation and diaphragm disease), or at other times ignored (tricyclic antidepressants increasing constipation) or life threatening (docetaxene). Some associations require further research (statin and anti-retroviral associated irritable bowel symptoms). Diagnosis is traditionally made by symptom improvement on discontinuation of the drug. More lately capsule enteroscopy is used to aid diagnosis.

Massive pan-gastrointestinal bleeding following cocaine use

BACKGROUND

An 18-year-old adolescent with cystic fibrosis developed massive gastrointestinal bleeding.

METHODS

History, physical examination, upper and lower endoscopy and wireless capsule endoscopy were performed.

RESULTS

Upper and lower endoscopy did not reveal cause of persistent bleeding. Wireless capsule endoscopy revealed pan-gastrointestinal ischemic injury. Further discussion with the patient revealed recent cocaine ingestion.

CONCLUSION

Most reported cases of gut injury following cocaine abuse describe juxtapyloric and colonic injury; this case demonstrates that ischemic gut injury after cocaine use can be extensive and may be the reason for the associated high mortality.

Cardiovascular complications of cocaine: imaging findings

Cocaine is the second most commonly abused illicit drug in the US and the most common one involved in emergency department visits, the majority of which are related to the cardiovascular system. Cardiovascular complications related with cocaine abuse include myocardial ischemia and infarction, myocarditis, hypertrophic cardiomyopathy, dilated cardiomyopathy, aortic dissection, thrombosis, stroke and cerebral hemorrhage, and different forms of visceral ischemia, among others. In an era where cocaine use has reached epidemic proportions, it is necessary for the radiologist to understand the pathophysiology, clinical presentation, and imaging characteristics of its cardiovascular complications.

The thrill can kill: murder by methylation

Why babies of crack-cocaine mothers develop heart problems has always been a mystery. In this issue of Molecular Pharmacology, Zhang et al. (p. 1319) show that a specific methylation occurs at the protein kinase Cepsilon (PKCepsilon) promoter of the babies born of mother rats exposed to cocaine. This reduces the expression of PKCepsilon, a naturally cardioprotective enzyme, which provides a plausible molecular mechanism for cardiac failure.