A 40-year-old male presented to the emergency department with abdominal pain.
Hypertensive patient treated with beta-blockers, heavy smoker and consumed opioid analgesics for three years due to recurrent colitis.
She complained of abdominal pain of two days duration with subsequent onset of diarrhea without pathological products and abdominal distension requiring emergency consultation.
On his arrival he was conscious of a significant degree of anxiety and burnout.
Abdominal disorientation, defense and peritoneal irritation mainly in hypogastrium and right iliac fossa.
Elevation of acute phase parameters in laboratory tests.
The CAT scan showed an appellation of the intestinal loops with fluid between them at the level of the right fossa secondary to a possible iliac process.
With this diagnosis he underwent emergency surgery finding a generalized intestinal dilation and normal cecal appendix.
Two segments were pale and located in the ileum with a thickened wall and a feeling of "cartonation" and in the ileum. The loops were then crushed forming a mesoforgill.
Resection of the affected ileum was decided with primary anastomosis.
Serology, autoimmunity tests for lupus and Behcet syndrome, hypercoagulability studies, and coprocultive including detection of Clostridium difficile toxin were performed, all negative.
Finally, the histological study of the specimen ruled out inflammatory bowel disease and confirmed the existence of hemorrhagic necrosis in serosa and subserosa, steatonecrosis with signs of ischemia and necrotizing phlebitis.
The final diagnosis is ischemic enteritis associated with drugs or toxics, discarding secondary vasculitis or veno-occlusive disease due to the absence of typical clinical and analytical signs of the disease.
The thorough questioning of the patient showed cocaine consumption in the days prior to consultation and psychiatric evaluation for repeated agitation episodes that confirmed the existence of opiate deprivation syndrome.
The subsequent evolution progressed to a worsening of the clinical condition resulting from an ischemic laparotomy, with resection of the loop at the level of the jejunum or iliac crest. The sigmoid colon showed no signs of parietal thickening or perforation.
Histological examinations were performed according to previous ones.
Posterior wound with C-sepsis, severe surgical site infection with mixed flora and fistulization at the midline of laparotomy with low output fecaloid drainage.
The opaque enema and barium transit demonstrated complex fistula with double Y-shaped path from the jejunal anastomotic to the sigmoid and from this to the skin.
Once the infection was controlled, the patient was discharged from the hospital with a progressive decrease in fistulous output, until it became occasional.
The presence of ulcerated area with chronic inflammation at the rectosigmoid level was demonstrated.
The current clinical situation of the patient is good, with normal bowel function and total withdrawal of cocaine and opioid analgesics.
