Danielle Tran, BS1, Ariana R. Tagliaferri, MD2, Subhash Chandra, MBBS, FACG2 1Creighton University School of Medicine, Omaha, NE; 2Creighton University Medical Center, Phoenix, AZ
Introduction: Over 30 million people use NSAIDs daily for their analgesic, anti-inflammatory and antipyretic effects. However, COX inhibition decreases prostaglandin synthesis, compromising the mucosal barrier of the GI tract. It is well known that NSAIDs cause PUD and/or bleeding, however their effect on the GI tract beyond the duodenum are less recognized. We report two cases of NSAID-induced diaphragm disease (NDD), highlighting their appearance capsule endoscopy.
Case Description/Methods: Case 1: A 68-year-old man was referred for evaluation of iron deficiency after a negative EGD and colonoscopy. His hemoglobin was between 8-9 g/dL with an iron saturation less than 15%. A capsule endoscopy found circumferential ulcers in the distal small bowel causing stricturing (Figure 1). He took diclofenac sodium 75 mg twice daily for many years for chronic back pain. He was diagnosed with NDD, diclofenac was discontinued and the patient was to follow-up with the referring provider.
Case 2: A 58 year-old woman with osteoarthritis on meloxicam 15 mg daily presented with acute cramping abdominal pain, nausea and vomiting. She had an extensive surgical history including a hysterectomy, appendectomy, cholecystectomy and two prior small bowel obstructions due to adhesions, requiring exploratory laparotomies. A colonoscopy was unremarkable. Labs revealed a normocytic anemia (Hgb 11.5 g/dL). A CT with IV contrast confirmed a small bowel obstruction managed conservatively with nasogastric decompression. Due to persistent pain, an EGD was performed and revealed H. pylori gastritis which was treated with quadruple therapy. A capsule endoscopy found multiple circumferential small bowel ulcers with strictures indicative of NDD (Figure 1). The capsule did not reach the cecum but passage was confirmed on interval x-ray's. The patient was advised to stop meloxicam. She has not been admitted to our facility since.
Discussion: NDD is a rare condition in which circumferential ulcers form from NSAID-induced mucosal damage and reparative submucosal granulation tissue pulls centrally to create a diaphragm-like stricture, most commonly in the ileum. Diagnosing NDD is challenging and often overlooked. Clinical suspicion should be high in patients with recurrent partial small bowel obstructions and clinicians should inquire about NSAIDs use. Familiarizing oneself with the endoscopic appearance is important to minimize an unnecessary work-up such as for Crohn’s disease, which is a common cause of small bowel ulcers in the Western population.
Figure: Figure 1. Circumferential ulcers with stricturing in the ileum captured on video capsule endoscopy in patient cases 1 (A, B) and 2 (C).
Disclosures:
Danielle Tran indicated no relevant financial relationships.
Ariana Tagliaferri indicated no relevant financial relationships.
Subhash Chandra indicated no relevant financial relationships.
Danielle Tran, BS1, Ariana R. Tagliaferri, MD2, Subhash Chandra, MBBS, FACG2. P5010 - NSAID-Induced Diaphragm Disease on Capsule Endoscopy: A Case Series, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
