Case 2: A 49-year-old man was referred to the authors’ institution for evaluation of recurrent small bowel obstruction. He reported a total of 26 episodes of partial small bowel obstruction that had responded to conservative treatment over the previous six to seven years. He underwent exploratory laparotomy two years previously with no source of obstruction found, but the jejunum was noted to have an area of active inflammation, and a local reactive mesenteric lymph node was excised. He subsequently underwent an EGD, which revealed a fairly tight postbulbar duodenal stricture that was twice dilated with a balloon dilator to 54 French with good endoscopic results. However, the patient continued to have recurrent episodes of partial small bowel obstruction. Before referral, he underwent a repeat upper endoscopy with a pediatric colonoscope that revealed a widely patent duodenum with no evidence of stricture recurrence and normal findings into the proximal jejunum. In addition, a small bowel follow-through showed no abnormalities. His medical history was significant for an appendectomy as a teenager, rotator cuff injury with arthroscopic surgery two years prior and a motorcycle accident five years prior. He had been using NSAIDs regularly for at least 25 years for various orthopedic injuries. He had been off all NSAIDs for about eight months. He was then referred to the authors’ institution, where he initially underwent a push enteroscopy that was normal to approximately 120 cm beyond the ligament of Treitz. He then underwent an intraoperative enteroscopy that revealed a discrete diaphragm-like stricture approximately 5 mm in diameter in the distal jejunum with an associated ulceration at one border (Figure 2); the enteroscope could not be passed through this stricture. Two other discrete areas of fibrotic-appearing small bowel were noted on external examination. A 30 cm segment of small bowel containing all three areas was resected. The remainder of the small bowel appeared normal. Pathological examination revealed that the area of stricture in the proximal jejunum seen endoscopically contained three successive plicae circulares fused into a thickened circumferential ring covered with granular-appearing mucosa with focal erosion, consistent with an NSAID-induced mucosal diaphragm (Figure 3). In addition, four small (less than 0.8 cm in diameter), nonobstructing carcinoid tumours were noted in the resected specimen extending through the muscularis propria; all seven lymph nodes were negative for tumour. Two of these tumours were associated with the more distal fibrotic areas palpated by the surgeons. One tumour was near but not involving the mucosal diaphragm. There have been no further bouts of intestinal obstruction at a four-month follow-up.
ARMI News - Part 64
NSAID-induced small bowel diaphragms and strictures diagnosed with intraoperative enteroscopy: CASE PRESENTATION Part 2
NSAID-induced small bowel diaphragms and strictures diagnosed with intraoperative enteroscopy: CASE PRESENTATION Part 1
Case 1: A 52-year-old man was referred to the authors’ institution with recurrent obscure gastrointestinal bleeding and iron-deficiency anemia. He initially presented two years previously with melena and hemoglobin of 0.868 mmol/L. Results of an upper gastrointestinal series with small bowel follow-through and barium enema were unremarkable except for colonic diverticulosis. He had no further melena and responded to iron supplementation with an increase in hemoglobin to 2.015 mmol/L. However, two years later, he experienced recurrent melena associated with a decline in hemoglobin to 1.5 mmol/L. He reported having used ibuprofen (600 mg daily) for at least 15 years to control pain associated with osteoarthritis. This medication was discontinued after his first episode of melena, and he denied any current NSAID use. His current medications included iron sulphate and a sedative at bedtime. Esophagogastro-duodenoscopy (EGD) revealed no source of the gastrointestinal hemorrhage. Colonoscopy revealed only a few diverticula. He was then referred to the authors’ institution, where he underwent a push enteroscopy that revealed a nonobstructing Schatzki’s ring, a small hiatal hernia and a normal small bowel to 100 to 120 cm into the jejunum. A contrast-enhanced computed tomography scan of the abdomen and pelvis revealed multiple hepatic cysts smaller than 1 cm in diameter, a left renal cyst and sigmoid diverticula. An intraoperative enteroscopy was then performed to the terminal ileum. Three distinct diaphragm-like strictures were identified in a 34 cm long area of the distal ileum. The most distal lesion had an associated 1 cm ulcer that was actively oozing at the time of endoscopy (Figure 1). This entire area was resected, along with a single reactive mesenteric lymph node. Pathological evaluation revealed four distinct well-circumscribed ulcerations. The three smaller lesions involved less than 20% of the internal lumen diameter, with the largest ulcer involving 50% of the internal diameter. Microscopic evaluation showed four discrete mucosal ulcerations and associated crypt inflammation, thickening of the muscularis mucosae and focal neuronal hyperplasia. Margins of resection were free of inflammation, and the intervening mucosa between ulcerations was normal. No fissures, fistulae or granulomas were identified. These findings were consistent with NSAID-induced small bowel strictures and ulceration. No further bleeding had occurred at a six-month follow-up.
Gastroduodenal mucosal damage is a known side effect more distal small bowel and colon. Reported lesions in the of nonsteroidal anti-inflammatory drugs (NSAIDs) small intestine associated with NSAID use have included. NSAIDs have also been reported to cause lesions in the ulcers, mucosal diaphragms, broad-based strictures and NSAID enteropathy. Nonspecific small intestinal ulceration may occur in up to 8% of patients on long term NSAIDs. Although most patients on NSAIDs have no complications, a small percentage may develop iron deficiency anemia, gastrointestinal hemorrhage, or small bowel obstruction or perforation. We report the use of intraoperative enteroscopy to diagnose two cases of small intestinal diaphragm disease and ulceration associated with NSAID use, and review the literature.