Not so Goody’s powder

Abstract

Over-the-counter analgesic medications are widely used amongst American adults and are also available in powder forms. Their adverse effects have been well documented in literature. Gastrocolic fistulas as a complication of peptic ulcer disease from analgesic powder usage have been previously unreported. Here, we report a patient with upper gastrointestinal bleeding and acute anaemia secondary to peptic ulcer complicated by gastrocolic fistula in a patient using analgesic powder.

Background

Over-the-counter (OTC) medications are widely used with studies indicating that approximately 80% of American adults utilise at least one OTC medication each week, most frequently analgesics.¹ These analgesics frequently include acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) with some in powder form (BC powder (a combination of 845 mg of aspirin and 65 mg of caffeine) and Goody’s powder).^{2 3} The adverse effects of NSAIDs (including intracerebral haemorrhage and salicylate toxicity) have been well documented in literature.^{3 4} We present a previously unreported case of upper gastrointestinal bleeding, feculent emesis and acute anaemia from a peptic ulcer complicated by gastrocolic fistula secondary to Goody’s powder.

Case presentation

A 39-year-old woman presented to an outside facility with abdominal pain, nausea and fatigue for 2 weeks. She also reported dyspnoea and ‘darker’ stool with an episode of emesis which she states was ‘dark’ in colour. She reported the use of Goody’s powder (a combination of 520 mg aspirin, 260 mg acetaminophen, 32.5 mg caffeine and 60 mg potassium) for chronic headaches due to a pituitary microadenoma. She had no other discernable medical history and family history was unremarkable.

On examination at the outside facility, she was normotensive with a blood pressure of 125/79 mm Hg and a heart rate of 75 bpm. General examination was notable for pallor but no icterus. Physical examination revealed left upper quadrant tenderness.

Investigations

On arrival at the outside facility, she was noted to have a haemoglobin of 77 g/L (previously normal). CT of her abdomen and pelvis was concerning for gastric neoplasia versus ulceration with colonic communication (figure 1).

Figure 1.

CT imaging concerning for gastric ulcer with colonic communication as denoted by arrow on axial (A) and coronal (B) views.

Treatment

Patient was transfused 1 unit of packed red blood cells and started on intravenous pantoprazole and oral carafate. A nasogastric tube was placed and apparent feculent liquid was seen on low intermittent suction. Patient was subsequently transferred to West Virginia University Hospital for further evaluation and management.

On transfer, she was clinically stable without additional complaint; her haemoglobin on arrival was 102 g/L. Esophagogastroduodenoscopy revealed a large ulcer in the antrum along the greater curvature (figure 2). Within the ulcer, normal appearing mucosa was identified; this was determined to be colonic tissue (figure 3). The fistulous tract was identified and traversed and colonic lumen was intubated (figure 4). No other abnormalities were identified, biopsies were obtained and the procedure was terminated. Definitive surgical treatment consisted of exploratory laparotomy, antrectomy with Roux-en-Y reconstruction, anterior and posterior vagotomy and partial transverse colectomy with primary anastomosis. Pathology report of the resected tissue was remarkable for benign changes with acute inflammation. No evidence of malignancy or Helicobacter pylori infection was identified on biopsy or resected tissue. Postoperative recovery was uneventful and patient was subsequently discharged with appropriate follow-ups in place.

Figure 2.

Large ulcer noted in the antrum along the greater curvature.

Figure 3.

Normal appearing mucosa identified as colonic tissue within the ulcer as denoted by arrow.

Figure 4.

Gastrocolic fistula identified within the ulcer as denoted by arrow (A) followed by colonic intubation and traversal (B).

Outcome and follow-up

At 3 months post intra-abdominal surgery, patient was able to return to work with minimal discomfort on exertion and tolerating diet with additional supplements and regular bowel movements.

Discussion

Peptic ulcer is defined as a digestive tract lesion induced by acid and is usually located in the stomach or proximal duodenum.⁵ It is well documented in literature that the main risk factors for peptic ulcer disease (PUD) are H. pylori infections and NSAID use, and the risk of complications of peptic ulcers is noted to be four times higher in NSAID users.⁵ PUD has been reported as a contributing aetiology to the formation of gastrocolic fistulas, however due to improved detection and treatment of the disease, fistulas are rare.⁶ To date, such a complication has not been reported due to usage of the powder form of NSAIDs.

Gastrocolic fistulas have been documented in association with various processes, including malignancy, inflammatory bowel disease and pancreatitis as well as from iatrogenic causes (eg, surgical complications or percutaneous gastrostomy tube migration).⁶ The majority of gastrocolic fistulas in the USA usually result from colonic adenocarcinoma.^{6 7}

The symptoms of gastrocolic fistulas typically include abdominal pain, nausea, vomiting, which may or may not be feculent, weight loss and diarrhoea.^{6 7} However, symptoms are largely undifferentiated, with the classically quoted triad of weight loss, faecal emesis and diarrhoea often being inconsistently observed.^{7 8} CT imaging can offer a diagnostic role, however it is largely utilised in staging and preoperative planning especially in cases of malignancy.⁷ Gastroscopies offer a more varied detection rate, however, it is recommended to perform gastroscopy with biopsy after a radiologic diagnosis is established in order to confirm the presence or absence of malignancy.^{7 8} Barium enemas remain the most accurate modality in establishing the diagnosis with studies suggesting a 100% detection rate.⁸ The diagnosis can also be easily missed clinically in the setting of complications such as bleeding or perforation.⁸

Several treatment modalities exist for the management of gastrocolic fistulas, with the mainstay being surgical resection. Literature has described en-bloc resections and Roux-en-Y gastrojejunostomy in the management of such fistulas.⁹ En-bloc resections of the fistula with primary gastrointestinal reconstruction have noted decreased incidence of recurrence in past reports.¹⁰ Gastroscopic interventions involving human fibrin sealant for closure have also been documented in addition to an over-the-scope clip placement method which is gaining favour as it is less invasive and can be offered as an alternative to patients with a higher perioperative risk.^{11 12} Successful non-surgical management of such fistulas arising as a complication of NSAID-related PUD has started to gain more traction and usually involve cessation of NSAIDs and pharmacological treatment with proton-pump inhibitors and H2-receptor blockers.^{10 13}

Learning points.

• This is an exceedingly rare complication due to overuse of an over-the-counter analgesic powder that has not been previously reported in published literature and emphasises the importance of drug history recording.

• A multidisciplinary team approach was required to direct and achieve appropriate management.

• Though this complication is rare, we encourage physicians to recognise early warning signs via clinical history and thoroughly review medication histories with their patients, thus enabling early diagnosis and appropriate timely intervention.

Ethics statements

Patient consent for publication

Obtained.