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NSAIDs enteropathy, small bowel strictures, bowel obstruction, and capsule endoscopy.
none
Abstract:
We report a case of a 56 year old, Caucasian female with recurrent small intestinal obstruction caused by NSAID induced small bowel strictures. NSAID strictures in the small bowel were discovered by PillCam SB (Given Imaging, Ltd Yoqneam, Israel) endoscopy. Operative endoscopy was successful in limiting the length of small intestine resected by endoscopic dilation of multiple small bowel strictures and retrieving the retained SB capsule. As of January 2009, the patient has remained symptom free for 5 years.
Case Report:
This patient presented to our emergency department twice in the summer of 2004, with over four hours of acute onset abdominal pain and distention. On each occasion flat and upright abdominal films identified dilated loops of small intestine and air fluid levels. CT scan of the abdomen with intravenous and oral contrast was remarkable for small bowel dilation but without obvious cause, Figure 1. The patient had no history of prior abdominal surgery and colon cancer screening at 50 yrs was negative. Brief hospitalization with narcotic analgesia and nasogastric bowel decompression was effective in resolving symptoms. The patient resumed her usual activities and diet without limitation. An outpatient UGI small bowel follow through (SBFT) examination was scheduled, but not completed by the patient. Roughly, three months later the patient presented to the emergency department with similar symptoms and radiographic findings of small bowel obstruction. Laboratory tests showed iron deficiency anemia. After brief hospitalization with intravenous fluids, narcotic analgesia and nasogastric decompression, the patient returned to baseline. Coloileoscopy showed only a few sigmoid diverticuli and upper endoscopy showed a small hiatal hernia and esophagitis. Biopsies of the stomach and duodenum identified only Helicobacter negative, chronic gastritis. A dedicated UGI series with SBFT was carefully conducted and reviewed, but noted to be unremarkable, Figure 2.
The patient’s past medical history was remarkable for seropositive rheumatoid arthritis, hyperparathyroidism, oral herpes simplex and gastroesophageal reflux. The patient had a past medical history of subtotal parathyroidectomy. Medications included Prilosec (omperazole) 20 mg daily, Plaquenil (hydroxychloroquine sulfate) 200 mg daily, Motrin (ibuprofen) 400 mg or 800 mg twice daily for over 8 years, and periodic prednisone for flares of rheumatoid arthritis.
After a careful multidiscipline review of all studies and discussion with the patient, we felt the most likely cause of the patient’s recurrent symptoms was NSAID enteropathy or other obstructive etiology that would necessitate exploratory abdominal surgery. We advised the patient that capsule endoscopy could give additional information as to the cause and location of recurrent small bowel obstruction, but there was a high likelihood that the capsule would not pass or would impact at the sight of the small bowel pathology. The patient gave informed written consent to proceed with capsule endoscopy, with knowledge that PillCam retention was likely. Images from the videocapsule showed multiple white septal strictures in the small intestine, Figures 3,4,5. Although the patient had no obstructive symptoms, the capsule did not pass spontaneously by two weeks.
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Figure 3 |
Figure 4 |
Figure 5 |
Surgical and gastrointestinal specialties planned for tandem operative intervention. After vertical midline incision, the small intestine was manually examined and confirmed the presence of multiple jejunal and ileal strictures, Figure 6. A palpable luminal defect (video capsule) was identified in the mid ileum. A pediatric colonoscope (Olympus PCF-140L, 11.3mm Diameter, 3.2mm Channel, 168cm working length) was passed per os. The endoscopist advanced the colonoscope into the pylorus. Then the surgeon applied gentle pressure to the anterolateral aspect of the stomach to splint the endoscope and facilitate passage of the endoscope into the jejunum. From this point the endoscope was gently advanced per os by the endoscopist with simultaneous gentle surgical traction and pleating of the small intestine over the tip of the endoscope and then gently sleeved over the length of the endoscope. As the endoscope was advanced multiple white circumferential strictures of variable diameter were evident in the distal jejunum, Figures 7,8.
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Figure 6 |
Figure 7 |
Figure 8 |
When the endoscope was advanced into the ileum, three consecutive strictures spaced over 10-12 inches were encountered that obstructed passage of the colonoscope. With hand occlusion of the distal ileum by the surgeon, the endoscopist distended the lumen with air. The circumferential band-like nature of the strictures was evident. Through the scope (TTS), graded balloon dilation (12, 13.5, 15 mm OD and 240 cm length, CRE™ Wireguided Balloon Dilator, Boston Scientific Corp) was effective in disruption of the strictures. Mild intraluminal bleeding was evident and the endoscope easily advanced to the next obstructing stricture, where graded balloon dilatation was repeated twice more, Figures 9A,B,C.
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Figure 9A |
Figure 9B |
Figure 9C |
Ultimately the PillCam capsule was identified. Beyond this was a much denser luminal structure with luminal narrowing of ~5 mm, Figure 10. Graded balloon dilation was attempted, but at a 50% reduction of recommended pressure for a 12 mm CRE balloon dilation a large serosal and mesenteric hematoma was evident, Figure 11. Examination of this stricture and the remainder of the ileum revealed a 10 cm segment of multiple, dense strictures and then normal distal ileum to the ileocecal region. The capsule was retrieved and a short segment of dense strictures in the distal ileum was surgically resected. The patient was managed in the usual post operative fashion and discharged from the hospital on a low roughage diet. She has been strictly prohibited from ingestion of any prescribed or over the counter NSAIDs and aspirin. At 5 years from surgery, this patient is well and has experienced no further bowel obstruction or other gastrointestinal issues.
Discussion:
NSAIDs are one of the most commonly used medications world wide, primarily because of their effectiveness as anti-inflammatory and analgesic agents.1,2 Although NSAIDs have great benefit, significant morbidity and even mortality from chronic use of NSAIDs has been acknowledged in the upper gastrointestinal tract. A prospective study by the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) determined that 13 of every 1000 patients with rheumatoid arthritis who take an NSAID for 1 year have a serious gastrointestinal complication.3 Most physicians are aware of NSAID complications in the UGI tract to include pill esophagitis and gastroduodenal ulceration and hemorrhage, but only recently has the medical community become aware of the significant potential for NSAID injury of the small intestine.4,5,6,7 Prospective evaluation with capsule endoscopy has shown NSAID enteropathy to be very common in both healthy subjects and arthritic patients, with multiple small bowel erosions or ulcers discovered in over 70% of subjects treated with NSAID vs. 10% among control subjects.8,9
Small bowel enteropathy caused by NSAIDs has been hypothesized to occur through disruption of the mucosal and cellular integrity.10 NSAIDs act as lipid-soluble weak acids that interfere with enterocyte phospholipid membranes, uncoupling of mitochondrial phosphorylation, ultimately loss of mucosal barrier and cyclooxygenase-mediated compromise of villous blood flow.10,11 Small intestinal injury from NSAIDs runs a spectrum from macroscopically undetectable increased intestinal permeability and mild mucosal inflammation to ulceration to diagphragmatic strictures.4,5,12-15 Diaphragm strictures are rare but pathognomonic of NSAID use.4,5 There are often multiple, 2-3 mm thick septae, usually in the small intestine, which can reduce the size of the intestinal lumen to a pinhole.5,15,16 These diaphragm strictures are thin and easily missed on enteroclysis, where they may resemble plicae circularis.5
Our case illustrates several important clinical points concerning NSAID enteropathy and unexplained recurrent small bowel obstruction. First, in a patient with unexplained small intestinal obstruction on chronic NSAIDs and without previous abdominal surgery, NSAID enteropathy should be considered in the differential diagnosis. In this scenario, clinicians should not be surprised when endoscopic and radiographic testing are negative, as the obstructing diaphragmatic septae are easily and often missed, even on the most carefully conducted radiographic examinations.5,6 The utility of capsule endoscopy in this clinical situation is illustrated in the case we report.
Secondly, the PillCam SB capsule (Given Imaging, Ltd Yoqneam, Israel) dimensions are 11 x 26 mm, and should pass through the normal small intestine without difficulty. However, capsule endoscopy is usually conducted to evaluate for intrinsic pathology, such as occult gastrointestinal bleeding, anemia or possible Crohn’s disease. The benefit of discovery of occult small intestinal pathology, must be weighted against the risk of capsule retention, which has been reported to occur in 1% (investigation of obscure GI bleeding) to ~10% (investigation of suspected Crohn’s disease) of cases.18,19,20 Surprisingly, a retained videocapsule rarely impacts at a site of intestinal stenosis causing complete bowel obstruction.16,20-22 The Agile patency capsule (Given Imaging, Yoqneam, Israel) provides a means of evaluating luminal patency without the risk for capsule retention. The patency capsule is constructed from a dissolvable matrix, which is designed to disintegrate after 30 hours and pass though strictures in tiny pieces.23 Although the Agile patency capsule is helpful in evaluating the risk for capsule retention, it unfortunately does not provide luminal images. In our case, the patency capsule would have confirmed our preoperative suspicion of small intestinal stenosis, but would not have provided the key information on the number and extent of the NSAID enteropathy seen in our patient. Our preoperative suspicion of extensive NSAID enteropathy was confirmed by capsule endoscopy and guided our decision to proceed with tandem surgery and operative endoscopy. We hoped that surgically assisted enteroscopy would facilitate endoscopic positioning for TTS dilation of multiple strictures, monitor for complications of TTS dilations and preclude resections of long or even multiple segments of the small intestine. Our suspicions were confirmed, we cannot over emphasize the importance of visually monitoring the serosal surface during TTS of tight strictures for signs of injury that could have resulted in perforation or restenosis. At the time of this patient's original presentation, balloon endoscopy was not available and not considered as an alternative to intraoperative endoscopy. Even now, the authors would suggest that the extensive nature of the NSAID enteropathy disclosed by capsule endoscopy in our report would still persuade us to proceed with a tandem surgical/operative endoscopic approach. Our experience of witnessing the serosal injury with dilation of tight NSAID strictures was helpful evaluating risk for bowel perforation. Had we followed the “rule of three,”24 for safe dilation of strictures, multiple sessions of balloon enteroscopy and sequentially larger TTS dilation sessions would have been needed to achieve luminal dilation of 15 mm used in our case. When small intestinal strictures are less numerous and less tight, single or double balloon enteroscopy and graded TTS dilation would be a less invasive option, shown to be useful by others.25,26
Lastly, the technique of tandem surgery and operative endoscopy is an advanced surgical procedure that requires experience, skill, patience and cooperative planning.27,28,29 Our center has conducted a number of tandem procedures and suspect that disciplines of Surgery and Gastroenterology will continue to work more closely with NOTES, Rendez-vous Laparoscopic cholecystectomy and ERCP, and therapeutic operative endoscopy.
References:
1. Cryer B. NSAID gastrointestinal toxicity. Current Opinion in Gastroenterology. 2000;16:495-502.
2. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs. NEJM. 1999;340:1888-1899.
3. Singh G, Triadafilopoulus G. Epidemiology of NSAID-induced GI complications. J Rheumatol. 1999;26:Suppl 26:18-24.
4. Fortun PJ and Hawkey CJ. Nonsteroidal Inflammatory drugs and the small intestine. Current Opinion in Gastroenterology. 2007;23:134-141.
5. Adebayo D, Bjarnason I. Is nonsteroidal anti-inflammatory drug (NSAID) enteropathy clinically more important than NSAID gastropathy? Postgrad Med J. 2006;82:186-191.
6. Lang J, Price AJ Burke M, Gumpel JM, Bjarnason I. Diaphragm disease: pathology of disease of the small intestine induced by non-steroidal anti-inflammatory drugs. J Clin Pathol. 1988;41:516-526.
7. Bjarnason I, Zanelli G, Smith T, Prouse P, Williams P, et al. Nonsteroidal anti-inflammatory drug-induced intestinal inflammation in humans. Gastroenterol. 1987;93:480-9.
8. Graham DY, Opekun AR, Willingham FF, et al. Visible small intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol. 2005;3:55-59.
9. Gomez-Rodriguez B, Cauendo-Alvarez A, Romero-Vasquez J, et al. NSAIDs erosive enteropathy assessed by capsule endoscopy: a prospective controlled trial. Gastroenterol. 2004;126:A96.
10. Bjarnason I, Takeuchi K, Simpson R. NSAIDs: the Emperor’s new dogma? Gut 2003;52:1376-1378.
11. Kelly DA, Piasecki C, Anthony A, et al. Focal reduction of villous blood flow in early indomethacin enteropathy: a dynamic vascular study in the rat. Gut. 1998;42:366-373.
12. Gargot D, d’Alteroche L, Desbazeille F, et al. Nonsteroidal anti-inflammatory drug-induced colonic strictures: two cases and literature review. Am J Gastroenterol 1995;90:2035-2038.
13. Morris AJ, MacKenzie JF. Small bowel enteroscopy in undiagnosed gastrointestinal blood loss. Gut. 1992;33:887-889.
14. Maiden L, Thjodleifsson B, Theodors A. A quantative analysis of NSAID-induced small bowel pathology by capsule enteroscopy. Gastroenterology. 2005;128:1172-1178.
15. Goldstein JL. Videocapsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omperazole, and placebo. Clin Gastroenterol Hepatol. 2005;3:133-141.
16. Cheifetz AS and Lewis BS. Capsule endoscopy retention: Is it a complication? J Clin Gastroenterol. 2006;40:688-691.
17. Barkin JS, Friedman S. Wireless capsule endoscopy requiring surgical intervention. The world’s experience. Am J Gastroenterol. 2002;97:A-83.
18. Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology. 2004;60:643-653.
19. Mow WS, Lo SK, Targan SR, et al. initial experience with wireless capsule endoscopy in the diagnosis and management of Inflammatory Bowel Disease. Clin Gastroenterol Hep. 2004;2:31-40.
20. Rondonotti E, Herrerias JM, Pennazio M, et al. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc. 2005;62:712-716.
21. Delvaux M, Ben Soussan E, Laurent V, et al. Clinical evaluation of the M2A patency capsule system before a capsule endoscopy procedure in patients with suspected intestinal stenosis. Endoscopy. 2005;37:801-807.
22. Cave D, Legani P, deFrachis R, et al. ICCE consensus for capsule retention. Endoscopy. 2005 ; 62 :712-716.
23. Herrerias JM, Leighton JA, Costamanga G et al. Agile patency system eliminates risk of capsule retention in patients with known intestinal strictures who undergo capsule endoscopy. Gastroint Endosc 2008;67: 902-909.
24. Boyce HW. Dilation of difficult benign esophageal strictures. Am J Gastroenterol. 2005;100:744-5.
25. Upchurch BR, Vargo JJ. Small bowel enteroscopy. Rev Gastroenterol Disord. 2008;8:169-77.
26. Aktas H, Mensink PB. Therapeutic balloon-assisted enteroscopy. Dig Dis. 2008;26:309-13.
27. Hammaker B and McNally PR. Utility of Emergent Endoscopy to Guide Laparoscopy in A Patient with Acute Cholecystitis and Unusual Laparoscopic Findings. http://www.vhjoe.org/Volume5Issue1/5-1-3.htm
28. Wilhelm D, von Delius S, Burian M, Schneider A, Frimberger E, Meining A, Feussner H. Simultaneous use of laparoscopy and endoscopy for minimally invasive resection of gastric subepithelial masses - analysis of 93 interventions. World J Surg. 2008 Jun;32:1021-8.
29. Wilhelm D, von Delius S, Weber L, Meining A, Schneider A, Friess H, Schmid RM, Frimberger E, Feussner H. Combined laparoscopic-endoscopic resections of colorectal polyps: 10-year experience and follow-up. Surg Endosc. 2009 Jan 24. [Epub ahead of print]
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