Clinical Features, Diagnosis, and Treatment Strategies of Gastrointestinal Diaphragm Disease Associated with Nonsteroidal Anti-Inflammatory Drugs

Abstract

Background. To demonstrate the clinical features, diagnosis, and treatment of nonsteroidal anti-inflammatory drug- (NSAID-) induced diaphragm disease (DD). Methods. A literature search between January 1973 and August 2015 was undertaken. The clinical data of patients with NSAID-induced DD were recorded and analyzed. Results. 159 patients were included. The ratio of male to female was 1 : 2.3; the mean age was 65 ± 11 years. The most common clinical manifestations were gastrointestinal bleeding and obstruction. 121 (84%) patients took traditional NSAIDs. The durations of NSAIDs use ranged from 2 to 300 months. A majority (59.7%) of DD were seen in the small bowel, were seen secondly in the colon (30.2%), and were mainly located in the ileum (57.9%) and right colon (91.7%), respectively. 80% of patients had multiple diaphragms. 41.5% of small bowel DD were diagnosed preoperatively by capsule endoscopy and/or double-balloon enteroscopy, 52.1% at laparotomy. Nearly 75% of patients underwent surgery, endoscopic balloon dilation was performed in 22 patients, and NSAIDs were withdrawn in 53 patients. Conclusions. NSAID-induced DD is relatively rare. The small bowel is most commonly involved. Preoperative diagnosis of small bowel DD is relatively difficult. Discontinuation of the NSAIDs is recommended, surgical resection is the main treatment presently, and endoscopic balloon dilation should be considered as an alternative therapy.

Small bowel diaphragm disease from long-term non-steroidal anti-inflammatory use

“…NSAIDs are one of the most widely prescribed drugs in the world for a multitude of indications including analgesia, heart disease and as in the case we have presented, rheumatological conditions 2 5. In an attempt to mitigate the gastroduodenal complications of NSAIDs, including ulceration and bleeding, enteric coated and slow release formulations have been developed 1 6.…”

“…In a capsule endoscopy study of 160 patients taking NSAIDs for 3 months or longer duration, two per cent of participants were found to have SBDD 9. With an ageing population and the widespread use of NSAIDs for rheumatoid conditions and heart disease, it may be that clinicians encounter an increasing incidence of SBDD 2. SBDD should be included in the differential diagnosis of small bowel obstruction especially when the symptoms are chronic or where the patient has not had significant previous surgery to suggest adhesions or internal herniation.…”

“…While the detrimental effects of non-steroidal anti-inflammatory drugs (NSAIDs) on gastric and duodenal mucosa are well recognised, less familiar is the damage caused to the small bowel mucosa distal to the duodenum 1 2. Small bowel diaphragm disease (SBDD), first described by Lang et al in 1988, is a complication of NSAID use and is characterised by circumferential lesions of short length (<5 mm), causing intrinsic stenosis of the small bowel lumen 3 4.…”

A Rare Cause of Colonic Stricture

“…The most common clinical presentations are obstructive symptoms and gastrointestinal bleeding after taking traditional NSAIDs or cyclooxygenase-2 inhibitors for >1 year. 1 The thin diaphragm strictures are difficult to detect on imaging studies. They are seen during endoscopy or surgery.…”

Non‐steroidal anti‐inflammatory‐induced small bowel diaphragm disease requiring bowel resection for recurrent small bowel obstruction

“…Small bowel diaphragm disease is an uncommon complication associated with NSAID use. It is thought to arise from mucosal and submucosal fibrosis causing a diaphragm or mucosal web, with luminal narrowing often to the size of a ‘pinhole’ leading to obstruction and potentially, perforation …”