Monday, January 09, 2006

Small Bowel Diaphragm Disease

Last month's Archives of Surgery contained the first article I have seen about a specific type of NSAID-induced small bowel injury with more than one case. The article, entitled Small-Bowel Diaphragm Disease: Seven Surgical Cases, basically is a case report of seven patients who presented with symptoms of chronic, incomplete bowel obstruction or GI bleeding. All were heavy users of NSAIDs (a variety of them), and all were diagnostic challenges. The diagnosis of "small bowel diaphragm disease" was eventually made at video capsule endoscopy or laparotomy, and diaphragms were randomly distributed in the jejunum and ileum; treatment was resection.

I have seen one case of this recently, in a patient who has been using NSAIDs for years for a variety of long distance running-induced chronic injuries. His symptoms were of vague abdominal discomfort and bloating, with normal upper and lower endoscopic studies. His gastroenterologist, however, had read a case report about small bowel diaphragm disease and appropriately ordered an enteroclysis.....which showed a series of what appeared to be strictures. At laparotomy, and upon pathologic evaluation of the specimens, the lesions were not typical cicatricial strictures; rather, they were a series of very rubbery webs. We were fortunate that a capsule endoscopy had not been done, as a few of these had openings far too small to allow passage of the capsule (see a related situation here); that problem was seen in the current report as well.

NSAIDs are great medications, widely used with a good degree of safety. Most patients who develop GI symptoms from their use get gastritis or ulcers. The patients who get small bowel injuries similarly will more often present with bleeding from very proximal small bowel NSAID-induced ulcers. This new category of problems may stem from patients doing all the right things -- i.e., taking their NSAIDs with food to prevent stomach injuries; the damage of their heavy NSAID use is therefore seen farther downstream. Given the huge numbers of patients on chronic NSAIDs, we may need to be a bit more aggressive about looking for this problem when they present with fairly vague GI symptoms.