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Duodenal Perforation in a Patient with Heroin Use

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Duodenal Perforation in a Patient with Heroin Use LETTER TO EDITOR Duodenal perforation in a patient with heroin use Opioid kullanýmý ile iliþkili duodenal perforasyon Ümit Haluk Yeþilkaya1, Yasin Hasan Balcýoðlu2, Mehmet Cem Ýlnem3 1M.D., 2M.D.,3Assoc. Prof., Department of Psychiatry, Bakirkoy Prof Mazhar Osman Training and Research Hospital for Psychiatry, Neurology, and Neurosurgery, Istanbul, Turkey 1https://orcid.org/0000-0001-8521-1613 2https://orcid.org/0000-0002-1336-1724 3https://orcid.org/0000-0003-4127-1627 SUMMARY ÖZET A number of vascular pathologies are attributed to the Yoðun opioid kullanýmý miyokardiyal enfarktüs, iskemik opiate exposure such as myocardial infarction, ischaemic inme ve gastrointestinal sistemin hipoperfüzyonu gibi stroke, and hypoperfusion of the gastrointestinal tract. bazý vasküler patolojilere sebep olur. Burada, bilinen her- Here we presented a 30-year-old male patient with no hangi bir iskemik veya gastrointestinal hastalýk öyküsü history of any ischemic or gastrointestinal disease known olmayan 30 yaþýnda bir erkek hastanýn 10 yýllýk yoðun to have 10-year opioid use and had suffered a duodenal opioid kullanýmý sonrasý meydana gelen duedonal per- perforation. Prolonged exposure of opioids may lead to forasyon vakasýný sunduk. Opioidlere uzun süre maruz hypersensitivity reactions, ischemia and hypoperfusion kalýnmasý hipersensitivite reaksiyonlarýna, iskemi ve and combination of these entities with opioid-related hipoperfüzyona neden olabilir. Ayrýca buna opioid ile gastrointestinal motility deficits could contribute to the iliþkili gastrointestinal motilite bozukluklarýnýn eklenmesi epithelial damage and perforation as a consequence. de epitel hasarýna ve perforasyona katkýda bulunabilir. The presence of ischemic events should be kept in mind Yoðun eroin kullanan kiþilerde gastrointestinal semptom- in the presence of gastrointestinal symptoms in people larýn varlýðýnda iskemik olaylarýn varlýðý akýlda tutul- using intensive heroin. malýdýr. Key Words: Heroin, ischaemia, duodenal perforation Anahtar Kelimeler: Eroin, iskemi, duodenal perforasyon (Turkish J Clin Psych 2019;22:116-118) DOI: 10.5505/kpd.2018.29484 To the Editor knowledge, duodenal perforation associated with opiate exposure and its underlying pathogenesis As is well known, use of heroin has an increasing has not been documented yet, and we aim to report rate in recent years. For this reason, in clinical prac- a case of heroin-related duodenal perforation. tice, systemic side effects of heroin are also seen in an incremental trend considerably depending on A 30-year-old male patient with no history of any the intensity of usage. A variety of systemic compli- ischemic or gastrointestinal disease known to have cations such as hepatitis, endocarditis, tetanus, and 10-year opioid use has received opioid addiction sepsis are well-known entities related to heroin use therapy for the past year, during which time no (1). Additionally, a number of vascular pathologies substance use has occurred. He started to use hero- are attributed to the opiate exposure;PROOF myocardial in by inhaler> 10gr / day after complaints of sleep- infarction, ischaemic stroke, and colon perforation lessness, loss of appetite and intense feelings of have been reported in the patients with heroin use guilt, which started with the death of a child in a (2-4). Besides vascular damage, the unfavourable traffic accident a week ago. Particularly during this effects of opiate on gastrointestinal tract manifest week, episodes of intermittent crying were shouting as nausea, vomiting and constipation particularly "I did not intentionally" to myself. He also said that through receptor activation (1). To the best of our from time to time he heard the child's voice. The Makalenin geliþ tarihi: 12.09.2018, Yayýna kabul tarihi: 01.11.2018 116 Yeþilkaya ÜH, Balcýoðlu YH, Ýlnem MC. patient with these complaints was hospitalized with chronic use, hypersensitivity reactions, ischemia, acute stress-related suicidal thoughts. In the exami- hypoperfusion occur as a systemic effect. nation of the patient, cooperation and orientation Hypotension, especially due to cardiac effects, and were intact. Speech output and speed were bradycardia also play a role in ischemia (5). These decreased. Affect was depressed while mood was mechanisms, which are triggered by intensive and dysphoric. No negative psychotic findings were chronic heroin use in our patient, are thought to detected. Auditory pseudo-hallucinations were cause ischemic perforation by impairing the perfu- present. There was no pathological abnormality in sion of the duodenal epithelium and subepithelial his physical examination. In urine screening, opioid tissues. Opioid receptors are expressed by central was positive. The patient was started treatment and peripheral neurons and neuroendocrine (pitu- with quetiapine 100 mg/day diazepam 30mg/day, itary, adrenal), immune, and ectodermal cells (7,8). paracetamol 1500 mg/day, and metoclopramide 30 These receptors are defined as 3 main receptors; mg/day in order to manage withdrawal symptoms. mu, delta and kappa (See Table). Opioids affect the On the third day of the hospitalization, constipa- gastrointestinal tract through the mu receptor. In tion, abdominal pain, nausea, and vomiting were this way, it is known that motility slows down and suddenly started. Positive palpatory findings indi- constipation is caused (1). There are case reports cating acute abdomen such as rigidity and rebound that constipation has negative effects for a long tenderness were present. Following a computed time and that it causes colon perforation in parti- tomography scan of the abdomen revealing a lesion cular (4). Additionally, it may be thought that the consistent with duodenal perforation (Figure), per- possible corticosteroid discharge associated with foration repair was planned after an emergent acute stress recently experienced by our patient is referral to general surgery. The patient was opera- the basis for this ischemia. The presence of ted on by general surgery. The patient was kept ischemic events should be kept in mind in the pre- under observation for 4 days in general surgery. sence of gastrointestinal symptoms in people using During this period, daily psychiatric interviews intensive heroin. Finally, it is also known that non- were performed with the patient. The patient was steroidal anti-inflammatory drugs increase duode- transferred to psychiatry service at the end of the nal perforation and bleeding risk (9). In most treat- fourth day. Serum sertraline 100 mg/day treatment ments, these drugs are sometimes used as anal- was administered to the patient who had a full gesics in the treatment of addictions, especially remission in psychiatric symptoms and an admis- during painful periods of acute withdrawal. In such sion to addiction department for opioid use disor- cases, using paracetamol-like drugs to reduce the der was offered after discharge. risk will be safer than these drugs. Heroin acts directly on the vasomotor centre, Acknowledgements: None increases parasympathetic activity, reduces sympa- thetic tone, thereby inducing the release of hista- Role of the funding source: No funding was mine from mast cells (5). The parasympathetic received relevant to this article. activity also plays a role in the formation of spasm in mesenchymal vessels (6). As a consequence of Figure. Perforated duodenal ulcer in computed tomography scan 117 Turkish J Clinical Psychiatry 2019;22:116-118 Duodenal perforation in a patientwith heroin use Table : Opioid receptors and ligands (Adapted from Stein and Machelski (8)) Site of Effects Agonist Antagonist Action mu Systemic Analgesia, euphoria, morphine, fentanyl, CTOP, naloxone constipation, endomorphins, beta - respiratory endorphin depression Peripheral Analgesia, loperamide, Alvimopan, constipation, frakefamide, naloxone reduced inflammation DALDA, morphine -6- methiodide, glucuronide methylnaltrexone delta Systemic Analgesia, convulsions, DPDPE, SNC 80, Naltrindole anxiolysis enkephalins, naloxone deltorphin, beta - endorphin Peripheral Analgesia, constipation UK-321,130; Naloxone ADL5747; methiodide ADL5859; JNJ - 20788560 kappa Systemic Analgesia, diuresis, bremazocine; Norbinaltorphimine, dysphoria dynorphin naloxone Peripheral Analgesia, reduced Asimadoline Naloxone inflammation methiodide Contributors: The authors contributed equally to document signed by index patient. this manuscript. Note: It is the policy of this Journal to provide a Conflict of interest: None of the authors has a free revision of English for Authors who are not financial or personal conflict of interest. native English speakers. Each Author can accept or refuse this offer. In this case, the Corresponding Ethics: Authors confirm that the submitted study Author accepted our service. was conducted according to the WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects. The study Correspendence Adress: M.D. Ümit Haluk Yeþilkaya, does not have IRB review/approval; this study does Department of Psychiatry, Bakirkoy Prof Mazhar Osman not require ethics committee approval because Training and Research Hospital for Psychiatry, Neurology, and "Letter to editors and case reports" do not require Neurosurgery, Istanbul, Turkey [email protected] ethics committee approval but an informed consent REFERENCES 1. Benyamin R, Trescot A, Datta S, Buenaventura R, Adllaka domyolysis caused by acute heroin intoxication]. Recenti Prog R, Sehgal N, Glaser SE, Vallejo R. Opioid complications
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