International Journal of Surgery Case Reports 114 (2024) 109116

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Fatal peritonitis due to gastric perforation in a male heroin addict: A case

report and literature review
Mahdieh Sadeghi a, Zakaria Zakariaei b, *, Ali Yaghoubinia c, Ali Abbasi d, Mahsa Ashrafi e
a
Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
b
Toxicology and Forensic Medicine Division, Mazandaran Registry Center for Opioids Poisoning, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran
University of Medical Sciences, Sari, Iran
c
Department of Psychiatry, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
d
Department of Forensic Medicine, Azad University, Sari branch, Sari, Iran
e
Legal Medicine Research Center, Legal Medicine Organization, Sari, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Perforation of hollow organs, such as the stomach, within the abdomen can lead to
Heroin the development of acute abdomen, a critical and potentially life-threatening condition. It is important to note
Addiction that there is currently insufficient information available regarding the specific effects of heroin, an illegal sub­
Perforation
stance commonly abused, in causing this particular complication.
Stomach
Peritonitis
Case presentation: We present the case of a 32-year-old male who is addicted to heroin and was admitted to an
addiction rehabilitation center with the aim of overcoming his addiction.
After a few days of admission, the patient developed symptoms of abdominal pain, anorexia, and subsequent
neurological manifestations, such as drowsiness, confusion, and a decreased level of consciousness. Tragically,
the patient suffered a cardiorespiratory arrest upon arrival at the emergency room and despite efforts to
resuscitate him, he unfortunately passed away.
Clinical discussion: During the autopsy of the aforementioned case, an observation was made of a perforation in
the stomach, which ultimately led to the cause of death being identified as peritonitis. Acute peritonitis is
recognized as one of the potential causes of acute abdomen, often resulting from the rupture of hollow organs
within the abdominal region. It is characterized by inflammation of the serous membrane that lines the
abdominal cavity.
Conclusions: Indeed, conducting original and coherent studies to investigate the potential effects of heroin on
gastric perforation could prove to be highly valuable in facilitating the timely diagnosis and treatment of this
fatal complication.

1. Introduction commonly occurs due to the introduction of irritating substances, such

Acute abdomen is a medical emergency that requires immediate
attention and treatment. It can be triggered by various factors such as
inflammation, vascular obstruction, infection, or mechanical obstruc­
tion. Common symptoms of acute abdomen encompass the sudden onset
of abdominal pain, accompanied by feelings of nausea or vomiting, and
an overall unwell appearance [1]. Acute peritonitis is a potential etiol­
ogy of acute abdomen, which may arise from the rupture of hollow
abdominal organs. It is characterized by the inflammation of the serous
membrane that envelops the abdominal cavity [1–3]. Acute peritonitis
as gastric acid, into a previously sterile environment through a punc­
tured wound or infection resulting from intestinal perforation [4]. If left
untreated, this condition can pose significant risks to one's health and
potentially become life-threatening.
Heroin, also referred to as diacetylmorphine or diamorphine, is a
semi-synthetic substance derived from morphine, a natural opioid ob­
tained from the opium poppy [5]. Historically, morphine had both
medical and non-medical applications. However, over time, the non-
medical use of morphine and its derivatives, including heroin, has
become more prevalent than their medicinal use. Heroin, in particular,

* Corresponding author at: Toxicology and Forensic Medicine Division, Mazandaran Registry Center for Opioids Poisoning, Orthopedic Research Center, Imam
Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, P.O box: 48166-33131, Iran.
E-mail address: ali.zakariaei@yahoo.com (Z. Zakariaei).

https://doi.org/10.1016/j.ijscr.2023.109116
Received 3 November 2023; Received in revised form 20 November 2023; Accepted 1 December 2023
Available online 13 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Sadeghi et al.
is a highly potent prodrug that is commonly abused for its euphoric
effects. While there are rare instances where physicians may prescribe
heroin for pain management, its illegal use is more widespread. Illicit
consumption methods include smoking, sniffing, or injecting the drug.
The misuse of heroin has led to a rise in health complications and fa­
talities [6–8]. After being introduced into the body, heroin undergoes a
rapid deacetylation process, converting it into 6-monoacetylmorphine
(6-MAM), which is subsequently acetylated to morphine. These metab­
olites have the potential to cause negative effects in humans. These ef­
fects can vary from common digestive symptoms like nausea, vomiting,
and constipation to more severe complications such as respiratory
depression and brain hypoxia, which can pose a significant risk to one's
life. However, despite extensive research, the complete pharmacody­
namics of heroin remains incompletely understood. This lack of under­
standing can make it challenging to comprehend how heroin specifically
impacts the gastrointestinal tract [9].
There is currently insufficient and conclusive evidence regarding the
specific impact of heroin on gastric rupture, although opioids have been
observed to induce gastroparesis by stimulating the pyloric sphincter or
inhibiting antral motility, potentially increasing the risk of gastric
rupture in individuals who abuse them [10,11]. Within the past two
decades, there have been no reported cases of gastric perforation spe­
cifically attributed to heroin abuse in the English-language literature.
However, we present a case of a 32-year-old man who was hospitalized
in a drug addiction center due to heroin abuse and subsequently brought
to our hospital after developing acute abdominal symptoms and expe­
riencing respiratory arrest. The work has been reported in line with the
SCARE 2020 criteria [12].
2. Presentation of case
On May 8, 2022, a 32-year-old man with a decade-long history of
inhalation heroin and oral opium addiction was referred for withdrawal
at a private rehabilitation center located in northern Iran. Following his
admission, the individual experienced symptoms commonly associated
Fig. 1. (A and B) show a 5 mm hole was identified in the fundus of the stomach, accompanied by the presence of approximately 100 mL of sero-purulent fluid within
the abdominal cavity.
2
International Journal of Surgery Case Reports 114 (2024) 109116
with withdrawal syndrome, including musculoskeletal pain, abdominal
pain, and loss of appetite. Over time, the abdominal pain intensified,
leading to abdominal distention and an inability to sit comfortably. To
address the issue of constipation, bisacodyl suppositories were pre­
scribed as part of the treatment plan. In the patient's medical history,
there was no consumption of non-steroidal anti-inflammatory drugs
(NSAIDs), presence of cardiac abnormalities, or previous instances of
endoscopy procedures. Following a period of eight days, the individual
in question experienced a gradual onset of symptoms including drows­
iness, confusion, and a decreased level of consciousness. All the symp­
toms exhibited by the patient were attributed to the withdrawal
syndrome, leading to the belief that the patient may have been malin­
gering. As a result, the patient was promptly referred to our medical
center for further evaluation and care. Regrettably, upon arrival at the
emergency room, the patient experienced a cardiorespiratory arrest and
despite immediate CPR efforts, succumbed to the event. In order to
ascertain the precise cause of death, the deceased's body was subse­
quently transferred to the forensic medicine organization and under­
went a thorough autopsy.
In the autopsy examination, specific findings were noted. The weight
of the heart was measured at 280 g, and no abnormalities were detected
in the coronary artery section. Similarly, no pathological findings were
observed in the lungs. During the intra-abdominal examination, a round
hole measuring 5 mm in diameter with a regular border was observed in
the fundus of the stomach. This observation was accompanied by the
presence of approximately 100 mL of sero-purulent fluid within the
abdominal cavity, as depicted in Fig. 1, A and B. In the histopathological
analysis, the sections of the gastric wall perforation site reveal the
presence of chronic inflammatory cells, predominantly composed of
lymphocytes and plasma cells. Additionally, there is evidence of fibri­
noid necrosis in the affected areas.
No abnormalities were detected in the other abdominal organs.
Based on these findings, the cause of death was determined to be peri­
tonitis and septic shock resulting from gastric perforation.
Written informed consent was obtained from the patient's parents for
M. Sadeghi et al.
publication of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request. This study was conducted according to the Decla­
ration of Helsinki Principles. The study is registered with the research
registry, and the UIN is research registry 9639 https://www.research
registry.com/register-now#home/registrationdetails/6537ddeea
ce8e800288a6e7d/.
3. Discussion
Peritonitis, a potential cause of acute abdomen, arises from the
rupture of hollow organs within the abdominal cavity, leading to the
release of their contents into the sterile environment encapsulated by the
serous membrane known as the peritoneum. This condition poses a
significant threat to life and necessitates immediate medical interven­
tion [1]. As previously stated in the introductory section of this article, it
is important to note that mechanical obstruction of the digestive system
can potentially result in perforation and peritonitis. It is worth consid­
ering the possibility of mechanical obstruction occurring as a conse­
quence of opioid abuse, given that opioids are known to cause
constipation and a decrease in bowel movements [9]. As widely recog­
nized, heroin is classified as a semi-synthetic derivative of morphine.
Consequently, it is plausible to hypothesize that similar side effects to
those observed with other opioids may arise from heroin usage. How­
ever, it is crucial to emphasize that any hypothesis put forth should al­
ways be substantiated by substantial scientific evidence.
To the best of our knowledge, there have been no reported cases of
gastric perforation resulting from heroin abuse in the English-language
literature within the past two decades. In our review of relevant studies,
we found that Placer et al. conducted a study in 1986 titled “Acute
abdomen in heroin addicts: presentation of 3 cases and review of the
literature.” However, we were unable to access an abstract for this study
[13]. In a study conducted in 1986 by Chen et al., three heroin addicts
were documented to have presented with acute abdominal pain, initially
suspected to be caused by appendicitis or gastric ulcer perforation.
However, after a period of observation and administration of dolantin,
all patients experienced recovery. The final diagnosis for these patients
was determined to be narcotic bowel syndrome. The study concluded by
emphasizing the importance for medical professionals to consider
narcotic bowel syndrome as a potential diagnosis in heroin addicts
presenting with acute abdominal pain [14].
In a recent study conducted by Deivasigamani et al. in 2021, a case
involving a 22-year-old male patient was reported. The patient pre­
sented with abdominal pain and peritonitis symptoms subsequent to
cocaine injection. Upon performing a laparotomy, a 2 × 1 cm perfora­
tion was discovered in the distal ileum. After the surgical removal of the
affected ileum, the patient experienced substantial lower gastrointes­
tinal bleeding six days post-operation. A subsequent colonoscopy
revealed indications of intestinal ischemia, while a tissue biopsy
exhibited inflamed, edematous, and bleeding intestinal mucosa [15].
CPR is a crucial medical procedure involving chest compressions and
rescue breaths, employed to revive individuals experiencing cardiore­
spiratory arrest [16]. In the context of CPR complications, gastric
mucosal tearing has been observed in approximately 9–12 % of cases
and is considered a common finding during autopsy in around 10–12 %
of unsuccessful CPR cases. Persisting with CPR efforts despite the pres­
ence of a gastric mucosal tear can potentially lead to the development of
pneumoperitoneum, followed by tension pneumoperitoneum [16,17].
According to Butterfield et al.'s report in 2017, a 26-year-old woman
experienced acute abdominal pain and distension following a heroin
overdose. Prior to the arrival of the ambulance, her husband adminis­
tered mouth-to-mouth ventilation without performing CPR. Subsequent
investigations revealed a significant pneumoperitoneum on the chest X-
ray. During the laparotomy procedure, a 4 cm tear in the lesser curvature
of the stomach was identified. These findings suggest that rescue
breathing performed with excessive force or by individuals lacking
3
International Journal of Surgery Case Reports 114 (2024) 109116
proper training may lead to stomach expansion and subsequent perfo­
ration [18].
Our patient, a 32-year-old male with a history of heroin addiction,
was receiving care and treatment at an addiction rehabilitation center.
After a few days, the patient experienced abdominal pain accompanied
by progressive anorexia. Eventually, after eight days, he was admitted to
our medical center presenting with a distended abdomen and a
decreased level of consciousness. Tragically, upon arrival at the emer­
gency room, the patient suffered a cardiorespiratory arrest and despite
CPR efforts, succumbed to the condition. During the autopsy, a round
hole measuring 5 mm in diameter with a regular border was identified in
the fundus of the stomach. Additionally, approximately 100 mL of sero-
purulent fluid was found in the abdominal cavity. In our reported case,
CPR was administered prior to the autopsy. It is important to acknowl­
edge that stomach tearing can be observed in approximately 10–12 % of
autopsies, as mentioned in the study conducted by Butterfield et al.
Additionally, the round and regular border of the observed hole (refer to
Fig. 1) may indicate a chronic process of its formation, potentially
attributed to the effects of heroin on the stomach.
4. Conclusion
In the literature review, there is a lack of definitive and compre­
hensive information regarding the impact of heroin on the stomach and
subsequent perforation. Our investigation reveals that there have been
no documented instances of stomach perforation resulting from heroin
abuse in the English-language literature within the past two decades.
Considering our reported case and the potential cases discussed, it ap­
pears that conducting original and cohesive studies to explore this effect
could greatly contribute to the prompt diagnosis and treatment of this
life-threatening complication.
Patient (parent's) consent
Written informed consent was obtained from the patient's parents for
publication of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Ethical approval
This research was approved by the Mazandaran University of Med­
ical Science Ethics Committee (No: IR.MAZUMS.REC.1399.7850) and
was carried out in accordance with the Helsinki Declaration Principles.
Funding
None.
CRediT authorship contribution statement
AA and MA involved in the collecting of samples and data. AY and ZZ
involved in writing, editing, and preparing the final version of the
manuscript. MS, ZZ preparing the draft and submitted of the manuscript.
All authors reviewed and approved the final version of the manuscript.
Guarantor
Ali Abbasi.
Research registration number
9639.
M. Sadeghi et al.
Declaration of competing interest
None declared.
Data availability statement
The data are available with the correspondence author and can be
achieved on request.
Acknowledgment
Declared none.
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