Diaphragm Disease After Use of Nonsteroidal Anti-inflammatory Agents

Abstract

Diaphragm disease of the small intestine is part of the spectrum of diseases associated with injury to the gastrointestinal tract induced by nonsteroidal anti-inflammatory drugs. Standard endoscopy or contrast studies of the small intestine rarely identify these lesions. The diagnosis usually is established at the time of surgery. We report the case of a 72-year-old woman with obscure gastrointestinal bleeding and intermittent obstruction of the small intestine who had had multiple hospitalizations and extensive testing. The patient had been treated with nonsteroidal anti-inflammatory drugs for osteoarthritis. A radiograph of the small intestine with barium contrast revealed no abnormalities, so capsule endoscopy was performed. Capsule endoscopy showed multiple small intestinal strictures beyond which the capsule could not pass. After the patient experienced continued symptoms suggestive of intermittent partial obstruction of the small intestine, computed tomography showed the capsule within a dilated loop of intestine adjacent to a stricture. After 9 days of conservative medical therapy and worsening symptoms, the patient required an exploratory laparotomy. The capsule was located in a 12-cm segment of intestine with 4 diaphragm-like lesions. Pathologic study found submucosal lesions with features identical to those of neuromuscular and vascular hamartoma (eg, mature, reactive tissue elements of smooth muscle, dense fibrous tissue, and nerve tissue bundles with scattered ganglion cells and vessels). No manifestations of Crohn disease were evident. This case represents the first diagnosis with capsule endoscopy of diaphragm disease of the small intestine with pathologic features of neuromuscular and vascular hamartoma.

Low-dose aspirin-induced gastrointestinal diseases: past, present, and future

“…62 Recent clinical trials and case reports using capsule endoscopy have shed light on NSAIDs causing lower GI ulcer or bleeding. [63][64][65] The development of capsule endoscopy and doubleballoon enteroscopy has allowed NSAID-induced small bowel injury, including erosions, ulcers, bleeding, and diaphragm-like strictures, to be more easily visualized. [66][67][68] One study evaluated small injury using capsule endoscopy in 21 chronic NSAID users and 20 controls and found small bowel injury in 71% of NSAID users compared with 10% of controls.…”

Subacute small bowel obstruction due to diaphragm disease

“…7 An identical histology has also been reported in the condition called neuromuscular and vascular hamartoma, which is much rarer than NSAID-induced DD and commonly presents as small bowel obstruction. 8,9 It is not known currently whether the two described conditions actually belong to the same nosological spectrum. 8,9 Diaphragms occur throughout the small bowel but are most common in the ileum.…”

“…8,9 It is not known currently whether the two described conditions actually belong to the same nosological spectrum. 8,9 Diaphragms occur throughout the small bowel but are most common in the ileum. Radiological confirmation is difficult as small bowel studies with luminal contrast are neither sensitive nor specific for the detection of diaphragms.…”

Diagnostic Value of Esophagogastroduodenoscopy in Patients with Ileal Pouch–Anal Anastomosis

“…The main limitations of VCE in the assessment of small bowel CD are the lack of uniform criteria for diagnosing CD, inability to allow for tissue acquisition or therapeutic intervention, and the risk for capsule retention. 35,36 In the meantime, push enteroscopy or balloon-assisted endoscopy are unlikely the first-line diagnostic modalities. There were limitations to this study.…”