Dv. Feliciano et al., The epidemic of cocaine-related juxtapyloric perforations - With a commenton the importance of testing for Helicobacter pylori, ANN SURG, 229(6), 1999, pp. 801-804
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.