Small Bowel Ulcers Are Common in Patients Not Taking NSAIDs

Abstract

Purpose: To assess the incidence of small bowel ulcers in a series of 194 patients undergoing wireless capsule endoscopy, and to evaluate for association with use of non-steroidal anti-inflammatory medications (NSAIDs). Methods: 194 sequential patients who underwent wireless capsule endoscopy (WCE) were used to evaluate the incidence of small bowel ulcer occurrence. For the purpose of this study, the definition of “ulcers” included superficial erosions. Patients with ulcers in the duodenal bulb or with suspected inflammatory bowel disease were excluded from the study. The association of ulcer occurrence with age, gender, NSAID use, proton pump inhibitor (PPI) use, and body mass index (BMI) were investigated. Results: Patient indications for WCE were anemia (66%), gastrointestinal hemorrhage (30%), diarrhea (11%), abdominal pain (20%), and other (9%). At least one small bowel ulcer was present in 36% of all patients, and in 39% of patients with anemia. Small bowel ulcers were not found to be associated with age (p = 0.69), male gender (p = 0.36), or BMI (p = 0.84). Although occurrence of ulcers in patients on NSAIDs were 10% greater than those not on NSAIDs, this difference was not statistically significant (p = 0.37). A large proportion of patients not taking NSAIDs had small bowel ulcers (32%). Patients on both NSAIDS and proton pump inhibitor medications did not have a lower incidence of small bowel ulcers than patients on NSAIDS alone (48% vs 40% respectively, p = 0.56). Conclusions: 1). Small bowel ulcers occur commonly in WCE patients not taking NSAIDs. This high rate occurrence may be idiopathic, due to medications, or due to unknown factors. 2). Proton pump inhibitor treatment is not associated with lower small bowel ulcer occurrence. 3). Because NSAID and PPI use are not associated with small bowel ulcer occurrence, the mechanism of ulcer formation in the small bowel is likely to be different from the gastric model, which involves prostaglandin inhibition and acid injury. 4). Given the remarkable high incidence of small bowel ulcers in this study, an examination of small bowel ulcer incidence in the asymptomatic general population would be warranted.