Evaluation of Small Bowel Injury in Patients with Rheumatoid Arthritis by Capsule Endoscopy: Effects of Anti-Rheumatoid Arthritis Drugs

Sugimori, Satoshi; Watanabe, Toshio; Tabuchi, Masahiko; Kameda, Natsuhiko; Machida, Hirohisa; Okazaki, Hirotoshi; Tanigawa, Tetsuya; Yamagami, Hirokazu; Shiba, Masatsugu; Watanabe, Kenji; Tominaga, Kazunari; Fujiwara, Yasuhiro; Oshitani, Nobuhide; Koike, Tatsuya; Higuchi, Kazuhide; Arakawa, Tetsuo

doi:10.1159/000190403

Cited by 54 publications

(52 citation statements)

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“…However, Maiden et al [71] recently found no difference in the incidence of small intestinal injury between chronic users of traditional NSAIDs and chronic users of selective COX-2 inhibitors. Furthermore, Sugimori et al [11] also found the incidence of mucosal breaks in chronic users of preferential COX-2 inhibitors (meloxicam and etodolac) was high, and similar to that in traditional NSAID users. Maiden [72] speculated the reasons as following.…”

Section: Prevention and Treatment Of Small Intestinal Mucosal Injury mentioning

confidence: 80%

“…They reported a high incidence of smallintestinal mucosal injury at 71% after NSAID administration. In Japan, Sugimori et al [11] also performed VCE in 28 rheumatoid arthritis patients who had been using disease-modifying antirheumatic drugs or low-dose steroids for at least 1 year. They observed small bowel injuries in 13 of 16 patients (81.3%) who used NSAIDs and in 4 of 12 patients (33.3%) who did not.…”

Section: Present Status Of Small Intestinal Mucosal Injury Caused By mentioning

confidence: 99%

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Present status and strategy of NSAIDs-induced small bowel injury

et al. 2009

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Non-steroidal anti-inflammatory drugs (NSAIDs) are well known to cause gastroduodenal mucosal lesions as an adverse effect. Recently, the serious problem of NSAID-induced small intestinal damage has become a topic of great interest to gastroenterologists, since capsule endoscopy and balloon enteroscopy are available for the detection of small intestinal lesions. Such lesions have been of great concern in clinical settings, and their treatment and prevention must be devised as soon as possible. The prevalence of NSAIDs-induced small intestinal injury is higher than had been expected. Recent studies show that more than 50% of patients taking NSAIDs have some mucosal damage in the small intestine. The gross appearance of NSAIDinduced enteropathy varies, appearing variously as diaphragm-like strictures, ulcers, erosions, and mucosal redness. To investigate NSAID-induced enteropathy, and to rule out other specific enteropathies, other useful methods (in addition to capsule endoscopy and balloon enteroscopy) include such modalities as radiological examination of the small intestine, the permeability test, scintigraphy or the fecal excretion test using 111 Indium-labeled white blood cells, and measurement of the fecal calprotectin concentration. Diaphragm-like strictures and bleeding from mucosal breaks may be treatable with interventional enteroscopy. Misoprostol, metronidazole, and sulfasalazine are frequently used to treat NSAID-induced enteropathy, but have undesirable effects in some cases. In the experimental model, we confirmed that several existing drugs for gastroduodenal ulcers prevented indomethacin-induced small intestinal injury. Such drugs may be useful for preventing the adverse effects of NSAIDs not only in the stomach but also in the small intestine. We hope to examine these drugs in future clinical studies.

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Section: Prevention and Treatment Of Small Intestinal Mucosal Injury mentioning

confidence: 80%

Section: Present Status Of Small Intestinal Mucosal Injury Caused By mentioning

confidence: 99%

Present status and strategy of NSAIDs-induced small bowel injury

et al. 2009

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“…More bowel ulcerative lesions are expected in the elderly because their large [18] and small bowel [19] is more vulnerable to NSAIDs. Patients with rheumatic diseases were excluded because rheumatoid artritis can cause small bowel ulcerative lesions in the absence of NSAID consumption [20] . Rheumatoid arthritis has been related to an increased frequency of iron deficiency anemia [21] and small bowel ulcerative lesions [20] , among NSAIDs consumers, but no overt bleeding episodes [21] .…”

Section: Discussionmentioning

confidence: 99%

“…Patients with rheumatic diseases were excluded because rheumatoid artritis can cause small bowel ulcerative lesions in the absence of NSAID consumption [20] . Rheumatoid arthritis has been related to an increased frequency of iron deficiency anemia [21] and small bowel ulcerative lesions [20] , among NSAIDs consumers, but no overt bleeding episodes [21] . Sample size although marginally adequate to explore the role of…”

Section: Discussionmentioning

confidence: 99%

Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding

Tsibouris

Kalantzis

Apostolopoulos

et al. 2014

WJGE

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AIM:To determine the frequency of small bowel ulcerative lesions in patients with peptic ulcer and define the significance of those lesions. METHODS:In our prospective study, 60 consecutive elderly patients with upper gastrointestinal bleeding from a peptic ulceration (cases) and 60 matched patients with a non-bleeding peptic ulcer (controls) underwent small bowel capsule endoscopy, after a negative colonoscopy (compulsory in our institution). Controls were evaluated for non-bleeding indications. Known or suspected chronic inflammatory conditions and medication that could harm the gut were excluded. During capsule endoscopy, small bowel ulcerative lesions were counted thoroughly and classified according to Graham classification. Other small bowel lesions were also recorded. Peptic ulcer bleeding was controlled endoscopically, when adequate, proton pump inhibitors were started in both cases and controls, and Helicobacter pylori eradicated whenever present.Both cases and controls were followed up for a year. In case of bleeding recurrence upper gastrointestinal endoscopy was repeated and whenever it remained unexplained it was followed by repeat colonoscopy and capsule endoscopy. RESULTS:Forty (67%) cases and 18 (30%) controls presented small bowel erosions (P = 0.0001), while 22 (37%) cases and 4 (8%) controls presented small bowel ulcers (P < 0.0001). Among non-steroidal antiinflammatory drug (NSAID) consumers, 39 (95%) cases and 17 (33%) controls presented small bowel erosions (P < 0.0001), while 22 (55%) cases and 4 (10%) controls presented small bowel ulcers (P < 0.0001). Small bowel ulcerative lesions were infrequent among patients not consuming NSAIDs. Mean entry hemoglobin was 9.3 (SD = 1.4) g/dL in cases with small bowel ulcerative lesions and 10.5 (SD = 1.3) g/dL in those without (P = 0.002). Cases with small bowel ulcers necessitate more units of packed red blood cells. During their hospitalization, 6 (27%) cases with small bowel ulcers presented bleeding recurrence most possibly attributed to small bowel ulcers, nevertheless 30-d mortality was zero. Presence of chronic obstructive lung disease and diabetes was related with unexplained recurrence of hemorrhage in logistic regression analysis, while absence of small bowel ulcers was protective (relative risk 0.13, P = 0.05). CONCLUSION:Among NSAID consumers, more bleeders than non-bleeders with peptic ulcers present small bowel ulcers; lesions related to more severe bleeding and unexplained episodes of bleeding recurrence.© 2014 Baishideng Publishing Group Inc. All rights reserved. PROSPECTIVE STUDY

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“…Small bowel ulcers were observed in 8 % of NSAIDtreated patients in comparison to 0.6 % of controls (with no history of NSAID use) in a prospective, autopsy-based study (713 cases) (4). The endoscopically evident changes (including ulcers) were diagnosed by means of sonde or push enteroscopy in 41-66 % (62, 63, 64) and by means of capsule and double balloon enteroscopy in 16-88 % of NSAID users (30,32,36,59,60,81). Other tests of small bowel damage and malfunction (faecal occult blood test, assessment of intestinal inflammation and permeability) confirm NSAID-enteropathy in 19-72 % (7, 8, 9, 10, 11, 12, 56, 83).…”

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Non-steroidal Anti-inflammatory Drug Induced Injury to the Small Intestine

Tachecí

Kopáčová

Rejchrt

et al. 2010

Acta Med. (Hradec Kralove, Czech Repub.)

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Non-steroidal anti-inflammatory drugs (NSAIDs) represent the group of most commonly used drugs worldwide. The target group for use of NSAIDs comprises the elderly population with higher morbidity and mortality and a higher risk of drug toxicity (91). This fact together with the aging of the population in developed countries means increasing medical and economical problems in this context. In a large prospective analysis of adverse drug reactions in 18,820 patients in the United Kingdom, NSAIDs were responsible for 1.9 % (363) of all hospital admissions (29.6 % of all drug-related adverse events) in the period of time studied (67). The most frequent were gastrointestinal, nervous system, renal, and allergic adverse effects. Gastrointestinal toxicity is widely recognised, especially in the gastroduodenal area.Over the past decade, an increasing quantity of data has been gathered documenting small bowel involvement and its importance, showing its previous underestimation. This is related to advancements in small bowel evaluation, especially in small bowel endoscopy. The goal of this review is to discuss current knowledge of the range of NSAID-induced small intestinal injury, its clinical features, diagnosis and management. HistoryThe first description of NSAID (aspirin)-induced gastropathy identified by endoscope was presented by Douthwaite and Lintott in 1938 (22). Small bowel damage due to indomethacin management was observed for the first time in humans in the 70s (80). Many cases of small bowel perforation (65) and other clinical manifestations of small bowel enteropathy were published (7,8,9,10,11,12,56) in the 80s. Most morphology data were acquired from autopsy (4) and surgical studies at that time (57). Because of the relative inaccessibility of the small intestine, initial endoscopy data were drawn from sonde enteroscopy, and were not published until the early 90s (64). The capsule endoscopy era begins in the year 2000 (44) and is linked with an information boom concerning NSAID-induced enteropathy. EpidemiologyAccording to the data published in the ARAMIS (Arthritis, Rheumatism, and Aging Medical Information System) database, up to 1.3 % of patients treated with NSAIDs are hospitalised for severe gastrointestinal complications in the USA and Canada, a 1-year mortality rate is seen in about 0.11-0.22 % in this population (75). Summary: Non-steroidal anti-inflammatory drug (NSAIDs) induced enteropathy represents an important complication of one of the most commonly used drugs worldwide. Due to previous diagnostics difficulties the real prevalence of this disease was underestimated for a long time. The pathogenesis of NSAID-enteropathy is more multifactorial and complex than formerly assumed but has still not been fully uncovered. A combination of the local and systemic effect plays an important role in pathogenesis. Thanks to novel enteroscopy methods (wireless capsule endoscopy, double balloon enteroscopy), small bowel lesions are described in a substantial section of NSAID users although most are clinical...

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Evaluation of Small Bowel Injury in Patients with Rheumatoid Arthritis by Capsule Endoscopy: Effects of Anti-Rheumatoid Arthritis Drugs

Cited by 54 publications

References 45 publications

Present status and strategy of NSAIDs-induced small bowel injury

Present status and strategy of NSAIDs-induced small bowel injury

Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding

Non-steroidal Anti-inflammatory Drug Induced Injury to the Small Intestine

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