Gastrointestinal: Ibuprofen‐induced duodenal stricture resulting in malnutrition

Abstract

Chronic use of non-steroidal anti-inflammatory drugs (NSAID) is known to be associated with small bowel ulceration as a result of direct mucosal toxicity. The development of distal small bowel and colonic diaphragm-like strictures has been described, but duodenal strictures due to chronic high-dose NSAID use are rare. A 26-year-old man had injury-related chronic back pain for which he was taking high doses of ibuprofen regularly for the past 5 years. He had no other medical conditions and was not on other medications. He presented to hospital with a six-week history of progressively severe nausea and vomiting with an inability to tolerate food intake resulting in an 8kg loss of weight over this period as he was reduced to consuming fluids only. He did not have any preceding symptoms of abdominal pain or gastrointestinal bleeding. On arrival he was malnourished and hypovolaemic due to dehydration. He was noted to have iron deficiency anaemia and his ibuprofen was ceased. Abdominal x-ray with oral contrast revealed a dilated stomach and proximal duodenum with a short stricture seen in the third part of the duodenum (Fig. 1). An upper gastrointestinal endoscopy was performed after a prolonged fast where a large residue of food was noted within the stomach, multiple shallow ulcers were seen within the duodenal cap and second part, and a tight stricture was found in the third part of the duodenum which did not allow passage of the endoscope (Fig. 2). Biopsy of this area revealed extensive ulceration with no evidence of malignancy, and no inflammation to suggest the presence of Crohn's disease. He was placed on a high protein, high caloric low residue liquid diet in order to improve his nutrition. Endoscopic dilatation of this duodenal stricture was performed and he may require repeated treatments to this area before he is able to resume a normal diet again. Contributed by