“Diaphragm-like” structures of the small bowel in patients treated with non-steroidal anti-inflammatory drugs

Abstract

The radiological findings are described in four patients who developed strictures of the small bowel, and who had received non-steroidal, anti-inflammatory drugs (NSAIDs) for 1.5-15 years. Clinical presentation was that of subacute small bowel obstruction. Small bowel barium studies showed multiple discrete strictures. Some strictures were indistinguishable from those of regional enteritis. Others however were narrow "diaphragm-like" septae encroaching on and markedly narrowing the ileal lumen, and shown histologically to be due to submucosal fibrosis. It is suggested that these strictures are likely to be consequent on NSAIDs administration and that radiologists and surgeons need to be aware of these "diaphragms" which can be very difficult to detect on barium examination, either small bowel follow-through or enteroclysis, and at laparotomy.

NSAID injury to the small intestine

“…These are usually short, tapered, and few. Multiple ring-like or diaphragm-like strictures such as those seen in our patients have only been previously described in NSAID enteropathy and ulcerative enteritis complicating celiac disease (1)(2)(3)(4)(5).…”

“…There is focal submucosal fibrosis at their apices with the collagen bundles aligning parallel to the valvulae. The diaphragm lesions are thin and do not distort the bowel wall, and, consequently, radiologic diagnosis is difficult (1)(2)(3)(4)(5)(6)9). Even at laparotomy they are easily missed.…”

Enteroclysis of non-neoplastic disorders of the small intestine

“…Their gross macroscopic appearances range from a single broad-based fibrous stricture to multiple ªdiaphragm-likeº stenotic lesions that encroach on and can narrow the lumen to as little as 1 mm in diameter (Fig. 25) [59]. The diaphragms develop mostly in the ileum and are composed of mucosa and submucosa with submucosal fibrosis.…”

Nonsteroidal Anti-Inflammatory Drugs: Gastroduodenal Injury and Beyond

“…A number of case reports have, collectively, inferred that a characteristic small-intestinal stricture may result from prolonged NSAID use [90][91][92][93][94][95]. Although several reports described broadbased strictures, it is the concentric, dia phragm-like septum which is felt to be the pathognomonic lesion [77], These are thin (2-4 mm), sometimes multiple, septa which of ten narrow the lumen to a pinhole opening.…”

“…The edge generally contains an acute and chronic inflammatory infiltrate [96] . In the majority of patients symptoms of subacute, or partial, small bowel obstruction predominate [91]. Preoperative diagnosis may be difficult because these thin strictures mimic plicae circulares on barium studies [77], Operative localization may be facilitated by air insufflation [77], Occult GI bleeding and unexplained hematochezia are often diagnostic dilemmas.…”