Small Intestinal Ischemia with Pneumatosis in a Young Adult: What Could Be the Cause?

This case highlights one of the infrequent complications of a commonly abused substance. A particular high index of suspicion of ischemic bowel is associated with cocaine abuse and should be included in the differential diagnosis of any young adult or middle-aged patient with abdominal pain and/or bloody diarrhea, particularly in the absence of other predisposing factors. To our knowledge, we report a rare case of ischemic small bowel associated with gangrene and pneumatosis intestinalis due to cocaine abuse. 1. Introduction This case highlights one of the infrequent complications of a commonly abused substance. A particular high index of suspicion of ischemic bowel is associated with cocaine abuse and should be included in the differential diagnosis of any young adult or middle-aged patient with abdominal pain and/or bloody diarrhea, particularly in the absence of other predisposing factors. Up to our knowledge, we report a rare case of ischemic small bowel associated with gangrene and pneumatosis intestinalis due to cocaine abuse. 2. The Case A 36-year-old Caucasian man presented to the emergency room with one-day history of acute onset right lower quadrant abdominal pain with nausea and vomiting. He denied any diarrhea, constipation, rectal bleed, fever, chills, food intolerance, or change in appetite. His medical and surgical history was unremarkable except for an appendectomy 10 years ago; he had never had a colonoscopy. His social history was significant for smoking (20-pack years) and occasional alcohol use. He denied the use of illicit drugs. On presentation, the patient was afebrile; other vital signs were within normal limits. He appeared well developed, well nourished, and in no acute distress. His abdomen was soft, with increased tenderness to palpation in the right lower quadrant with no rebound tenderness or palpable masses. The remainder of the physical examination, including a rectal examination, was unremarkable, and a test for fecal occult blood was negative. Initial blood workup revealed a slightly elevated white blood cell count of 12,500？cells/mL (4,500–11,000？cells/mL) with a normal differential. Serum calcium, kidney and liver function, and urinalysis results were normal. Computed tomography (CT scan) of abdomen and pelvis revealed only a 2？mm nonobstructing right lower renal stone with no hydronephrosis. Over the next 24 hours, however, the patient’s abdominal pain worsened. He was in obvious distress. Vital signs included tachypnea in the 30？s and a sinus tachycardia to the 130？s. The remainder of the physical exam revealed a