Sickle cell–related acute abdominal painful crisis complicating the clinical management of a cocaine‐packer
Authors: Letizia Del Monte, Riccardo Manfredi, Oliviero Olivieri, Lucia De Franceschi
Journal: American Journal of Hematology (2010)

A 17-year-old Nigerian man was admitted to our Department for acute abdominal pain with a visual analogical pain score (VAS) of 9 (VAS: from 1 to 10; 1: no pain, 10: worst pain) mainly localized in the epigastrium and associated with nausea [1]. His medical history was positive for sickle cell disease (SCD) with related retinal damage and one prior acute chest syndrome. His blood pressure was 100/60 mmHg, heart rate 100 beats/min, and respiratory rate 12 breath/min. Physical examination revealed dehydrated skin and mucosa surfaces and the presence of a nonpulsating mass in the mesogastric area. A diagnostic work-up including chemistries, complete blood count, abdomen X-ray, ultrasound, and computed tomography (CT) was performed. Abdominal CT showed a high number of foreign bodies, with oval morphology (major axis of 4.5 cm and 1.7 cm thick) mostly located in the stomach, in the right colic flexure, and in the right portion of the transverse colon; two foreign bodies were recognized at the passage from rectum to sigma as possible cocaine ovules (Image 1, white arrows). On noncontrast-enhanced CT images, a hyperdense pattern due to iron accumulation compatible with sickle cell–related organ damage was observed (Image 1). A conservative approach for the clinical management of cocaine body packers was selected [2]. The patient underwent a gastroscopy, which showed the stomach full of white ovules (n = 10), and whole bowel irrigation with a polyethylene-glycol (PEG) solution at the rate of 1 L/hr orally (total volume of 4 L) until another 20 packets were passed with almost complete resolution of the abdominal pain, disappearance of the abdominal mass observed before, and radiological confirmation of bowel clearance. No signs of cocaine intoxication or bowel obstruction were present. However, 48 hr after hospital admission, a new episode of acute generalized dull abdominal pain with VAS-pain of 9 and musculoskeletal pain at major joints ensued. Since no clinical or instrumental signs of acute kidney, gallbladder disease, appendicitis, or ischemic colitis were present, we suspected this presentation to be one of sickle cell–related abdominal pain, most likely triggered by the treatment for clearing the cocaine packets. A therapeutic erythrocytoapheresis to rapidly reduced HbS levels was performed in conjunction with balanced analgesia and intravenous hydration [1]. The patient was discharged after a 9-day hospital course. Thus, treatment of cocaine body packers with PEG whole bowel irrigation, that acts as an osmotic agent drawing water into the lumen of gastroenteric tract, might contribute to patient dehydration [3, 4], which is one of the factors triggering sickle cell–related acute pain episodes [5]. Thus, SCD should be considered as an additional risk factor possibly contributing to complications during the clinical management of cocaine body packers. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]