Obscure GI Bleeding Due to Chronic Nonspecific Ulcers of the Small Intestine (CNSU)

Abstract

Purpose: With the widespread advent of video capsule endoscopy (VCE) and double balloon endoscopy (DBE), evaluation of the small intestine for causes of obscure GI bleeding is no longer a distant dream. Vascular lesions are the commonest cause of small intestine bleeds, ulcers are increasingly being identified as a source. Most of them are attributed to NSAIDS use. There are many reports of chronic nonspecific small intestinal ulcers causing obscure GI bleeding. The etiology, differentiating features and management of chronic non specific ulcers (CNSU) of small intestine is still unclear. We present a case of recurrent obscure bleeding from CNSU. Case: A 75 y/o female with past medical history of hypertension, hyperlipidemia and atrial fibrillation on Coumadin presented in 2009 with symptomatic anemia, melena and a hematocrit of 16. She had no abdominal pain, diarrhea, weight loss. She received transfusion. EGD showed hiatal hernia, colonoscopy revealed diverticulosis and a sessile polyp in ascending colon. VCE revealed multiple ulcers in ileum without any stenosis. A second VCE a few months later showed similar circular ulcers in the ileum without strictures or diaphragms. She presented again in 2012 with weakness and anemia and was transfused. VCE again showed multiple superficial ulcers in the ileum, without inflammation. She was on Coumadin but not NSAIDS or aspirin. After transfusion she was discharged with instructions to avoid NSAIDs, and check CBC. Discussion: Nonspecific ulcers of the small intestine are increasingly recognized with the use of VCE and DBE. The proposed etiologies includes: infection, trauma, ischemia, chemical and neoplasia. A majority of them presented without any attributable etiology. CNSU was first described in Japan in 1960s; since then, cases have been reported from world over. It has a chronic recurrent course with GI bleeding induced anemia as the most typical presenting symptom. Ulcers occur predominantly in ileum and are discrete lesions with flat ulcer bed and never extend beyond the submusocal layer. They are usually diagnosed with capsule endoscopy as was done for our patient. CNSU and NSAID induced enteropathy share common clinical presentation and appearance. Lack of history of NSAID ingestion along with ulcers seen mainly in the ileum, and absence of leisons in proximal small bowel are features favoring a diagnosis of CNSU. Further studies are needed to better understand the pathophysiology and treatment options for CNSU. It is important to recognize CNSU as an independent cause of obscure GI bleed.