Gastric Perforations Associated With the Use of Crack Cocaine

Gastric perforation is a rare but serious complication of crack cocaine use, accounting for up to 36% of all acute gastroduodenal perforations.¹ Gastroduodenal ulcer perforations that are temporally associated with crack cocaine have been increasingly recognized,² likely because of the rising use of this substance.^3,4 Uzzaman and colleagues report a case of a 19-year-old female who presented with acute gastric perforation without any apparent risk factors for peptic ulcer disease.⁵ Upon further investigation, the patient reported recent inhalation of crack cocaine. This case illustrates the need for a heightened awareness of this complication and the challenge of making an accurate and prompt diagnosis.

Crack cocaine, an alkaloid extracted from the leaves of the Erythroxylon coca plant,⁶ is a less expensive, smok-able version of cocaine created via the addition of baking soda.⁷ Crack cocaine causes a wide range of potential cardiac, pulmonary, obstetric, musculoskeletal, neurologic, and gastrointestinal complications. Gastrointestinal complications are relatively uncommon; however, they tend to be significant when they do occur, as they can include both bowel ischemia and perforation.^8–12 The inhalation of crack cocaine leads to higher peak levels of the drug² secondary to its rapid absorption in the vast pulmonary absorptive surface,¹³ which may account for the more severe complications associated with this form of the drug. In addition, multiple studies suggest a temporal association between crack cocaine use and the development of gastroduodenal ulcers.^2,9,14

The typical clinical presentation of acute gastroduodenal perforation includes sudden onset and sharp epigastric pain; at times, patients may also have referred shoulder pain¹⁵ due to free air under the diaphragm. Other patients may present with less classic symptoms, including nausea, vomiting, diarrhea, and mild abdominal pain. Because symptoms may be nonspecific, the diagnosis can initially be missed, especially in younger patients. In addition, there may be no abnormal imaging findings such as free intraperitoneal air⁹; therefore, a high index of suspicion for this condition is required.

The pathogenesis of gastroduodenal ulcer perforation in association with crack cocaine use remains unclear. Cocaine acts by blocking reuptake of dopa-mine, epinephrine, and norepinephrine, leading to sympathetic nervous system stimulation and subsequent vasoconstriction.^1,16 Several other pathophysiologic mechanisms have also been proposed, including focal ischemia,^3,17 microthrombi, embolism,¹² delayed gastric emptying,^1,14 and an increase in intra-abdominal pressure due to chronic aerophagia.^9,18 A possible association with Helicobacter pylori infection has also recently been described. One retrospective chart review of 50 cases of acute gastroduodenal perforation associated with crack cocaine use reported an 80% incidence of H. pylori infection in antral biopsies¹; however, this finding has not been subsequently confirmed. Currently, the leading theory is that cocaine-associated perforation is caused by focal ischemia secondary to profound vasoconstriction and does not follow a traditional ulcer-related developmental pathway.^2,3,7

The management of perforated gastric ulcers must be individualized. Conservative management with the Taylor method consists of intravenous fluids, nasogas-tric aspiration for gastric decompression, and antibiotic therapy for H. pylori infection.¹⁹ Although conservative management has the advantage of avoiding the morbidity and mortality associated with surgery and anesthesia, surgical management is more commonly used today. Types of surgical repair procedures include formal anti-ulcer operations (including vagotomy and pyloroplasty, vagotomy and antrectomy, and subtotal gastrectomy) as well as omental patch repairs. The omental patch, first described in 1937,²⁰ has become the most commonly used procedure for treating a perforated peptic ulcer,^21,22 and it can be performed via either an open or laparoscopic approach. In one recent retrospective chart review of 16 cases of crack cocaine–associated gastric perforation, 75% were treated with omental patch repair compared to 25% who underwent formal anti-ulcer pro-cedures.⁷ The patients who had omental patch closures had a recurrence rate greater than 50%, while there were no recurrences in patients who underwent formal anti-ulcer procedures. Further studies are needed to identify the optimal surgical approach in this population and to further define factors that influence recurrence, including perforation location and recurrent cocaine use.

Gastroduodenal perforations associated with crack cocaine use most often affect the first portion of the duodenum or pylorus.⁶ In addition, they are usually small (measuring 3 –5 mm),¹ they predominantly affect men, and they occur at a younger age than peptic ulcer disease–related perforations. The case presented by Uzzaman and colleagues has several unusual features; in particular, this case occurs in a female patient, and it is the youngest case of perforation secondary to cocaine use reported in the literature.⁵ Furthermore, the location in the posterior portion of the upper gastric body near the greater curve has been reported only once previ-ously.¹⁴ This atypical location led to greater difficulty in identifying the lesion during laparotomy.

Crack cocaine is increasingly recognized as a risk factor for gastroduodenal perforation. In this report, Uzza-man and colleagues present a case of acute abdomen due to cocaine-associated gastric perforation in a previously healthy, young female.⁵ Further studies are needed to provide a better understanding of the pathophysiologic mechanism underlying this entity and to clarify the optimal surgical approach. This case nicely illustrates a subtle presentation of this disease entity and should heighten awareness among clinicians about the need to obtain a history of cocaine smoking in patients who present with unexplained abdominal pain or pneumoperitoneum.