NSAID-Induced Colonic Stricture Requiring Right Hemicolectomy

Abstract

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used medications for their analgesic, anti-inflammatory, and, in the case of aspirin, anti-thrombotic properties. Most of the detrimental gastrointestinal effects of NSAIDs are well-studied. However, NSAID-induced colonic strictures are rarely reported but can have devastating consequences without prompt diagnosis. A 63-year-old man with osteoarthritis on chronic diclofenac was referred for microcytic anemia in the setting of unintentional weight loss. Esophagoduodenoscopy (EGD) revealed linear gastric ulcerations and colonoscopy showed mucosal ulceration and luminal narrowing in the proximal ascending colon (figure 1) thought to be due to chronic diclofenac use. Patient continued to use diclofenac despite cessation recommendation. Due to persistent symptoms, colonoscopy was repeated which showed smooth, severe stricture at the area of prior ulceration (figure 2). The stricture was dilated with a 15mm balloon over a guidewire. No evidence of colon mass was seen. An abdominal computed tomography angiogram (CTA) to rule out bowel ischemia was normal. The colonic stricture was thought to be due to chronic use of NSAIDs. One week later, the patient was admitted with persistent abdominal pain and constipation with persistence of stricture on a third colonoscopy (figure 3). Surgery consult was placed and the patient underwent laparoscopic right hemicolectomy resulting in symptom resolution. Pathology of the resected specimen showed a benign stricture with a small proximal diverticulum, likely due to increased colonic pressure proximal to the stricture. This case emphasizes the need to increase awareness about NSAID-induced colonic strictures. Generally, patients present with obstructive symptoms and gastrointestinal bleeding after at least one year of NSAID use. Endoscopy or surgery is used for diagnosis with the most common location being the proximal ascending colon. Though this is a rare consequence of NSAID use with only 50 cases reported to date, correct diagnosis and cessation of the offending agent can lead to resolution of symptoms. However, when severe stenosis is present, pneumatic dilatation or surgical resection may be necessary.Figure: Luminal narrowing of the proximal ascending colon.Figure: Severe stricture at the area of prior ulceration.Figure: Persistence of stricture despite intervention with balloon dilation.