IDDF2019-ABS-0309\u2005Gastro-intestinal ulcerations/strictures in opioid abusers

Abstract

Background Opioid-induced bowel dysfunction include constipation, gastro-oesophageal reflux, abdominal distension and intestinal pseudo-obstruction. We report patients presenting with gastro-intestinal strictures and ulcers secondary to opioid abuse, an entity not well described in the literature. Methods This is a prospective observational study of patients with opioid abuse (, who were diagnosed as having GI ulcers or strictures, between January 2016 and December 2018, at Dayanand Medical College and Hospital, Ludhiana, India. The diagnosis was made on the basis of radiology (Computed Tomography Enterography or Magnetic Resonance Enterography) and/or endoscopy (gastroduodenoscopy or ileocolonoscopy). The ulcer/stricture was attributed to opioids once other possible etiologies of GI stricture like non-steroidal anti-inflammatory drugs, Crohn’s disease, infections, neoplasias, corrosive ingestion, ischaemia and peptic ulcers were excluded. Clinical parameters including presenting complaints, site of disease, haematological and biochemical parameters and treatment given were recorded. Results During the study period, 18 patients (mean age 38.46 ±14.86 years, 100% males) were diagnosed to have opioid-induced GI ulcers/strictures. Tramadol capsules (77.78%) followed by poppy husk (22.22%) were the most common forms of opioid consumption. Iron deficiency anaemia [n=16 (88.89%)], fatigue [n= 14 (77.78%)], vomiting [n=11 (61.11%)], pain abdomen and loss of weight [n=10 (55.55%) each] were the most common presenting complaints. Five (27.78%) patients presented with GI bleed. There were two common sites of involvement, gastroduodenal (n=11, 61.11%) and jejuno-ileal (n=7, 38.88%). Four (22.22%) patients had ulcers whereas 14 (77.78%) patients had strictures on evaluation. Ten (55.55%) patients underwent balloon dilatation of stricture, six of whom (60%) failed to respond and needed surgical intervention. Two patients (11.11%) were taken up for emergency surgery (without attempting balloon dilatation) as both had deep Forrest Ia duodenal ulcers, refractory to endoscopic management. Results are summarized in table 1 (table 1).Abstract IDDF2019-ABS-0309 Table 1 (n=18) Mean Age ( ± Standard Deviation) (Years) 38.46 ± 14.86 Males (N) (%) 18 (100) Clinical Presentation Pain Abdomen (N)(%) 10 (55.55) Vomiting (N)(%) 11 (61.11) Loss Of Weight (N)(%) 10 (55.55) Loss Of Appetite (N)(%) 3 (16.66) Fatigue (N)(%) 14 (77.78) Anemia (Hemoglobin <10 g%) (N)(%) 16 (88.89) Gastric Outlet Obstruction (N)(%) 9 (50.0) Small Bowel Obstruction (N)(%) 5 (27.78) GI Bleed (N)(%) 5 (27.78) Mean Weight Loss ( ± Standard Deviation)(Kg) 22.85 ± 9.06 Co-Addictions Alcohol (N)(%)Tobacco (N)(%) 3 (16.66)- Co-Infections (N)(%) HCV/HBV/HIV 2 (11.11)/-/- Mean Opium Consumption ( ± Standard Deviation)Kg/month 1.46 ± 0.43 Mean Duration of Opioid Addiction ( ± Standard Deviation)(Years) 4.69 ± 6.09 Mean Duration of Symptoms ( ± Standard Deviation)(Days) 222.07 ± 392.93 Endoscopic Findings Ulcers (N)(%) Esophageal (N)(%)Gastro-Duodenal (N)(%)Jejuno-Ileal (N)(%)Colonic (N)(%) 4 (22.22) -2 (11.11)2 (11.11)- Strictures (N)(%) Esophageal (N)(%)Gastro-Duodenal (N)(%)Jejuno-Ileal (N)(%)Colonic (N)(%) 14 (77.78) -9 (50.00)5 (27.78)- Treatment Balloon Dilatation (N)(%) 10 (55.55) Mean Number Of Dilatation Sessions ( ± Standard Deviation) (N) 1.57 ± 0.78 Failed Balloon Dilatation (N)(%) 6 (33.33) Surgery (N)(%) 8 (44.44) Conclusions Opioid abusers can have gastro-intestinal ulcers and strictures and are difficult to treat with medical/endoscopic therapy.