The epidemic of cocaine-related juxtapyloric perforations - With a commenton the importance of testing for Helicobacter pylori

Objective This is a report of 50 consecutive patients with juxtapyloric per forations after smoking "crack" cocaine (cocaine base) at one urban public hospital. Summary Background Data Although the exact causal relation between smoking crack cocaine and a subsequent juxtapyloric perforation has not been define d, surgical services in urban public hospitals now treat significant number s of male addicts with such perforations. This report describes the patient set, presentation, and surgical management and suggests a possible role fo r Helicobacter pylori in contributing to these perforations. Methods A retrospective chart review was performed, supplemented by data fr om the patient log in the department of surgery. Results From 1994 to 1998, 50 consecutive patients (48 men, 2 women) with a mean age of 37 had epigastric pain and signs of peritonitis a median of 2 to 4 hours (but up to 48 hours) after smoking crack cocaine. A history of c hronic smoking of crack as well as chronic alcohol abuse was noted in all p atients; four had a prior history of presumed ulcer disease in the upper ga strointestinal tract. Free air was present on an upright abdominal x-ray in 84% of patients, and all underwent operative management. A 3- to 5-mm juxt apyloric perforation, usually in the prepyloric area, was found in all pati ents. Omental patch closure was used in 49 patients and falciform ligament closure in I. Two patients underwent parietal cell vagotomy as well. In the later period of the review, antral mucosal biopsies were performed t hrough the juxtapyloric perforation in five patients. Urease testing was po sitive for infection with H. pylori in four, and these patients were prescr ibed appropriate antimicrobial drugs. Conclusions Juxtapyloric perforations after the smoking of crack cocaine oc cur in a largely male population of drug addicts who are 8 to 10 years youn ger than the patient group that historically has perforations in the pyloro duodenal area. These perforations are usually 3 to 5 mm in diameter, and an antral mucosal biopsy for subsequent urease testing should be performed if the location and size of the ulcer allow this to be done safely. Omental p atch closure is appropriate therapy for patients without a history of prior ulcer disease; antimicrobial therapy and omeprazole are prescribed when H. pylori is present.