Case Report: Methamphetamine overdose causing ileal perforation

Introduction

Methamphetamine is a powerful psychostimulant that is commonly abused through smoking, snorting, or, less frequently, ingestion.¹ The abuse of methamphetamine has been rapidly increasing worldwide, with estimates suggesting that about 2.1% of the population in the United States has used this substance at some point.² Individuals who engage in chronic methamphetamine abuse are more likely to experience psychiatric disorders such as depression, panic disorder, and post-traumatic stress disorder.³ They also exhibit higher rates of suicide attempts and increased mortality.^3,4

The symptoms of methamphetamine intoxication can vary widely, ranging from no symptoms at all to severe sympathomimetic crises. Life-threatening intoxication is typically marked by symptoms such as high hypertension, tachycardia, metabolic acidosis, hyperkalemia, acute renal injury, and seizures. Sometimes, cardiovascular collapse and death.^5,6

There have been rising reports of methamphetamine being ingested for recreational use, as well as its use among body packers (those who transport drugs internally) and body stufferers (who ingest substances to avoid arrest).⁷ Prolonged use of methamphetamine can lead to a rapid and sustained release of norepinephrine, which may result in serious complications such as intestinal ischemia and perforation.^8,9

Case report

A 57-year-old male patient with a prior history of hyperlipidemia and long-term methamphetamine abuse lasting approximately seven years presented to the emergency room after orally ingesting a small bag of methamphetamines. He had been inhaling methamphetamines and, under the drug's influence, falsely believed he was being followed. Fearing arrest, he ingested the bag of methamphetamines he had in his possession. Based on history, we could not determine the exact quantity he consumed.

Upon arrival at the emergency room, the patient exhibited severe nausea, vomiting, agitation, chest pain with palpitations, and abdominal pain. Clinical examination revealed nonspecific diffuse abdominal tenderness. A complete blood count, chemistry profile, and further blood work indicated acute renal injury, with creatinine levels increased to 3.66 mg/dL and a reduced glomerular filtration rate of 19 mL/min/1.73 m². Additionally, there was an elevated creatine kinase level of 426700 U/L. This patient also presented with acidosis, changes in sodium and chloride electrolyte levels, and elevated ALT and AST levels. Urine toxicology confirmed the presence of methamphetamines. Values mentioned in Table 1.

Fluid hydration was initiated for the acute renal injury secondary to methamphetamine overdose. A computed tomography (CT) scan of the abdomen and pelvis at this time did not reveal any acute pathology other than a dilated stomach ( Figure 1). Over the next few days, the patient's creatinine kinase and renal function demonstrated improvement; however, he continued experiencing increasing abdominal pain and discomfort.

Figure 1. Computed tomography scan of the abdomen, arrow showing dilated stomach.

Given the persistent abdominal pain despite a benign abdominal examination, a follow-up CT scan of the abdomen and pelvis was performed three days after ingestion of the methamphetamine. This scan revealed a dilated stomach and pneumatosis of the small bowel ( Figure 2). At this time, the patient's white blood cell count was 16700/ml, an increase from 12000/ml. Due to gastric distention, the patient was initiated on bowel rest, and nasogastric decompression of the dilated stomach was conducted, providing him with relief.

Figure 2. Computed tomography scan of the abdomen, blue arrow showing dilated stomach and red arrow showing pneumatosis of the small bowel.

On the sixth day post-ingestion, the patient demonstrated improvement in blood work with signs of recovering renal function; however, he continued to experience increased abdominal pain and leukocytosis, with an elevated white blood cell count of 34500/ml. In light of the worsening abdominal pain and clinical signs suggestive of peritonitis, the patient was taken for another CT scan, which revealed pneumatosis and free air in the abdominal cavity ( Figure 3). Given the development of pneumoperitoneum, the patient was taken for exploratory laparotomy.

Figure 3. Computed tomography scan of the abdomen, blue arrow showing pneumatosis and red arrow showing development of free air in the abdominal cavity.

During the procedure, the surgeon found severe ischemia of the distal ileum with perforation. The ischemic segments of the terminal ileum and the associated cecum were resected, and an ileo-ascending anastomosis was performed. Histopathological evaluation of the specimen confirmed necrosis of the bowel tissue ( Figure 4). This patient recovered without complication following the surgery.

Figure 4. Hematoxylin and eosin stain showing an extensive inflammatory infiltrate, as shown by blue arrow and red arrow, showing congested capillaries in the submucosa.

Gupta A. Methamphetamine Overdose Causing Ileal Perforation [Data set]. Zenodo. 2025. https://doi.org/10.5281/zenodo.15428668.

Discussion

Methamphetamine, commonly known by street names such as chalk, ice, and crystal, is a neurostimulant that increases the availability of neurotransmitters like norepinephrine, epinephrine, dopamine, and serotonin while inhibiting their reuptake.¹⁰ Its most frequent method of abuse is through inhalation, although oral consumption has been on the rise among users.¹¹

The local action of methamphetamine on the gastrointestinal tract primarily causes vasoconstriction due to its sympathomimetic effects. When ingested, it can lead to stomach pain or changes in bowel habits, such as constipation or diarrhea. The localized vasoconstriction can result in ulcers and paralytic ileus.¹² Chronic use may also disrupt the gut barrier, potentially causing symptoms like anxiety, stress, and depression. Methamphetamine is believed to increase local inflammatory cytokines, enhance sympathetic activity, and allow permeability changes in the blood-brain barrier, which may affect intestinal muscle tone, leading to paralytic ileus, arterial vasoconstriction, and gut ischemia.^12,13

Acute methamphetamine intoxication typically presents with symptoms such as sweating, hypertension, tachycardia, agitation, and psychosis. The predominant effects manifest neurologically, cardiovascularly, and renally.¹⁴ Neurological findings may include agitation, delirium, or acute psychosis, while cardiovascular symptoms can present as chest pain, tachycardia, hypertension, hypotension, excessive sweating, or even cardiovascular collapse. Renal issues may involve acidosis, hyperkalemia, and rhabdomyolysis.¹⁴

There have been reports of methamphetamine use leading to ulcers, severe mesenteric vascular vasoconstriction, and ischemic colitis.^15,16 Anecdotal evidence suggests that methamphetamine abuse may also result in gastroparesis.¹⁷ Although the literature on this topic is limited, there is evidence indicating patients have experienced gangrene and perforation of the small bowel, particularly the ileum, as noted in our case.^18,19

Our patient presented with severe abdominal pain and nausea as the primary gastrointestinal symptoms. Initially, clinical examination did not indicate peritonitis, and imaging suggested a dilated stomach and an ileus-like pattern, which was managed with bowel rest and nasogastric decompression. However, this condition gradually progressed to pneumatosis and eventually led to frank perforation of the ileum.

Conclusion

Methamphetamine overdose can lead to gastric dilatation and an ileus-like pattern, which may progress to perforation due to bowel ischemia. Perforation can occur away from the site of ingestion, such as in the distal ileum.

Consent

Informed consent for participation and publication was obtained from the patient. The consent was obtained in written form after a detailed discussion of his clinical condition and the intended use of his anonymized data for academic publication. As the patient was an adult with full decision-making capacity.