Pancreatitis Induced by Cocaine

A Case of Cocaine-Induced Acute Liver Failure Reversed With N-Acetylcysteine

Acute liver failure (ALF) is a life-threatening injury that is most often caused by drug-induced injury, including acetaminophen overdose, in the United States. The hallmarks of ALF are hepatic encephalopathy and coagulopathy in a patient without an established history of liver disease. While acetaminophen overdose has an antidote, that is N-acetylcysteine (NAC), when given acutely, most other causes of hepatic failure require an urgent liver transplant. In this paper, we report a case of cocaine-induced acute liver failure that was reversed with the administration of NAC. Our case began when a middle-aged male presented to the emergency department complaining of nausea, vomiting, fatigue, and confusion for the past three days. His past medical history was pertinent for a history of opioid use disorder and his physical exam was remarkable for somnolence, asterixis, and periumbilical ecchymoses. His initial lab results showed markedly elevated liver function tests, prolonged coagulation studies, and a urine drug screen that was positive for cocaine. During the patient's interview, his vital signs became unstable. He was intubated for airway protection and transferred to a tertiary care facility for liver transplant evaluation with the diagnosis of cocaine-induced acute liver failure. There he received NAC, lactulose, rifaximin, and vasopressors. On day two of treatment, his clinical condition greatly improved, and he was extubated. He continued to receive NAC until day five when his liver function tests and coagulopathy improved enough to stop treatment. This case report highlights the clinical benefit of NAC in a case of cocaine-induced acute liver failure, improving the patient's survival and eliminating his need for a liver transplant.

Cocaine Induced Biliary Tree Obstruction in a Middle-Aged Male

A sixty-two-year-old male with a history of extensive crack cocaine use and cholecystectomy presented to the emergency department with abdominal pain, nausea, vomiting, and urobilia. The physical exam revealed moderate epigastric tenderness without scleral icterus or jaundice. The patient's total bilirubin was elevated at 5.2, and his direct bilirubin was 3.7. A computed tomography angiogram (CTA) of the abdomen and pelvis subsequently showed a 3.1 x 2.8 cm mass compressing porta hepatis. A magnetic resonance cholangiopancreatography (MRCP) showed a 4.9 x 3.0 cm mass at the porta hepatis with corresponding biliary duct obstruction at that level. An endoscopic retrograde cholangiopancreatography (ERCP) was performed with stent placement and brush biopsy, which showed predominantly benign ductal epithelium with rare, atypical cells and stenosis of the proximal common bile duct suggestive of cholangiocarcinoma. Cytology was performed on the ductal fluid and was also negative. The carbohydrate antigen (CA) 19-9 level at that time was 94.3. We discussed the possibility of performing surgery as an inpatient, but the patient had various psychosocial issues, which prompted a psychiatric evaluation. He subsequently had an internal-external biliary drain placed. The patient was discharged with plans to obtain an endoscopic ultrasound as an outpatient. He was admitted and discharged several times over the span of six months for various issues. He received an endoscopic ultrasound (EUS) at a surrounding hospital. The results were inconclusive, and a repeat EUS was recommended. On the last admission to the hospital for abdominal pain, a CT scan showed no biliary tree obstruction, which was further confirmed with an MRCP. The internal-external biliary drain was removed without recurrence of hyperbilirubinemia. We suspect that the patient's initial symptoms and radiographic findings of a biliary tree mass may have been induced by extrinsic compression secondary to lymphadenopathy caused by an adulterant used in the cutting process of abused cocaine. This is a rare occurrence that has not been described in the literature. There are associations of cocaine use to pulmonary hilar lymphadenopathy, but not biliary lymphadenopathy. We strongly suspect that this patient's obstructive jaundice and extrinsic biliary tree obstruction were caused by underlying cocaine use.

Substance Use Affects Type 1 Diabetes Pancreas Pathology: Implications for Future Studies

Access to human pancreas samples from organ donors has greatly advanced our understanding of type 1 diabetes pathogenesis; however, previous studies have shown that donors have a high rate of substance use, and its impact on pancreatic histopathology in this disease is not well described. One-hundred-thirty-one type 1 diabetes and 111 control organ donor pancreata from persons 12-89 years of age (mean 29.8 ± 15.5 years) within the Network for Pancreatic Organ donors with Diabetes (nPOD) were examined for insulin positivity, insulitis, amyloid staining, acute and chronic pancreatitis, and chronic exocrine changes (acinar atrophy, fibrosis, fatty infiltration, or periductal fibrosis); findings were compared by history of substance use. A secondary analysis compared exocrine pancreatic histopathologic findings in type 1 diabetes versus control organ donors regardless of substance use history. We observed a high but congruent rate of substance use in type 1 diabetes and control organ donors (66.4% and 64% respectively). Among donors with type 1 diabetes (but not controls), islet amyloid (OR 9.96 [1.22, 81.29]) and acute pancreatitis (OR 3.2 [1.06, 9.63]) were more common in alcohol users while chronic exocrine changes (OR 8.86 [1.13, 69.31]) were more common in cocaine users. Substance use impacted the pancreata of donors with type 1 diabetes more than controls. Overall, despite similar rates of substance use, acute pancreatitis (15.3% versus 4.5%, p=0.0061), chronic pancreatitis (29.8% versus 9.9%, p=0.0001), and chronic exocrine changes (73.3% versus 36.9%, p<0.0001) were more common in type 1 diabetes donors than controls. Alcohol and/or cocaine use in type 1 diabetes organ donors increases exocrine pancreas pathology and islet amyloid deposition but does not affect insulitis or insulin positivity. Exocrine pathology in type 1 diabetes donors is common, and further study of the pathophysiology of these changes is needed.

Acute pancreatitis secondary to cocaine use: a case-based systematic literature review

Cocaine use continues to be an important global public health problem. As the use of cocaine remains pervasive so have a myriad of adverse events associated with this drug. These deleterious effects are well-studied, but gastrointestinal complications remain esoteric and the existing clinical evidence is scarce. Ischemia of the esophagus and small bowel, perforation, peptic ulceration, gastrointestinal bleeding, and ischemic colitis are among the reported complications. In specific, acute pancreatitis secondary to cocaine use is an exceedingly rare clinicopathologic entity. To date, only 7 cases of this condition have been reported in the English-language literature. We hereby delineate a rare case of a 29-year-old female who developed her first episode of cocaine-associated pancreatitis. The diagnosis was made based on a standard battery of investigations and meticulous exclusion of common etiologies of acute pancreatitis. To our knowledge, this case represents the first report of re-occurrence of acute pancreatitis upon subsequent crack cocaine insufflation, adding a higher level of evidence to a fallible association. We also present a systematic review of the existing literature on acute pancreatitis following cocaine use. An updated knowledge regarding this rare association is of paramount importance for early diagnosis and astute management.

Cocaine-Induced Acute Pancreatitis

Cocaine use is prevalent worldwide and affects multiple organ systems. Ischemia of the esophagus and small bowel are examples of its gastrointestinal complications. Cocaine-induced pancreatitis is a rare entity. Only 8 cases of cocaine-induced pancreatitis have been described in the literature. We present a rare case of a 61-year-old man cocaine user who presented with his first episode of acute pancreatitis (AP) in which common etiologies of AP were excluded. In addition, we explore the pathophysiology of cocaine-induced AP.

Cocaine-Induced Acute Pancreatitis: A Rare Etiology

An 18-year-old male with a medical history of trigeminal neuralgia presented to the emergency department with complaints of severe abdominal pain associated with nausea, projectile vomiting, and watery diarrhea with no fever, rigors, and chills. The abdominal examination was unremarkable. His lab results showed elevated serum lipase and amylase. Gallstones were ruled out by abdominal ultrasonography. His computed tomography (CT) revealed pancreatic enlargement with ill-defined borders. He reported cocaine use but had no history of alcohol abuse. A urine drug screen was positive for cocaine. He was managed conservatively with a possible diagnosis of acute pancreatitis due to cocaine abuse after carefully ruling out other causes. The patient was symptom-free on day 7 and discharged from hospital on day 8 with follow-up with his gastroenterology doctor and drug counseling service. Although cocaine-induced pancreatitis is rare, it should be considered a differential diagnosis in patients with a history of cocaine use.

Ever-increasing diversity of drug-induced pancreatitis

With over 100000 hospital admissions per annum, acute pancreatitis remains the leading gastrointestinal cause of hospitalization in the United States and has far-reaching impact well beyond. It has become increasingly recognized that drug-induced pancreatitis (DIP), despite accounting for less than 3% of all cases, represents an important and growing though often inconspicuous cause of acute pancreatitis. Nevertheless, knowledge of DIP is often curtailed by the limited availability of evidence needed to implicate given agents, especially for non-prescription medications. Indeed, the majority of available data is derived from case reports, case series, or case control studies. Furthermore, the mechanism of injury and causality for many of these drugs remain elusive as a definitive correlation is generally not established (< 10% of cases). Several classification systems have been proposed, but no single system has been widely adopted, and periodic updates are required in light of ongoing pharmacologic expansion. Moreover, infrequently prescribed medications or those available over-the-counter (including herbal and other alternative remedies) are often overlooked as a potential culprit of acute pancreatitis. Herein, we review the ever-increasing diversity of DIP and the potential mechanisms of injury with the goal of raising awareness regarding the nature and magnitude of this entity. We believe this manuscript will aid in increasing both primary and secondary prevention of DIP, thus ultimately facilitating more expedient diagnosis and a decrease in DIP-related morbidity.

Acute Methamphetamine-Induced Hepatic and Pancreatic Ischemia

Methamphetamine is a central nervous system stimulant that induces arousal, a positive mood, cardiac stimulation, and an acute improvement in cognitive domains. Its illicit exploitation is rapidly growing in North America. Typically, extended use of the drug induces organ damage via vasoconstriction and subsequent ischemia. This case specifically discusses hepatic and pancreatic pathology resulting from methamphetamine overdose alongside an unusual discovery of globally necrotic von Meyenburg complexes.