|Case of the Week - Patient Summary 13288|
Peer Reviewed and Certified -
|Demographics: 19 y.o. man|
|History & Chief complaint:|
| 19 y.o. man who presents w/ six hours of severe epigastric and upper abdominal pain, radiating to his back. He volunteered that he had been smoking cocaine (crack) one hour prior to the start of his symptoms. Social history is positive for EtOH (six drinks daily), tobacco, and cocaine abuse. He has no prior medical or surgical history and no previous abdominal complaints. |
|Physical exam and Laboratory:|
| • Vital signs: stable, afebrile, with mild sinus tachycardia.
• Abdomen is soft, non-distended with positive bowel sounds, but with positive guarding and rebound tenderness.
• WBC count eleated at 15.1, lactic acid 2.5 mmol/L (high), potassium 6.4 mmol/L (critical high), urinalysis positive for protein, ketones and urobilinogen.
|Summary of Findings:|
|Single AP supine view of abdomen demonstrates a thin line of gas in the right upper quadrant, concerning for free air. Mildly distended prominent centralized loops of small bowel are seen in the mid abdomen which may represent a regional ileus. Gas is seen outlining the left psoas muscle.
Single AP frontal view of chest demonstrates a subtle area of lucency under the right hemidiaphragm suspicious for free air in the abdomen. No pneumothorax is noted.
• Perforated hollow viscus (eg. gastric - peptic ulcer disease)
• Ischemic enteritis
• Pneumomediastinum/pneumothorax decompressing into abdomen
• Gas-forming bacterial peritonitis
• Penetrating trauma to abdomen
| Pre-pyloric Gastric perforation, cocaine abuse |
|Confirmed by: Exploratory Lapartomy|
|Treatment and Followup:|
|Due to high clinical suspicion, acute abdomen in the setting of crack abuse, and with positive imaging findings indicating pneumoperitoneum, our patient underwent emergent exploratory laparotomy and subsequent repair of his pre-pyloric perforation. No findings of ulcer disease were found. The clinical presentation was classic for gastric perforation from crack abuse.|
|Patient Specific Discussion: (Also Read the Disease Discussion)|
|Companion case: - LINK -|
|Lesions/Condition: Perforation of prepyloric region of the stomach
Cell of Origin: Gastric cell
Associations/Predisposing Factors: Crack abuse. Both crack and cocaine can lead to an acute abdomen secondary to ischemia. However, while cocaine is primarily linked to mesenteric ischemia/gangrene leading to small and large bowel perforation, the usual cause of an acute abdomen after crack abuse is gastric or duodenal perforation. Although the underlying pathophysiology of both drug forms is vasoconstriction, it is thought that crack specifically decreases gastric motility and that increased intraluminal gastric pressure associated with smoking of this drug with air swallowing and breath holding compounds the problem.
Common Locations: Pre-pyloric region of stomach, duodenum
Demographics: Crack abusers
Gross Appearance: Perforation of hollow viscus
Radiology: Pneumoperitoneum, Rigler's sign
Prognosis and Treatment: Mortality in crack abusers secondary to gastrointestinal complications such as perforation have been reported to be as high as 21%. High clinical suspicion for an acute abdomen is required in patients who abuse crack cocaine. Early surgical intervention via exploratory laparotomy and repair of the perforation is key in reducing mortality. Additionally, patients should be tested for Helicobacter pylori because these patients have a high incidence of infection.