Electronic Clinical Challenges and Images in GI

Abstract

Question: A 75-year-old woman presented with vomiting. She had a past history of right hip replacement and pyloric ulceration caused by the use of diclofenac, a nonsteroidal anti-inflammatory drug (NSAID) that she had been prescribed for many years. She was taking omeprazole 20 mg once daily and had avoided all NSAIDs for the previous 12 months. On examination, her abdomen was distended and exhibited a succussion splash. A clinical diagnosis of gastric outflow obstruction was made. Initial laboratory investigations showed evidence of iron deficiency anemia with hemoglobin 10.3 g/dL (normal range, 11.5–16.5), mean cell volume 70.3 fl (normal range, 76–96), and ferritin 8 μg/L (normal range, 10–210). Blood clotting was normal. Biochemistry investigations showed normal urea, electrolytes, and liver function except hypoalbuminemia 21 g/L (normal range, 35–50). Her admission plain abdominal radiograph is shown (Figure A). A gastroscopy was performed, which demonstrated large amounts of food residue within a grossly distended stomach. The pylorus was patent, leading into the first part of duodenum, which was dilated. A tight stricture with circumferential ulceration was identified at the junction of the first and second part of her duodenum, which was successfully balloon dilated. The endoscope was only just able to cross the stricture owing to the gastric distention. The next day, her symptoms and clinical examination findings persisted. What is the reason for the lack of clinical improvement despite successful dilatation of the stricture? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Owing to lack of resolution of the symptoms of gastric outflow obstruction, a repeat gastroscopy was undertaken using an enteroscope (Figure B). This showed that the index stricture remained patent, but a second discrete stricture was identified. This distal stricture was balloon dilated and the patient's clinical condition improved. Review of the abdominal radiograph shows evidence of 2 “diaphragm–like” strictures. The stomach is grossly distended, tapering to the pylorus. The first part of the duodenum is dilated owing to the proximal stricture and there is further dilated duodenum from the distal stricture. This demonstrates the usefulness of abdominal radiography in predicting endoscopic findings. This is a clinical example of the long-term sequelae of NSAID use, which is well known to cause bleeding and ulceration, as well as obstruction caused by luminal narrowing. Diaphragms are thin, septate narrowings, usually of the small intestinal mucosa and are thought to arise from circumferential ulcers.1Tibble J. Smale S. Bjarnason I. Adverse effects of drugs on the small bowel.Adv Drug React Bull. 1999; 198: 755-758Crossref Scopus (1) Google Scholar Multiple diaphragm strictures are rare and usually seen in the mid small bowel. They are pathognomonic of NSAID-induced intestinal damage.2Fortun P.J. Hawkey C.J. Nonsteroidal antiinflammatory drugs and the small intestine.Curr Opin Gastroenterol. 2007; 23: 134-141PubMed Google Scholar This patient also showed evidence of small bowel enteropathy (iron deficiency and hypoalbuminemia), which is thought to be due to increased small bowel permeability and microscopic blood loss from NSAID-induced small bowel inflammation, which can occur after as little as 6 months of treatment.2Fortun P.J. Hawkey C.J. Nonsteroidal antiinflammatory drugs and the small intestine.Curr Opin Gastroenterol. 2007; 23: 134-141PubMed Google Scholar Importantly, the deleterious effects of NSAIDs can last for up to 16 months after discontinuation.3Bjarnason I. Zanelli G. Smith T. et al.Nonsteroidal antiinflammatory drug-induced inflammation in humans.Gastroenterology. 1987; 93: 480-489PubMed Google Scholar