Fishel R, Hamamoto G, Barbui A, Jiji V, Efron G. Cocaine colitis: is this a new syndrome? Dis Colon Rectum 1985;28:264-266. An unusual case of colitis in a ...
Cocaine Colitis Is This a N e w Syndrome? R H O N D A F I S H E L , M.D., G A R Y H A M A M O T O , M . D . , ADRIAN BARBUI,
M.D., V I O L E T J I J l , M.I)., G E R S I I O N E F R O N , M . D .
From the Departments o] Surgery and Pathology, Sinai Hospital o/Baltimore, Baltimore, Maryland.
Fishel R, H a m a m o t o G, Barbui A, Jiji V, Efron G. Cocaine colitis: is this a new syndrome? Dis Colon Rectum 1985;28:264-266. An unusual case of colitis in a 37-year-old cocaine addict is described. T h e patient presented with rlght-sided abdominal pain and diarrhea exacerbated by his use of cocaine. Significant antibiotic ingestion was denied. At iaparotomy, an edematous cecum and ascending colon were found, the cut surface of which revealed diffuse superficial ulcerations and yellowish fibrinous material. Microscopic examination demonstrated findings consistent with pseudomembranous colitis with an ischemic component. A mechanism involving cathecholamineinduced mucosal ischemia is postulated to explain the findings seen in this patient. [Key words: Cocaine; Diarrhea; Pseudomembranous colitis; Ischemic colitis; Catecholamines]
the st(x)l. The rest of tile examination was normal. "l'he white blo(xt cell count on admission was 23,600 with a mild left shift. No biochemical abnormalities were detected. Abdominal roentgenoga-ams revealed lack of bowel gas, with no flee air. Clostridium di]ficile toxin was not found in stool swcilnens. +Ihe patient was admitted to the hoslfital where a (;astrografJn!': enenaa showed (e(al irzitabilit 3 suggesti',e of culitb, with a que>tionabh' mass in tht" light ilia~ ionia. Sigmoidoscol)y revealed ti)e recttun to be llOlln~t]. I h e l)aticl'l[ devt'lof• free1 with sigm, of ill(revising p e l i tonitis in serial abdominal examinations. Under am,sthesia, a mobile mass ~ as palp:m.d in the light lower quadrant whi(h, at lal)arotomy. l)ro~ed to be a ma,'kedH edematous cecum and as(etMing (olon with thickening u[ the tx)wel wall. These (hange> ended ahruptl'~ at the t l a n s x e r s e (O]Ol). J ' t l e Slnall inte,,tine down to tht' ih'o( ecal waive wax
T H E RECREATIONAl. USE OF COCAINE is t h i s c o u n t r y
has risen dramatically in the last several years. C o n c o m i t antly, rel:x)rts of untoward side effects from its use n o w abound. In this report, w e describe an unusual case of colitis that w e believe was exacerbated by cocaine.
lIOrl)la]. ;D, w a s tilt' al)l)t'ndix. N o tR)wI'] ] R ' l l o l a t i o n lIOl t {)lnpl ou)i~,i:' (;,l
the ', a~,culatule was fotmd. A ~ight helnicolectom', was ix'rfot mt'd with i]t'Otlall.',vel"~r cob)l) al)aM(llllOSis. l'ht' po.,,tolx'rative COUl~,e w a s u n t'~ entful. ()n fl)llow-ul)examination, the p,ment denied t• cmrcnt ('(X a i l w u.',c' a n d dial I hea.
Report of a Case P a t h o l o g i c Findings
A 37-year-old black man presented to the emergency room with a three-day histc, ry of severe right lower quadrant pain, diarrhea, and v,'ate~ ~ t temoccu It.R:tx~itive styx)Isass(x'iated with nausea :rod ', omit rag. There was no blood in the vomitus. The pain was not reliew~d by antacids or ntild narcotic analgesics. Past history included a partial gastrectomy for peptic ulcer in 1969. The patient gave a history of infrequent epis(Mes of diarrhea, mainly associated with meals and anxiety throughout his life. An increase in the severity and frequency of stools was noted with the onset of cocaine use about seven years prior to adlnission, eight years after the ulcer surgery. The patient consumed 1~ to 2 gm of cocaine three times a week by "free basing," a prc, cess whereby cocaine hydrochloride is converted to c{waine sulfate. Within 15 minutes of using cocaine, he would need to move Iris bowels and then have watery diarrhea. This symptom occasionally was duplicated whet) the patient merely anticipated cocaine use. The diarrhea was essentially painless until about one year before admission, when the patient began having crampy abdominal pain with bowel movements while using c(x:aine. There was no nausea and only ()tie episode of vomiting. He denied the regular use of other drugs, except alcohol, while using cocaine. He denied taking antibiotics except four oral doses of tetracycline, over a tx~ri(xf of four mouths ending one mouth prior to admission, for an unrelated illness. On examination, vital signs were normal. Abdominal examination revealed a very tender area in the right lower quadrant, with rebound tenderness attd guarding. No bowel sounds were heard. No mass was felt in the right lower quadrant or rectum. Occuh blood was preser, t in
Gross e x a m i n a t i o n of the right colon revealed diffuse supelficial ulcerations covered with scant yellow fibrinous mawrial with an intensely hyperemic base (Fig. 1). In some areas, the ulcerations were serpiginous with a c o b b l e s t o n e 1-mttern to t h e r n t t c o s a . N u m e r o u s lymph
microscol)ic examinafi(m
demonstrated
ent with l)seudometnbranous were
enlarged
nodes were present. The ileunt was normal. The
suggestive
of
ischemic
findings consist-
colitis and some areas that colitis.
No
evidence
of
chronic inflanmaatory bowel disease, granulotnas or vasculitis was fotmd (Fig. 9). Discussion T h e occurrence of diarrhea wittt cocaine c o n s u m p t i o n is apparently well k n o w n to cocaine users, but has rarely been relx)rted in the medical literature. ~ Cocaine is an ester of benzoic acid and a nitrogenc o n t a i n i n g base. T h e most i m p o r t a n t k n o w n effects of cocaine are on the central nervous system where it acts as a stimulant (at all levels from cortex to cord) possibly by blocking inhibitory pathways. T h e d r u g also has powerful effects on the sympathetic nervous system. It blocks
Rec~:ived for publication August 27, 1984. Address leprint requests to 1)r. Efron: Sinai Hospital of Baltimore. Belvedere 8,: Greenspring Avenues, Bahirmne. Maryland 91213.
264
Vl~lumv28 x~,,~.-, .~
COCAINE COLITIS
5)65
FIG 1. Gross aptx~arance of right hemicolectomy specimen. T h e mucosa of the cecum a n d ascending colon shows discrete a n d c o n f l u e n t p a t c h e s of g r a y - w h i t e plaques (pseudomembrane) overlying areas of ulcerations.
Flq:;. 2. P h o t o m i c r o g r a p h of
