Intestinal perforation in a patient with severe ankylosing spondylitis

Abstract

Case historyA 54 year old man who had suVered from predominantly axial ankylosing spondylitis for 25 years was referred to see a gastroenterologist because of pallor in 1983. He was found to be anaemic, haemoglobin (Hb) 7.7 g/dl (13-18), mean cell volume (MCV) 57 fl (78-98), mean corpuscular haemoglobin (MCV) 17.5 pg (27.5-32.5), ferritin 27 µg/l (41-480), B12 and folate within normal limits, and to have a raised plasma viscosity 2.17 cps (1.5-1.72). He was taking indomethacin 25 mg thrice daily. Upper gastrointestinal endoscopy and barium enema were normal. The small bowel was not visualised and despite a microcytic hypochromic picture an anaemia of chronic disease was diagnosed. The haemoglobin had subsequently returned towards normal limits, Hb 10.3 g/dl, MCV 66 fl, MCH 20.3 pg, and ferritin 58 µg/l, when reviewed one year later.At the age of 60 years the patient attended the rheumatology department for the first time. Severe, predominantly axial, ankylosing spondylitis was noted with no lumbar spine movement and only 1 cm of chest expansion. Ranitidine 150 mg twice daily was added to the indomethacin for empirical gastrointestinal protection.At the age of 63 years the patient underwent a C2-C6 laminectomy for severe upper limb parasthesia. Later that year he was admitted as a general medical patient with suspected melaena with Hb 10.6 g/dl, MCV 75 fl (folate, B12, iron, and total iron binding capacity values were not recorded). A barium swallow was normal. Misoprostol was started in place of the ranitidine. The patient was advised to discontinue the indomethacin. However, because of good symptomatic relief this advice was not taken.One year later, at the age of 64 years the patient was again admitted to a general medical ward with suspected melaena, Hb 10.2 g/dl, MCV 66.7 fl. Upper gastrointestinal endoscopy was normal. It was assumed that the suspected melaena was secondary to non-steroidal anti-inflammatory drug (NSAID) use despite normal endoscopy, and that the anaemia was also a consequence of the chronic severe disease. A left total hip replacement was also carried out that year.