University of Texas Health Science Center San Antonio, TX
Grace Hopp, DO, MBA1, Tamneet Singh, MD1, Charles Brady, III, MD, FACG2; 1University of Texas Health Science Center, San Antonio, TX; 2UT Health San Antonio, San Antonio, TX
Introduction: Ischemic colitis can be caused by a wide variety of factors and is most often seen as an atherosclerotic event in the elderly. We report a case of a healthy young male who presented with multiple episodes of hematochezia and was found to have ischemic colitis due to cocaine use.
Methods: A healthy 27 year old male presented to the emergency department with one day history of left lower quadrant abdominal pain and over 10 episodes of hematochezia. He denied recent travel, sick contacts or family history of inflammatory bowel disease. His exam revealed diffuse abdominal tenderness. Laboratory data was significant for hemoglobin of 16 g/dL on arrival, which decreased to 12.7 g/dL after ongoing hematochezia. A CT of his abdomen/pelvis revealed diffuse circumferential wall thickening of sigmoid and descending colon with adjacent pericolonic fat stranding, suggestive of colitis. A GI PCR for infectious diarrhea was negative. Fecal calprotectin was greater than 1,250 μg/g. A colonoscopy demonstrated diffuse, erythematous and friable mucosa in the sigmoid and transverse colon with discontinuous areas of nonbleeding ulcerated mucosa. Biopsies showed surface ulceration, regenerative epithelial changes and superficially injured and withered crypts as seen with ischemia. Once pathology results returned, the patient disclosed using intranasal cocaine prior to the onset of the abdominal pain and his hematochezia was the result of cocaine induced ischemic colitis. Discussion: Our patient was a young male presenting with hematochezia, diffuse abdominal pain, signs of colitis on imaging and had an elevated fecal calprotectin. Because of this, inflammatory bowel disease was high on the differential diagnosis. However his biopsies revealed pathology consistent with ischemia. A study by Hsieh et al, evaluated ten patients with ischemic colitis and found that each of them had an elevated fecal calprotectin. The levels were not indicative of severity or prognosis. Cocaine induced ischemic colitis is well described, especially in young patients with severe abdominal pain and hematochezia, as in our patient. Early suspicion and a careful history are essential to avoid significant morbidity and mortality. This case highlights the importance of maintaining high suspicion of cocaine abuse in young patients with ischemic colitis despite an elevation in fecal calprotectin levels.