An Unusual Case of Lower Gastrointestinal Bleeding

Abstract

Harmful effects of non-steroidal anti-inflammatory drugs (NSAIDs) are well recognized in the stomach and duodenum. However, NSAID related damage to the colon is less common. We present the case of a 54-year-old female with a history of hypertension, chronic tension headaches, osteoarthritis of knees who presented to our hospital with complaint of painless bright red rectal bleeding for 2 days. Her medications included amlodipine 5 mg daily and ibuprofen 800 mg two times daily. On admission, her BP was 138/78, heart rate was 82/min, respiratory rate was 19/min and temperature was 98.4 F. Her physical exam was within normal limits. Laboratory investigations including complete blood count, basic metabolic panel and liver function test were within normal limits. ANA and ANCA were negative. CT abdomen did not reveal any acute intra-abdominal process. Colonoscopy was done which revealed erosions and 1-2 sharp circumferential ulcers in the ascending colon. Biopsy of these lesions revealed non-specific chronic inflammatory cell infiltrate with focal recent hemorrhage and superficial epithelial erosion. Patient was asked to discontinue ibuprofen and a repeat colonoscopy 8 weeks later revealed a normal colon. Based on presence of erosions and ulcers on the right side of the colon and normalization of the colon after discontinuation of ibuprofen, a diagnosis of NSAID colopathy was made. NSAID induced colopathy has been described as an important cause of lower GI bleeds. The use of enteric-coated NSAIDs has led to greater exposure of the colon to these medications predisposing the colonic mucosa to inflammatory damage and ulcer formation. Erosions, ulcers, diaphragms and strictures are typically present on the right side of the colon. Histopathological features are similar to ischemic colitis and it is important to correlate these with clinico-endoscopic findings. Withdrawal of NSAIDs leads to healing of ulcers and erosions. Long-term complications include colonic obstruction and perforation warranting endoscopic and surgical intervention. Therefore, it is pertinent to diagnose and treat this condition in a timely fashion.Figure 1Figure 2