paralytic ileus secondary to methamphetamine abuse: a paralytic ileus secondary to methamphetamine...
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Case ReportParalytic Ileus Secondary to Methamphetamine Abuse:A Rare Case
Mark AidanMcKelvie1,2 and Yuksel Gercek2
1School of Clinical Medicine, University of Cambridge, Addenbrookes Hospital, Cambridge CB2 0SP, UK2Department of General Surgery, Bedford Hospital NHS Trust, Kempston Road, Bedford MK42 9DJ, UK
Correspondence should be addressed to Mark Aidan McKelvie; firstname.lastname@example.org
Received 3 June 2017; Accepted 7 August 2017; Published 31 August 2017
Academic Editor: Gabriel Sandblom
Copyright 2017 Mark Aidan McKelvie and Yuksel Gercek.This is an open access article distributed under theCreativeCommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.
Methamphetamine hydrochloride, colloquially referred to as crystal meth, is a potent psychoactive amphetamine derivate.Methamphetamine produces stimulant effects in the user including increased energy and alertness as well as inducingintense euphoric symptoms and suppressing appetite through its dopaminergic, serotonergic, and adrenergic actions. Useof methamphetamine can adversely affect cardiovascular, neurological, and gastrointestinal physiology leading to significantmorbidity.Wepresent a rare case of paralytic ileus secondary tomethamphetamine abusewhich has only once before been describedin the literature.
Methamphetamine hydrochloride, colloquially referred toas crystal meth, is a potent psychoactive amphetaminederivate. Its use produces stimulant effects in the individualuser; these include feelings of increased energy and alertnessin addition to intense euphoria and appetite suppression. The prevalence of methamphetamine use is lower inthe United Kingdom than it is in the United States witha recent Home Office survey revealing 0.2% of 1624 yearolds reporting methamphetamine use in 2014-15 . Com-paratively, in the United States, 0.9% of 1825 year olds hadreported use of methamphetamine in 2014-15 . Seriousneurologic, cardiovascular, and gastrointestinal harm haspreviously been reported following methamphetamine use,probably through the downstreameffects ofmonoamine neu-rotransmitter release [1, 4]. We describe a rare case, hithertoreported only once before in the English-written literature,of methamphetamine-induced paralytic ileus and discuss thepossible underlying pathophysiological mechanisms.
2. Case Presentation
A forty-two-year-old gentleman presented to the emergencydepartment complaining of a one-day history of increasing
central abdominal pain and distension. He was nauseatedand had vomited watery-brown vomitus five times prior toadmission. His bowels had opened the day before but hadnot opened on the day of admission nor had he passed flatus.His past medical history included regular methamphetamineuse (approximately one-quarter ounce, equivalent to approx-imately seven grams, every five days), previous intravenousdrug use, and asthma, forwhich he regularly used a combinedsteroid and beta-agonist inhaler. He had had no previousabdominal surgery. He volunteered that in the four days priorto the onset of symptoms he had consumed two to three timeshis usual amount of methamphetamine, which he swallowedas an oral paste. Physical examination revealed he was mildlydehydrated, with no pallor or icterus. His abdomen wasdistended and tympanic with absent bowel sounds. Therewere no signs of peritonism or herniae. Rectal examinationrevealed a collapsed rectum with no masses. Vital signsshowed a tachycardia of 116 beats per minute, blood pressureof 132/84mmHg, and temperature of 36.0C. Laboratorystudies revealed a white cell count of 14.0 109 cells/l (91%neutrophils) and a C-reactive protein of 43mg/l. Renal andliver function tests, and amylase, were normal and venousgas analysis revealed a pH of 7.39, PaCO2 of 6.0 kPa, serumbicarbonate of 27.2mmol/l, base excess of 2.2mmol/l, and
HindawiCase Reports in SurgeryVolume 2017, Article ID 9762803, 3 pageshttps://doi.org/10.1155/2017/9762803
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Figure 1: Abdominal plain film radiography demonstrating multi-ple dilated small bowel loops.
serum lactate of 0.9mmol/l. Dipstick urinalysis was negativeand plain film radiography of the chest was unremarkable.Abdominal plain film radiography demonstrated multipledilated loops of small bowel (Figure 1). The patient wasadmitted under the general surgical team with paralytic ileussecondary to methamphetamine use, made nil-by-mouthand treated with intravenous fluids and a nasogastric tubefor gastric decompression. The patients symptoms began toimprove within twenty-four hours of admission after whichthe nasogastric tube was removed. By forty-eight hours hereturned to full oral diet and was discharged home withoutpatient drug liaison service follow-up. There had beenno recurrence of symptoms since discharge when he wasfollowed up two months later.
Multiple harmful effects, secondary to the use of metham-phetamine, on the neurological, cardiovascular, and gas-trointestinal systems have been described in the literature.Methamphetamine-induced cerebrovascular accident (bothischaemic and haemorrhagic) , neurodegenerative dis-orders , and dyskinesias  have been described andcardiovascular complications include acute coronary syn-drome  and aortic dissection . These effects appearto be related to the stimulated release of neurotransmittersincluding dopamine, serotonin, and/or noradrenaline [1, 10],with noradrenaline acting via alpha-1 receptors in arterialvasculature to stimulate vasoconstriction and via beta-1receptors to increase cardiac contractility and heart rate ,leading to hypertension and tachycardia, and promoting car-diac ischaemia. More recently, a study has demonstrated howmethamphetamine directly stimulates the release of endothe-lin, a potent vasoconstrictor, in mouse arteriole suggest-ing an additional mechanism in which methamphetamineinduces arterial vasoconstriction . With this in mind,methamphetamine-induced ischaemic colitis/infarction has
also been described several times before [13, 14], the mech-anism of which may also lie in noradrenergic/endothelin-mediated mesenteric arterial vasoconstriction. Carlson et al. have described a single case of paralytic ileus secondaryto methamphetamine. Similarly to the case described in ourreport the patient presentedwith a short history of abdominalpain, tachycardic, and with abdominal signs consistent withileus. Plain film radiography in both cases demonstratedmultiple dilated bowel loops. Like the patient describedin our report, there were no signs of intestinal ischaemia(given the normal venous lactate level). In contrast, thepatient described in our report presented with multipleepisodes of vomiting and so a decision was made to inserta nasogastric tube to provide gastric decompression andsymptomatic relief. The onset of symptoms also clearlycoincided with a preceding binge of two to three timesthe quantity of methamphetamine usually ingested by thepatient. With no other obvious aetiology for the ileus, wepropose that the cause of the ileus was as a result of theingestion of a higher-than-usual dose of methamphetamine.Separate to the vascular effects of the monoamine neuro-transmitters, there appear to be direct effects of dopamineand noradrenaline on the function of the gastrointestinaltract. Studies implicate dopamine in intestinal motility ,with one study demonstrating how dopamine, acting atthe D1 receptor, causes concentration-dependent reductionin mouse ileum muscle tone and markedly reduces smallbowel contractility . Separately, noradrenaline acting onintestinal smooth muscle has been shown to reduce motility. Whilst the exact mechanism for paralytic ileus in thepresented case is uncertain, in the absence of evidence ofmesenteric ischaemia and other precipitants of ileus, theauthors propose that the underlying mechanism for thepresentation may involve direct, nonvascular dopaminergicand/or noradrenergic effects on intestinal smooth muscle,secondary to methamphetamine administration, leading tothe symptoms and signs of ileus.
The case described is only one of two documented casesof ileus secondary to methamphetamine abuse but reflects agrowing trend in recent years of more complications beingattributed to the potent stimulant.Whilst these complicationsare rare, serious sequelae can occur in multiple systemsfollowing methamphetamine use, leading to significant mor-bidity. It is therefore important for the clinician to understandthe possible pathophysiological effects of the drug and toconsider this as a differential diagnosis in a user of metham-phetamine who presents acutely with abdominal symptoms.
Conflicts of Interest
The authors declare that there are no conflicts of interest.
 S. J. Kish, Pharmacologic mechanisms of crystal meth, Cana-dianMedical Association Journal, vol. 178, no. 13, pp. 16791682,2008.
 L. Deborah, Drug Misuse: Findings from the 2014/15 CrimeSurvey for England and Wales, Second edition, 2016, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/462885/drug-misuse-1415.pdf.
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 Center for Behavioral Health Statistics and Quality, 2015National Survey on Drug Use and Health: Detailed Tables.Substance Abuse and Mental Health Services Administration,2016, Rockville, MD