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Sample JW, Solanki MH, Thiels C, Bingener J. Nonsteroidal anti-inflammatory drug-induced small bowel strictures (diaphragm disease) - an under-recognized cause of small bowel obstruction. J Gastrointest Surg 2024:S1091-255X(24)00498-0. [PMID: 38871074 DOI: 10.1016/j.gassur.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/01/2024] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Small bowel obstruction is a major source of morbidity and mortality that carries a significant economic burden. Recurrent small bowel obstruction may be secondary to circumferential strictures (small bowel diaphragm disease), an under-recognized entity secondary to long-term nonsteroidal anti-inflammatory drug (NSAID) use. We aimed to describe the sensitivity of preoperative computed tomography (CT) enterography in patients with surgically treated small bowel diaphragm disease. METHODS We retrospectively reviewed adult patients who underwent elective small bowel resection for small bowel obstruction performed by a single minimally invasive surgeon between 2010 and 2023. Patient history, radiographic, endoscopic, operative, and pathology reports were reviewed for reference to NSAID use, small bowel strictures, diaphragms, and enteropathy. Exclusion criteria were prior radiation, inflammatory bowel disease, malignancy, adhesive disease, and anastomotic strictures. RESULTS A total of 225 patients were identified, 22 (10%) of whom met the inclusion criteria. The mean age was 60.7 years (range 29-78), with 15 women (68%). All patients underwent minimally invasive small bowel resection for obstruction with histopathologic evidence of stricture without evidence of transmural inflammation, granuloma, or dysplasia and confirmed NSAID use (n = 22, 100%). Anemia was present in 36% (n = 8). Preoperative CT or magnetic resonance (MR) enterography was performed in 18 patients (82%), of which stricturing was reported in 13 (72%). Intraoperatively, palpation identified strictures in all patients. CONCLUSION NSAID-induced small bowel injury is an under-recognized condition that, in severe cases, can present as small bowel obstruction. Surgeons should consider diaphragm disease in patients with obstruction and NSAID use, in which preoperative CT or MR enterography may be useful but cannot rule out disease.
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Affiliation(s)
- Jack W Sample
- Department of Surgery, Mayo Clinic Rochester, Minnesota, United States.
| | - Malvika H Solanki
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Minnesota, United States
| | - Cornelius Thiels
- Department of Surgery, Mayo Clinic Rochester, Minnesota, United States
| | - Juliane Bingener
- Department of Surgery, Mayo Clinic Rochester, Minnesota, United States
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2
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Johnson N, Solkar M, Sehgal R, Riyad K. Non-steroidal anti-inflammatory drug induced intestinal stricturing: diaphragm disease. J Surg Case Rep 2024; 2024:rjad489. [PMID: 38250134 PMCID: PMC10799247 DOI: 10.1093/jscr/rjad489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/13/2023] [Indexed: 01/23/2024] Open
Abstract
Diaphragm disease (DD) is a rare small bowel enteropathy associated with non-steroidal anti-inflammatory drug use. Since the first description there have only been approximately 100 cases of DD reported in the literature. Stricturing webs or 'diaphragms' form in the bowel, causing non-specific abdominal symptoms that can ultimately lead to bleeding and obstruction. Diagnosis is notoriously challenging as there is no single gold standard investigation. We present two cases of DD both of which were ultimately diagnosed by surgical resection. We also propose a novel flow algorithm that can be utilized for working up patients with suspected DD.
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Affiliation(s)
- Nathan Johnson
- John Goligher Colorectal Surgery Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Maseera Solkar
- John Goligher Colorectal Surgery Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Rishabh Sehgal
- John Goligher Colorectal Surgery Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Kallingal Riyad
- John Goligher Colorectal Surgery Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
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3
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Jeong Y, Chung JH, Lim DW, Lee SH, Hwang SH, Shin DH. Small bowel diaphragm disease with multiple cluster lesions in one segment of the small bowel mimicking an adhesion band: A case report. Medicine (Baltimore) 2023; 102:e35235. [PMID: 38013339 PMCID: PMC10681587 DOI: 10.1097/md.0000000000035235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/24/2023] [Indexed: 11/29/2023] Open
Abstract
RATIONALE Small bowel diaphragm disease (SBDD) is a rare case, caused by long-term administration of nonsteroidal anti-inflammatory drugs (NSAIDs). The circumferential diaphragm in the lumen of small bowel causing mechanical obstruction is the characteristic finding. PATIENT CONCERNS A 74-year-old male was transferred to Pusan National University Yangsan Hospital (PNUYH) due to abdominal pain lasting for 2 months. He was treated in the local medical center (LMC) with Levin tube insertion and Nil Per Os (NPO) but showed no improvement. DIAGNOSIS According to abdomen-pelvis computed tomography (CT) result, small bowel obstruction due to the adhesion band was identified, showing dilatation of the small bowel with abrupt narrowing of the ileum. INTERVENTIONS Laparoscopic exploration was done but failed to find an adhesion band. An investigation of the whole small bowel was done with mini-laparotomy. At the transitional zone, the intraluminal air could not pass so the segmental resection of small bowel including the transitional zone and end-to-end anastomosis was done. OUTCOMES After surgery, every laboratory finding recovered to the normal range in 4 days, but the patient's ileus lasted for 8 days. The patient's symptoms were relieved after defecation, he was discharged on postoperative day 10. LESSONS For patients who show mechanical obstruction without an operation history but with long-term administration of NSAIDs, the clinicians should suspect small bowel diaphragm disease.
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Affiliation(s)
- Youseok Jeong
- Division of Gastrointestinal Surgery, Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae Hun Chung
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Pathology, School of Medicine, Pusan National University, Pusan National University Yangsan Hospital, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dong Won Lim
- Division of Gastrointestinal Surgery, Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Si Hak Lee
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Pathology, School of Medicine, Pusan National University, Pusan National University Yangsan Hospital, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sun-Hwi Hwang
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Pathology, School of Medicine, Pusan National University, Pusan National University Yangsan Hospital, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dong Hoon Shin
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
- Pusan National University, School of Medicine, Busan, Korea
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4
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Ballal RR, Ahmed T, Ail DA, Colaco SM. A rare presentation of idiopathic small bowel diaphragm disease - A case report. Int J Surg Case Rep 2023; 112:108966. [PMID: 37883871 PMCID: PMC10667883 DOI: 10.1016/j.ijscr.2023.108966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/12/2023] [Accepted: 10/21/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION Diaphragm disease, typically associated with long-term non-steroidal anti-inflammatory drug (NSAID) use, manifests as diaphragm-like small bowel strictures, often resulting in bowel obstruction. CASE DESCRIPTION A 75-year-old male presented with features of recurrent subacute intestinal obstruction, later diagnosed with multiple small bowel strictures via CT imaging. Surgical intervention, including resection and anastomosis, was performed to alleviate the obstruction. Histopathological examination of the resected specimen confirmed diaphragm disease, challenging its traditional association with NSAID use. DISCUSSION Diaphragm disease, characterized by mucosal and submucosal diaphragm-like strictures, is typically attributed to NSAID usage. However, this case underscores the possibility of diaphragm disease in the absence of NSAID exposure. Pathological findings supported the presence of diaphragm-like strictures, despite the patient's denial of NSAID use. CONCLUSION This case emphasizes the importance of considering diaphragm disease as a differential diagnosis in patients with intermittent bowel obstruction, even in the absence of NSAID history.
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Affiliation(s)
- Rajesh R Ballal
- Department of General Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Talha Ahmed
- Department of General Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India.
| | | | - Sumith Marian Colaco
- Department of General Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
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5
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Mohamed DI, Abo Nahas HH, Elshaer AM, El-Waseef DAEDA, El-Kharashi OA, Mohamed SMY, Sabry YG, Almaimani RA, Almasmoum HA, Altamimi AS, Ibrahim IAA, Alshawwa SZ, Jaremko M, Emwas AH, Saied EM. Unveiling the interplay between NSAID-induced dysbiosis and autoimmune liver disease in children: insights into the hidden gateway to autism spectrum disorders. Evidence from ex vivo, in vivo, and clinical studies. Front Cell Neurosci 2023; 17:1268126. [PMID: 38026692 PMCID: PMC10644687 DOI: 10.3389/fncel.2023.1268126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023] Open
Abstract
Autism spectrum disorders (ASD) represent a diverse group of neuropsychiatric conditions, and recent evidence has suggested a connection between ASD and microbial dysbiosis. Immune and gastrointestinal dysfunction are associated with dysbiosis, and there are indications that modulating the microbiota could improve ASD-related behaviors. Additionally, recent findings highlighted the significant impact of microbiota on the development of autoimmune liver diseases, and the occurrence of autoimmune liver disease in children with ASD is noteworthy. In the present study, we conducted both an in vivo study and a clinical study to explore the relationship between indomethacin-induced dysbiosis, autoimmune hepatitis (AIH), and the development of ASD. Our results revealed that indomethacin administration induced intestinal dysbiosis and bacterial translocation, confirmed by microbiological analysis showing positive bacterial translocation in blood cultures. Furthermore, indomethacin administration led to disturbed intestinal permeability, evidenced by the activation of the NLRP3 inflammasomes pathway and elevation of downstream biomarkers (TLR4, IL18, caspase 1). The histological analysis supported these findings, showing widened intestinal tight junctions, decreased mucosal thickness, inflammatory cell infiltrates, and collagen deposition. Additionally, the disturbance of intestinal permeability was associated with immune activation in liver tissue and the development of AIH, as indicated by altered liver function, elevated ASMA and ANA in serum, and histological markers of autoimmune hepatitis. These results indicate that NSAID-induced intestinal dysbiosis and AIH are robust triggers for ASD existence. These findings were further confirmed by conducting a clinical study that involved children with ASD, autoimmune hepatitis (AIH), and a history of NSAID intake. Children exposed to NSAIDs in early life and complicated by dysbiosis and AIH exhibited elevated serum levels of NLRP3, IL18, liver enzymes, ASMA, ANA, JAK1, and IL6. Further, the correlation analysis demonstrated a positive relationship between the measured parameters and the severity of ASD. Our findings suggest a potential link between NSAIDs, dysbiosis-induced AIH, and the development of ASD. The identified markers hold promise as indicators for early diagnosis and prognosis of ASD. This research highlights the importance of maintaining healthy gut microbiota and supports the necessity for further investigation into the role of dysbiosis and AIH in the etiology of ASD.
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Affiliation(s)
- Doaa I. Mohamed
- Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Asmaa M. Elshaer
- Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Omnyah A. El-Kharashi
- Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Soha M. Y. Mohamed
- Physiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Yasmine Gamal Sabry
- Physiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Riyad A. Almaimani
- Department of Biochemistry, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Hussain A. Almasmoum
- Department of Laboratory Medicine, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Abdulmalik S. Altamimi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Ibrahim Abdel Aziz Ibrahim
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Samar Z. Alshawwa
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Mariusz Jaremko
- Smart-Health Initiative and Red Sea Research Center, Division of Biological and Environmental Sciences and Engineering, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
| | - Abdul-Hamid Emwas
- Advanced Nanofabrication Imaging and Characterization Center, King Abdullah University of Science and Technology, Core Labs, Thuwal, Saudi Arabia
| | - Essa M. Saied
- Chemistry Department, Faculty of Science, Suez Canal University, Ismailia, Egypt
- Institute for Chemistry, Humboldt Universität zu Berlin, Berlin, Germany
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6
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Boulagnon-Rombi C, Dufour C, Chatelain D. [Drug induced gastro-intestinal tract lesions: A pathologist point of view]. Ann Pathol 2023:S0242-6498(23)00045-7. [PMID: 36868901 DOI: 10.1016/j.annpat.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/31/2023] [Accepted: 02/08/2023] [Indexed: 03/05/2023]
Abstract
The number of drugs available to clinicians, especially targeted therapies, grows continuously. Some drugs are known to cause frequent digestive adverse effects, which may affect the gastro-intestinal tract in a diffuse or localized manner. Some treatments may leave relatively pathognomonic deposits, but histological lesions of iatrogenic origin are mostly non-specific. The diagnostic and etiological approach is often complex because of these non-specific aspects and also because (1) a single type of drug may cause different histological lesions, (2) different drugs may cause identical histological lesions, (3) the patient may receive different drugs, and (4) drug-induced lesions may mimic other pathological entities such as inflammatory bowel disease, celiac disease, or graft versus host disease. The diagnosis of iatrogenic gastrointestinal tract injury therefore requires close anatomic-clinical correlation. The iatrogenic origin can only be formally established if the symptomatology improves when the incriminating drug is stopped. This review aims to present the different histological patterns of gastrointestinal tract iatrogenic lesions, the potentially incriminate drugs, as well as the histological signs to look for in order to help the pathologist to distinguish an iatrogenic injury from another pathology of the gastrointestinal tract.
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Affiliation(s)
- Camille Boulagnon-Rombi
- Service de pathologie, centre hospitalier universitaire de Reims, 51092 Reims cedex, France; Université de Reims Champagne Ardenne, CNRS, MEDyC UMR 7369, 51097 Reims, France.
| | - Charlotte Dufour
- Institut de pathologie, centre de biologie pathologie, centre hospitalier universitaire de Lille, 59000 Lille, France
| | - Denis Chatelain
- Service d'anatomie pathologique du CHU d'Amiens, site Nord, 80080 Amiens, France
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7
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Hamon A, Cazals-Hatem D, Stefanescu C, Uzzan M, Treton X, Sauvanet A, Panis Y, Monsinjon M, Bonvalet F, Corcos O, Azouguene E, Cerf-Bensussan N, Bouhnik Y, Charbit-Henrion F. Crohn-like disease affecting small bowel due to monogenic SLCO2A1 mutations: First cases of Chronic Enteropathy Associated with SLCO2A1 gene (CEAS) in France. J Crohns Colitis 2022; 17:816-820. [PMID: 36480694 PMCID: PMC10155746 DOI: 10.1093/ecco-jcc/jjac181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Multiple chronic ulcers of small intestine are mainly ascribed to Crohn's disease. Among possible differential diagnoses are chronic ulcers of small bowel caused by abnormal activation of the prostaglandin pathway either in the archetypal but uncommon non-steroidal anti-inflammatory drug (NSAID)-induced enteropathy, or in rare monogenic disorders due to PLA2G4A and SLCO2A1 mutations. SLCO2A1 variants are responsible for CEAS (Chronic enteropathy associated with SLCO2A1), a syndrome which was exclusively reported in patients of Asian origin. Herein, we report the case of two French female siblings with CEAS. CASE REPORT P1 underwent iterative bowel resections (removing 1 meter of small bowel in total) for recurrent strictures and perforations. Her sister P2 had a tight duodenal stricture which required partial duodenectomy. Next-generation sequencing was performed on P1's DNA and identified 2 compound heterozygous variants in exon 12 in SLCO2A1, which were also present in P2. CONCLUSION CEAS can be detected within the European population and raise the question of its incidence and recognition outside Asia. Presence of intractable recurrent ulcerations of the small intestine mimicking Crohn's disease with concentric stricture should motivate a genetic search for SLCO2A1 mutations, particularly in the context of family history or consanguinity.
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Affiliation(s)
- Annick Hamon
- Department of Gastroenterology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France
| | - Dominique Cazals-Hatem
- Department of Pathology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France
| | - Carmen Stefanescu
- Department of Gastroenterology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France.,Groupe hospitalier Ambroise Paré - Hartmann, Institut des MICI, Neuilly sur Seine, France
| | - Mathieu Uzzan
- Department of Gastroenterology, Mondor Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France
| | - Xavier Treton
- Department of Gastroenterology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France.,Groupe hospitalier Ambroise Paré - Hartmann, Institut des MICI, Neuilly sur Seine, France
| | - Alain Sauvanet
- Department of Hepato-biliary Surgery, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France
| | - Yves Panis
- Department of Hepato-biliary Surgery, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France
| | - Marie Monsinjon
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France
| | - Fanny Bonvalet
- Department of Radiology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France
| | - Olivier Corcos
- Department of Gastroenterology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France
| | - Emilie Azouguene
- Department of Genomic Medecine for Rare Diseases, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, University of Paris-Cité, Paris, France
| | | | - Yoram Bouhnik
- Department of Gastroenterology, Beaujon Hospital, Assistance Publique - Hôpitaux de Paris-Cité, University of Paris, Paris, France.,Groupe hospitalier Ambroise Paré - Hartmann, Institut des MICI, Neuilly sur Seine, France
| | - Fabienne Charbit-Henrion
- Department of Genomic Medecine for Rare Diseases, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, University of Paris-Cité, Paris, France.,INSERM UMR1163, Intestinal Immunity, Institut Imagine, Paris, France
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8
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Gupta S, Allegretti JR. Mimics of Crohn's Disease. Gastroenterol Clin North Am 2022; 51:241-269. [PMID: 35595413 DOI: 10.1016/j.gtc.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Crohn's disease is a chronic inflammatory disease that can affect any portion of the gastrointestinal tract. Associated symptoms can vary based on the severity of disease, extent of involvement, presence of extraintestinal manifestations, and development of complications. Diagnosis is based on a constellation of findings. Many diseases can mimic Crohn's disease and lead to diagnostic conundrums. These include entities associated with the gastrointestinal luminal tract, vascular disease, autoimmune processes, various infections, malignancies and complications, drug- or treatment-induced conditions, and genetic diseases. Careful consideration of possible causes is necessary to establish the correct diagnosis.
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Affiliation(s)
- Sanchit Gupta
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 850 Boyslton Street, Suite 201, Chestnut Hill, MA 02467, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 850 Boyslton Street, Suite 201, Chestnut Hill, MA 02467, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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9
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Feakins R, Torres J, Borralho-Nunes P, Burisch J, Cúrdia Gonçalves T, De Ridder L, Driessen A, Lobatón T, Menchén L, Mookhoek A, Noor N, Svrcek M, Villanacci V, Zidar N, Tripathi M. ECCO Topical Review on Clinicopathological Spectrum and Differential Diagnosis of Inflammatory Bowel Disease. J Crohns Colitis 2022; 16:343-368. [PMID: 34346490 DOI: 10.1093/ecco-jcc/jjab141] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Many diseases can imitate inflammatory bowel disease [IBD] clinically and pathologically. This review outlines the differential diagnosis of IBD and discusses morphological pointers and ancillary techniques that assist with the distinction between IBD and its mimics. METHODS European Crohn's and Colitis Organisation [ECCO] Topical Reviews are the result of an expert consensus. For this review, ECCO announced an open call to its members and formed three working groups [WGs] to study clinical aspects, pathological considerations, and the value of ancillary techniques. All WGs performed a systematic literature search. RESULTS Each WG produced a draft text and drew up provisional Current Practice Position [CPP] statements that highlighted the most important conclusions. Discussions and a preliminary voting round took place, with subsequent revision of CPP statements and text and a further meeting to agree on final statements. CONCLUSIONS Clinicians and pathologists encounter a wide variety of mimics of IBD, including infection, drug-induced disease, vascular disorders, diverticular disease, diversion proctocolitis, radiation damage, and immune disorders. Reliable distinction requires a multidisciplinary approach.
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Affiliation(s)
- Roger Feakins
- Department of Cellular Pathology, Royal Free Hospital, London, and University College London, UK
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures, Portugal
| | - Paula Borralho-Nunes
- Department of Pathology, Hospital Cuf Descobertas, Lisboa and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Tiago Cúrdia Gonçalves
- Department of Gastroenterology, Hospital da Senhora da Oliveira, Guimarães, Portugal.,School of Medicine, University of Minho, Braga/Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Lissy De Ridder
- Department of Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, The Netherlands
| | - Ann Driessen
- Department of Pathology, University Hospital Antwerp, University Antwerp, Edegem, Belgium
| | - Triana Lobatón
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Luis Menchén
- Department of Digestive System Medicine, Hospital General Universitario-Insitituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain.,Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Aart Mookhoek
- Department of Pathology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Magali Svrcek
- Department of Pathology, Sorbonne Université, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Vincenzo Villanacci
- Department of Histopathology, Spedali Civili and University of Brescia, Brescia, Italy
| | - Nina Zidar
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Monika Tripathi
- Department of Histopathology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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10
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Nguyen J, Lee S, Yang GY. Comprehensive Evaluation and Unique Morphologic Features of Nonsteroidal Anti-Inflammatory Drug (NSAID) Enteropathy in the Terminal Ileum. Int J Surg Pathol 2022; 30:616-622. [PMID: 35098774 DOI: 10.1177/10668969221076549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Differentiating NSAID enteropathy from Crohn disease can be challenging on terminal ileum biopsy. It is important to distinguish these two entities for management. In this study, clinical, radiographic, endoscopic, and histologic features of 30 patients diagnosed with NSAID enteropathy and 30 patients diagnosed with Crohn disease on terminal ileal biopsy were compared. None of the patients in the NSAID cohort demonstrated significant changes on imaging performed prior to biopsy. Depending on disease severity, patients with Crohn disease showed imaging findings ranging from minimal changes to significant bowel wall and/or luminal changes. Endoscopically, erythema, erosions, and/or ulcers in the terminal ileum were observed in a majority of NSAID cases. Patients with active Crohn disease were noted to have erythema, ulcers, strictures, and/or visible inflammation throughout the distal ileum and colon. Histologically, at least 80% of cases in each cohort showed ulceration/erosion and cryptitis/crypt abscesses. The Crohn disease cohort had significantly higher degree of lymphoplasmacytic inflammation in the lamina propria compared to the NSAID cohort. In contrast, a significantly higher percentage of the NSAID cohort had gland/crypt atrophy. A decrease in number of Paneth cells was found in the NSAID cohort. Decreased lamina propria lymphoplasmacytic inflammation was the most specific and the presence of gland atrophy the most sensitive feature favoring NSAID enteropathy. In summary, the combination of gland/crypt/Paneth cell atrophy with decreased lamina propria lymphoplasmacytic inflammation can aid in differentiating NSAID enteropathy from Crohn disease in terminal ileal biopsies; however, correlation with clinical, radiographic, and endoscopic findings is still required.
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Affiliation(s)
| | - Sherry Lee
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.,Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Guang-Yu Yang
- Northwestern Memorial Hospital, Chicago, IL 60611, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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11
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Tayyub MU, Egan L, Goulding C. Endoscopy Capsule Retention in a Young Female with Small Bowel Strictures Secondary to Non-Steroidal Anti-Inflammatory Drugs. Case Rep Gastroenterol 2021; 15:948-953. [PMID: 34949980 PMCID: PMC8647053 DOI: 10.1159/000519551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/07/2021] [Indexed: 12/21/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) can cause small bowel damage, which could present in different ways, including abdominal pain and occult gastrointestinal bleeding. NSAID use can also result in small bowel strictures, which can be challenging to diagnose and manage. Here, we describe a case of a 49-year-old female who presented with chronic anaemia and intermittent abdominal pain, with a history of NSAID use. She underwent capsule endoscopy as part of the workup for anaemia and subsequently had capsule retention due to a small bowel stricture.
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Affiliation(s)
- Muhammad Umair Tayyub
- Department of Gastroenterology, University Hospital Galway, Saolta University Healthcare Group, Galway, Ireland
| | - Laurence Egan
- Department of Gastroenterology, University Hospital Galway, Saolta University Healthcare Group, Galway, Ireland
| | - Carol Goulding
- Department of Gastroenterology, University Hospital Galway, Saolta University Healthcare Group, Galway, Ireland
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Wu RM, Fisher LR. Role of Video Capsule in Small Bowel Bleeding. Gastrointest Endosc Clin N Am 2021; 31:277-306. [PMID: 33743926 DOI: 10.1016/j.giec.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Video capsule endoscopy has an essential role in the diagnosis and management of small bowel bleeding and is the first-line study recommended for this purpose. This article reviews the risk factors for small bowel bleeding, optimal timing for video capsule endoscopy testing, and algorithms recommended for evaluation. Used primarily for the assessment of nonacute gastrointestinal blood loss, video capsule endoscopy has an emerging role for more urgent use in emergency settings and in special populations. Future software incorporation of neural networks to enhance lesion detection will likely result in an augmented role of video capsule endoscopy in small bowel bleeding.
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Affiliation(s)
- Richard M Wu
- Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania Health System, 4th Floor GI Department, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
| | - Laurel R Fisher
- Small Bowel Imaging Program, Division of Gastroenterology and Hepatology, University of Pennsylvania Health System, 3400 Civic Center Drive, PCAM 7S, Philadelphia, PA 19104, USA.
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Osman KT, Maselli DB, Mounajjed TM, Grotz TE. Can cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) be diagnosed in a patient with non-steroidal anti-inflammatory drug exposure? BMJ Case Rep 2021; 14:14/2/e238160. [PMID: 33542016 PMCID: PMC7868250 DOI: 10.1136/bcr-2020-238160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The differential diagnosis for ulcerating small bowel strictures is extensive and includes exposure to non-steroidal anti-inflammatory drugs (NSAIDs), Crohn's disease, infections, gastrointestinal lymphoma and vasculopathy. It also encompasses the exceptionally rare and poorly understood diagnosis of cryptogenic multifocal ulcerative stenosing enterocolitis (CMUSE), often a diagnosis of exclusion and considerable difficulty. We present a case of persistent proximal jejunal ulcerating stenoses in a 75-year-old Caucasian man, which continued despite cessation of NSAIDs. After extensive clinical, radiographic, laboratory and ultimately surgical pathological appraisal-as well as failure to improve with both misoprostol and budesonide-he was diagnosed with CMUSE and managed with limited small bowel resection. In the presentation of this case, we aim to underscore the diagnostic challenges that clinicians face in differentiating CMUSE from other more common diagnoses, particularly NSAIDs-induced enteropathy.
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Affiliation(s)
- Karim T Osman
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel B Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Taofic M Mounajjed
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Travis E Grotz
- Department of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Chawla S, Kaur A, Yadav N, Sharma S. Unusual case of recurrent intestinal obstruction. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2021. [DOI: 10.4103/mjdrdypu.mjdrdypu_23_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Wu L, Jia G, Hu Y, Zhu L, Wang S. A rare case of duodenal diaphragm in an adult during ERCP treatment for choledocholithiasis. BMC Surg 2020; 20:273. [PMID: 33160346 PMCID: PMC7648286 DOI: 10.1186/s12893-020-00934-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Duodenal Diaphragm in adults is very uncommon, caused by congenital and acquired changes. It is reported that acquired duodenal diaphragm is related to the long-term use of nonsteroidal anti-inflammatory drugs. Case summary We report an adult presentation of duodenal diaphragm in a 77-year-old woman, suffered from acute cholangitis and choledocholithiasis. She was performed endoscopic retrograde cholangiopancreatography (ERCP) procedure to remove the stone in common bile duct (CBD). After the stenosis ring dilated by endoscopic balloon dilatation, ERCP procedure was applied, and the CBD stone was removed successfully. Conclusion Duodenal diaphragm is difficult to diagnose in clinic. Although the patient in this case had relatively mild symptoms of incomplete upper hemi-abdominal obstruction, these symptoms could be obscured by the emergency acute upper abdominal pain with fever as clinical manifestations of acute cholangitis.
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Affiliation(s)
- Liying Wu
- Department of Gastroenterology, Huaibei People's Hospital, No. 66 Huaihai West Road, Huaibei, 235000, Anhui, People's Republic of China.
| | - Guofa Jia
- Department of Gastroenterology, Huaibei People's Hospital, No. 66 Huaihai West Road, Huaibei, 235000, Anhui, People's Republic of China
| | - Yiheng Hu
- Department of Gastroenterology, Huaibei People's Hospital, No. 66 Huaihai West Road, Huaibei, 235000, Anhui, People's Republic of China
| | - Liangsong Zhu
- Department of Gastroenterology, Huaibei People's Hospital, No. 66 Huaihai West Road, Huaibei, 235000, Anhui, People's Republic of China
| | - Shuhai Wang
- Department of Gastroenterology, Huaibei People's Hospital, No. 66 Huaihai West Road, Huaibei, 235000, Anhui, People's Republic of China
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Marghich O, Maubert A, Amouzou EGYO, Denimal L, Benizri E, Rahili MA. Idiopathic small bowel diaphragm disease: a case report. J Surg Case Rep 2020; 2020:rjaa358. [PMID: 33133497 PMCID: PMC7584463 DOI: 10.1093/jscr/rjaa358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/10/2020] [Indexed: 11/14/2022] Open
Abstract
Small bowel diaphragm disease is a rare condition usually associated with the prolonged use of non-steroidal anti-inflammatory drugs (NSAID) and that can be mistaken and treated as other pathologies. We describe a case of a 64-year-old man with a prolonged course of pain and subacute bowel obstructions, without any history of NSAID usage, found to have a multiple diaphragmatic stricture in the small bowel.
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Affiliation(s)
- Omar Marghich
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Alexandre Maubert
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | | | - Louis Denimal
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Emmanuel Benizri
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
| | - Mohammed Amine Rahili
- General and Oncology Surgery Unit, Archet 2 Hospital, University Hospital of Nice, Nice, France
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Jung CY, Bae JM. Fatal course of idiopathic chronic ulcerative enteritis with panenteritis and perforation: a case report and review of literature. BMC Surg 2020; 20:196. [PMID: 32894105 PMCID: PMC7487647 DOI: 10.1186/s12893-020-00850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background Idiopathic chronic ulcerative enteritis (ICUE) is a very rare disease with high mortality. Because of clinical rarity, several small case reports have been published and there is a lack of large sample study. Preoperative definite diagnosis is difficult. Although definite treatment for ICUE is radical surgical resection, surgical decision in operative field is difficult. Case presentation A 77-year-old man came to the emergency department with complaints of a 1-day history of abdominal pain and abdominal distension. Abdominal computed tomography revealed ileus and focal free air. Laparotomy revealed multiple small bowel tiny perforations in the ileum. The serosa surface in the whole small bowel had small multiple yellowish tiny discolored lesions. Despite the presence of multiple mucosal ulcers in entire small bowel, the ileum including perforation site was resected segmentally. Microscopically, mucosal ulcers in resected small bowel demonstrated transmural inflammation, no granuloma, and no lymphoid aggregates. These features were consistent with a diagnosis of ICUE with panenteritis and perforation. After surgery, the patient’s general condition gradually aggravated. Unfortunately, the patient died of multiple organ failure on post-operative day 14. Conclusion Surgically, the decision including resection range, anastomosis or enterotomy becomes difficult in ICUE with panenteritis. According to recent 40 year’s revised data, the post-operative mortality of ICUE is about 53.4%. Although ICUE is rare, its recognition is important for appropriate diagnosis and treatment. Retrospective multicenter case studies are required to determine proper treatment and improve prognosis.
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Affiliation(s)
- Chang-Yeon Jung
- Department of Surgery, Yeungnam University Medical Center, 170 Hyeonchung-ro, Nam-gu, Daegu, 42415, Republic of Korea
| | - Jung-Min Bae
- Department of Surgery, Yeungnam University Medical Center, 170 Hyeonchung-ro, Nam-gu, Daegu, 42415, Republic of Korea.
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Abstract
BACKGROUND/AIMS Diaphragm disease of the small bowel has been described in the literature over the last three decades. The pathognomonic characteristic of multiple circumferential stenosis is noted on gross examination of the bowel. It is a severe form of non-steroidal anti-inflammatory drug-induced enteropathy, often presenting as acute small bowel obstruction. A systematic review was performed to identify risk factors and patient outcomes in histologically-proven diaphragm disease of the small intestine in patients undergoing emergency operation for small bowel obstruction. METHODS A comprehensive search was performed between January 1975 and March 2019 using relevant MeSH terms. Studies were chosen based on predefined inclusion criteria. Diaphragm disease of the small intestine was defined as macroscopically detected thin diaphragm-like mucosal folding inside the lumen of the bowel. The parameters assessed included patient characteristics, duration of use of non-steroidal anti-inflammatory drugs, type of emergency surgery performed, complications, recurrence, presentation and diagnosis of diaphragm disease. RESULTS A total of 21 studies were analysed which included 17 case reports, one case series, and three retrospective comparative studies. Overall 29 patients with diaphragm disease of the small bowel were reported following emergency laparotomy for small bowel obstruction. Use of non-steroidal anti-inflammatory drugs was noted in all cases with an average duration of 3-5 years. All patients presented acutely with features of small bowel obstruction and had emergency laparotomy, except one who underwent laparoscopic resection. In the comparative studies patients were more likely to be female and to have been taking non-steroidal anti-inflammatory drugs for more than 7 years. CONCLUSIONS This is a rare disease, difficult to diagnose and often confirmed by the intra-operative macroscopic appearance of circumferential stenosis of the bowel. Risk factors for developing small bowel diaphragm disease include long-term use of non-steroidal anti-inflammatory drugs, and female gender. Patients with this disease are at increased risk of developing acute small bowel obstruction, so early identification is important.
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Affiliation(s)
- Diwakar R Sarma
- Department of General Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Pratik Bhattacharya
- Department of General Surgery, Sandwell and West Birmingham NHS Trust, Birmingham, UK
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Bennett S, Martin J, Mahler-Araujo B, Gourgiotis S. Diaphragm disease of the terminal ileum presenting as acute small bowel obstruction. BMJ Case Rep 2020; 13:13/2/e233537. [PMID: 32034000 DOI: 10.1136/bcr-2019-233537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Diaphragm disease (DD) of the small bowel is a rarely reported complication of non-steroidal anti-inflammatory drug (NSAID) use, characterised by diaphragm-like strictures, most commonly in the ileum, causing varying degrees of obstruction. It typically presents in the elderly, over many years with non-specific symptoms. Diagnosis is challenging, the majority of cases relying on histopathology for confirmation. Treatment involves NSAID cessation and surgery through a combination of stricturoplasties and/or segmental resection. Very rarely DD presents as a surgical emergency. A case presenting as acute small bowel obstruction (SBO) is described, initially diagnosed as adhesions, later confirmed to be DD of the terminal ileum following histopathological examination. Given the widespread use of NSAIDs and an ageing population, it is likely the incidence of DD will increase. It is, therefore, important that surgeons are aware of this disease entity and consider it as a potential diagnosis in patients presenting with acute SBO.
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Affiliation(s)
- Stephen Bennett
- Cambridge Oesophago-Gastric Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jack Martin
- Cambridge Oesophago-Gastric Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Betania Mahler-Araujo
- Histopathology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stavros Gourgiotis
- Cambridge Oesophago-Gastric Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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20
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Mori A, Hashida H, Kitamura K, Matsui J, Mizuno R, Tanigawa Y, Izumi A, Ishida S, Yamashita D, Yamaguchi T, Kaihara S. Diaphragm disease associated with nonsteroidal anti-inflammatory drugs mimicking intestinal tumor: A case report. Int J Surg Case Rep 2020; 76:121-124. [PMID: 33032041 PMCID: PMC7551975 DOI: 10.1016/j.ijscr.2020.09.110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Diaphragm disease is rare and caused by intestinal obstruction due to nonsteroidal anti-inflammatory drugs (NSAIDs). Given the availability of video capsule endoscopy (VCE) and balloon enteroscopy (BE) this disease will be diagnosed more often. PRESENTATION OF CASE A 73-year-old man was presented to our hospital for persistent nausea and vomiting. Abdominal ultrasound and computed tomography revealed small-bowel thickening, stricture in the terminal ileum, and dilation of the proximal small intestine. Differential diagnosis included ileal lymphoma and multiple ileal adenocarcinomas, and a diagnostic laparoscopy was performed. Twenty-centimeter of ileum was resected by primary ileo-ileal anastomosis. On pathological examination, fibrosis of the submucosa was identified, and erosions and numerous inflammatory cells reaching the submucosa were also identified from the specimen. DISCUSSION The preoperative diagnosis of diaphragm disease is sometimes challenging due to its uncharacteristic symptoms; moreover, radiological findings are usually indefinite and distinctive. Currently, the main treatment for diaphragm disease is surgery. CONCLUSION We have documented a case of intestinal obstruction by NSAIDs. However, it is desirable to determine the course of treatment based on small bowel endoscopic dilatation cases in the future.
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Affiliation(s)
- Aya Mori
- Department of Surgery, Kobe City Medical Center General Hospital, Japan.
| | - Hiroki Hashida
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
| | - Koji Kitamura
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
| | - Jun Matsui
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
| | - Ryosuke Mizuno
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
| | - Yuma Tanigawa
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
| | - Ai Izumi
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
| | - Satoshi Ishida
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
| | - Daisuke Yamashita
- Department of Diagnostic Pathology, Kobe City Medical Center General Hospital, Japan
| | - Takako Yamaguchi
- Department of Diagnostic Pathology, Kobe City Medical Center General Hospital, Japan
| | - Satoshi Kaihara
- Department of Surgery, Kobe City Medical Center General Hospital, Japan
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Ayyanar P, Purkait S, Mishra TS, Patra S, Mitra S. Histopathologic Spectrum of Neuromuscular and Vascular Hamartoma With Special Reference to the Vasculopathic Phenomenon. Int J Surg Pathol 2019; 28:382-392. [DOI: 10.1177/1066896919890129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neuromuscular and vascular hamartoma (NMVH) is an unusual lesion presenting as intestinal obstruction by stricture formation. It is characterized by a hamartomatous mass comprising haphazardly arranged mesenchymal tissue native to the intestinal mucosa and submucosa. We aimed to characterize the clinicohistopathological spectrum of NMVH in adult subjects with a search for an etiological clue. We reviewed 84 resected specimens (adult cases) of intestinal obstruction in our institute and diagnosed 4 cases with NMVH. A panel of special stains (Masson trichrome, Verhoeff-van-Gieson, and periodic acid–Schiff) and immunohistochemistry (smooth muscle actin, S100, Bcl2, CD34, vimentin, desmin, CD117, and CD3) were performed in all cases. All cases of NMVH showed characteristic hamartomatous mounds comprising haphazardly arranged smooth muscle, nerves, ganglia, vessels, and collagen with overlying mucosal ulceration. Adjacent bowel showed submucosal fibrosis, muscularis mucosae thickening, and duplication along with vasculopathy. A typical vasculopathy (“vessel-in-vessel” appearance) was seen in the submucosal and/or subserosal veins. Besides, different other forms of vasculopathic changes like obliterative venopathy and concentric myohypertrophy were also seen. One case had vasculitis and the patient died despite successful surgery. One other case was associated with lymphocytic ganglioneuronitis and granulomatous etiology. We conclude that NMVH can be multifactorial in origin although ischemia resulting from vasculopathy appears to be directly causative. The characteristic vasculopathy in the submucosal location may aid in the diagnosis of NMVH in small biopsy samples.
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Affiliation(s)
| | | | | | - Susama Patra
- All India Institute of Medical Sciences, Bhubaneswar, India
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22
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Pereira R, Slater K. Small bowel diaphragm disease from long-term non-steroidal anti-inflammatory use. BMJ Case Rep 2019; 12:12/10/e230735. [PMID: 31586954 DOI: 10.1136/bcr-2019-230735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Small bowel diaphragm disease (SBDD) is characterised by circumferential lesions of short length (<5 mm), causing intrinsic stenosis of the small bowel lumen. A 63-year-old women with a history of long-term non-steroidal anti-inflammatory use, presented with a 12-month history of intermittent episodes of colicky abdominal pain, nausea and vomiting. Her only past surgery was a laparoscopic hysterectomy. Abdominal CT demonstrated an area of thickening in the mid small bowel, however a diagnostic laparoscopy failed to demonstrate adhesions or any external abnormality. A capsule endoscope did not progress beyond the mid small bowel at the site of a suspected diaphragm. The patient underwent a laparotomy and using the retained capsule as a marker, the area of bowel affected by SBDD was identified. With an ageing population and the widespread use of non-steroidalanti-inflammatory drugs, general surgeons may see an increase in the incidence of SBDD.
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Affiliation(s)
- Ryan Pereira
- Department of Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Department of Surgery, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Kellee Slater
- Department of Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia .,Department of Surgery, Greenslopes Private Hospital, Brisbane, Queensland, Australia
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Ekanayaka A, Anderson JT, Lucarotti ME, Valori RM, Shepherd NA. The isolated caecal patch lesion: a clinical, endoscopic and histopathological study. J Clin Pathol 2019; 73:121-125. [DOI: 10.1136/jclinpath-2019-206146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/11/2022]
Abstract
ObjectiveTo describe and investigate the potential causes of the isolated caecal patch lesion, a previously undescribed endoscopic phenomenon of a lesion fulfilling endoscopic and histopathological criteria for chronic inflammatory bowel disease but without evidence of similar inflammatory pathology elsewhere at colonoscopy.MethodsCases were collected prospectively by one specialist gastrointestinal pathologist over a 10-year period. Full endoscopic and histopathological analysis was undertaken and follow-up sought to understand the likely cause(s) of the lesions.ResultsSix cases are described. Two had very close links with ulcerative colitis, one predating the onset of classical distal disease and the other occurring after previous demonstration of classical distal ulcerative colitis. Two occurred in younger patients and we postulate that these lesions may predict the subsequent onset of chronic inflammatory bowel disease. Finally two can be reasonably attributed to the effects of non-steroidal inflammatory agent therapy.ConclusionsCaecal patch lesions can be demonstrated in isolation. Despite the strong association of caecal patch lesions with ulcerative colitis, solitary lesions may well have disparate causes but nevertheless possess a close relationship with chronic inflammatory bowel disease.
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Danial AK, Al-Mouakeh A, Danial YK, Nawlo AA, Khalil A, Al-Haj A. A rare cause of small bowel diaphragm disease presenting with palpated abdominal mass. J Surg Case Rep 2019; 2019:rjz230. [PMID: 31391917 PMCID: PMC6681771 DOI: 10.1093/jscr/rjz230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/28/2019] [Accepted: 07/09/2019] [Indexed: 12/22/2022] Open
Abstract
Small bowel diaphragm disease is a rare complication related to non-steroidal anti-inflammatory drug (NSAID) use. It presents with non-specific symptoms such as vomiting, abdominal pain, subacute bowel obstruction and occasionally as an acute abdominal condition. We report a case of diaphragm disease in a 33-year-old female who presented with vomiting, constipation and abdominal pain started 5 days earlier. Physical examination revealed palpated abdominal mass. The patient’s past medical history was remarkable for NSAID use. The patient was managed by surgical resection of involved intestine and diagnosis was confirmed by histological examination. Although there are few published cases of diaphragm disease in the medical literature, we recommend that this disease should be considered as one of the differential diagnoses when assessing patients presenting with non-specific abdominal symptoms with remarkable past medical history of NSAID use.
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Affiliation(s)
- Aghyad K Danial
- Department of General Surgery, Aleppo University Hospital, Aleppo, Syria
| | | | - Yaman K Danial
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Ahmad A Nawlo
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Ahmad Khalil
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Ahmad Al-Haj
- Department of General Surgery, Aleppo University Hospital, Aleppo, Syria
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Experience with Balloon Dilatation in Crohn's and Non-Crohn's Benign Small-Bowel Strictures: Is There a Difference? Gastroenterol Res Pract 2019; 2019:1262595. [PMID: 31198420 PMCID: PMC6526561 DOI: 10.1155/2019/1262595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/06/2019] [Accepted: 03/21/2019] [Indexed: 11/17/2022] Open
Abstract
Background/Aim Endoscopic balloon dilation (EBD) has been effective for small-bowel strictures in patients with Crohn's disease (CD). However, its efficacy and indication for small-bowel strictures in non-CD patients have not been established. This study evaluated the clinical efficacy and safety of EBD for small-bowel strictures in non-CD patients compared with CD patients. Methods Ninety-eight consecutive patients (mean age, 53 years; average observation period, 45 months) with small-bowel strictures diagnosed by double-balloon endoscopy were retrospectively evaluated at Hiroshima University Hospital from August 2003 to April 2017. The average number of procedures, short-term and long-term EBD success rates, and safety profiles between the non-CD and CD groups were examined. Results Surgery was selected as the initial treatment in 44 cases (45%) (non-CD group, 27 (61%); CD group, 17 (39%)) as EBD is not indicated. Fourteen non-CD patients had strictures due to malignant tumors, while 13 patients had benign strictures. Twenty-three patients (non-CD, 12; CD, 11) underwent EBD. Forty-three EBD procedures were performed for 17 stricture sites (average: 2.5 procedures/site) in non-CD patients and 41 EBD procedures for 18 stricture sites (average: 2.3 procedures/site) in CD patients. The short-term success rate was 100% (23/23), whereas the long-term success rate was 92% (11/12) in non-CD patients and 82% (9/11) in CD patients. No significant differences in the surgery-free rate occurred between both groups. Furthermore, one adverse event, bleeding after EBD, was encountered in the non-CD group (8%, 1/12). Conclusion EBD for small-bowel strictures demonstrated good clinical outcomes in non-CD patients.
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Review of Drug-induced Injury in Mucosal Biopsies From the Tubular Gastrointestinal Tract. Adv Anat Pathol 2019; 26:151-170. [PMID: 30870181 DOI: 10.1097/pap.0000000000000230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The use of prescription and over-the-counter medications is on the rise in the US population, especially among those aged 65 and over, with over 46% of the population taking at least 1 prescription medication. Given the frequency of medication use, and that the majority of these medications are taken orally, it has become increasingly relevant for pathologist examining endoscopically obtained gastrointestinal tract mucosal biopsies to consider and recognize patterns of mucosal injury associated with various drugs. Reports on injuries associated with certain classes of drugs can be scattered among different sources, making a comprehensive view of various injury patterns and the drugs known to cause them difficult to obtain. Herein, we provide a comprehensive overview of the drugs known to cause mucosal injuries in the tubular gastrointestinal tract organized by the organ involved and the prominent pattern of injury.
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Kagebayashi S, Yamamoto S, Seno H. Jejunal diaphragm disease associated with cytomegalovirus infection. Endosc Int Open 2019; 7:E533-E536. [PMID: 31041370 PMCID: PMC6447397 DOI: 10.1055/a-0848-8172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/26/2018] [Indexed: 11/15/2022] Open
Abstract
Background and study aims Diaphragm disease (DD) is a rare gastrointestinal disease featuring multiple thin, circumferential strictures in the intestine, related to prolonged intake of nonsteroidal anti-inflammatory drugs (NSAIDs). Here, we report a case of DD associated with cytomegalovirus (CMV) infection in a patient not taking NSAIDs. A 72-year-old man was referred to our hospital due to persistent epigastric pain. Push enteroscopy showed extensive mucosal detachment in the upper jejunum. Immunohistochemistry examination of biopsy specimens revealed CMV positivity. In addition, CMV antigenemia was positive. Antiviral treatment with ganciclovir improved his symptoms and the CMV antigenemia became negative. Wireless capsule enteroscopy performed 1 month after antiviral treatment showed regenerated mucosa and multiple diaphragm-like strictures in the jejunum, resulting in capsule retention. Balloon dilatation using double balloon enteroscopy (DBE) was performed and the capsule was retrieved endoscopically. DBE 6 months after antiviral therapy confirmed no recurrence of stenosis or inflammation. The patient had no history of long-term NSAID use. In a case of DD unassociated with NSAIDs, CMV infection should be considered in the differential diagnosis.
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Affiliation(s)
- Sumika Kagebayashi
- Department of Gastroenterology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuji Yamamoto
- Department of Gastroenterology, Kyoto University Graduate School of Medicine, Kyoto, Japan,Corresponding author Shuji Yamamoto, MD, PhD Department of GastroenterologyKyoto University Graduate School of Medicine54 Shogoin Kawahara-cho, SakyoKyoto 606-8507Japan+81-75-751-4338
| | - Hiroshi Seno
- Department of Gastroenterology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Huddleston WR, Johnson C. A fatal case of bowel obstruction caused by non-steroidal anti-inflammatory drug enteropathy. Forensic Sci Med Pathol 2019; 15:502-505. [PMID: 30632013 DOI: 10.1007/s12024-018-0079-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
We report the case of a 34-year-old woman who died after presenting to hospital with a 2-month history of vomiting, abdominal pain and diarrhea. Subsequent inquiries revealed that she had a history of non-steroidal anti-inflammatory drug (NSAID) abuse, and the autopsy revealed stricture formation consistent with being caused by NSAID enteropathy.
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Affiliation(s)
| | - Christopher Johnson
- State Pathologist's Department, Institute of Forensic Medicine, Grosvenor Road, Belfast, BT12 6BS, UK
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29
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Cubero Rego D, Qualia CM, Chismark AD, Strait L, Lee H. Gastrointestinal Diaphragm Disease With Retained Capsule Endoscope, Associated With Crohn's Disease: A Case Report. Pediatr Dev Pathol 2019; 22:75-79. [PMID: 29890901 DOI: 10.1177/1093526618780766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Gastrointestinal diaphragm disease is a rare entity characterized by the formation of thin membranous circumferential mucosal septa, resulting in marked narrowing of the intestinal lumen. The most frequent etiology is the chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs). Idiopathic cases and other possible etiologies have been reported. We present a rare association of diaphragm disease with Crohn's disease in a boy without a history of significant NSAID usage.
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Affiliation(s)
- David Cubero Rego
- 1 Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York
| | - Cary M Qualia
- 2 Pediatric Gastroenterology, Albany Medical Center, Albany, New York
| | | | - Lauren Strait
- 3 Colorectal Surgery, Albany Medical Center, Albany, New York
| | - Hwajeong Lee
- 1 Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York
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30
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Roa Colomo A, Martín-Lagos Maldonado A, Díaz Alcázar MDM, Casado Caballero FJ. Iron deficiency anaemia secondary to small-bowel diaphragm disease not associated with NSAIDs. Is there anything else to consider? GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 42:433-434. [PMID: 30459057 DOI: 10.1016/j.gastrohep.2018.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/02/2018] [Accepted: 09/07/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Amparo Roa Colomo
- Servicio Aparato Digestivo, Hospital Universitario San Cecilio, Hospital Campus de la Salud, Granada, España.
| | | | - María Del Mar Díaz Alcázar
- Servicio Aparato Digestivo, Hospital Universitario San Cecilio, Hospital Campus de la Salud, Granada, España
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31
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Gecse KB, Vermeire S. Differential diagnosis of inflammatory bowel disease: imitations and complications. Lancet Gastroenterol Hepatol 2018; 3:644-653. [PMID: 30102183 DOI: 10.1016/s2468-1253(18)30159-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 12/16/2022]
Abstract
Inflammatory bowel disease (IBD) is characterised by episodes of relapse and periods of remission. However, the clinical features, such as abdominal pain, diarrhoea, and rectal bleeding, are not specific. Therefore, the differential diagnosis can include a broad spectrum of inflammatory or infectious diseases that mimic IBD, as well as others that might complicate existing IBD. In this Review, we provide an overview of ileocolitis of diverse causes that are relevant in the differential diagnosis of IBD. We highlight the importance of accurate patient profiling and give a practical approach to identifying factors that should trigger the search for a specific cause of intestinal inflammation. Mimics of IBD include not only infectious causes of colitis-and particular attention is required for patients from endemic areas of tuberculosis-but also vascular diseases, diversion colitis, diverticula or radiation-related injuries, drug-induced inflammation, and monogenic diseases in very-early-onset refractory disease. A superinfection with cytomegalovirus or Clostridium difficile can aggravate intestinal inflammation in IBD, especially in patients who are immunocompromised. Special consideration should be made to the differential diagnosis of perianal disease.
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Affiliation(s)
- Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.
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32
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Pattnaik SA, Mitra S, Mishra TS, Purkait S, Kumar P, Naik S. A Vasculitis-Associated Neuromuscular and Vascular Hamartoma Presenting as a Fatal Form of Abdominal Cocoon. Int J Surg Pathol 2018; 27:108-115. [PMID: 29992844 DOI: 10.1177/1066896918786582] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Neuromuscular and vascular hamartoma (NMVH), also known as neuromesenchymal hamartoma, is a rare hamartomatous condition of the intestine. It usually presents with submucosal humps protruding in the intestinal lumen causing obstructive features. The other clinical manifestations are hematochezia or melena and protein-losing enteropathy. The etiopathogenesis of these lesions is not well known, although an association with small bowel Cröhn's disease and diaphragm disease had been postulated, the latter related to chronic nonsteroidal anti-inflammatory drug intake. Only 24 cases of NMVH are reported in the English literature and all of them could be adequately cured by resection of the affected part of the bowel. Moreover, none of these cases presented with abdominal cocoon or showed any evidence of vasculitis. We describe a peculiar case of NMVH in a 45-year-old male who presented with abdominal cocoon with symptomatic recurrence and fatal outcome within a month of surgery. Histopathology revealed classical histomorphology of NMVH with evidence of vasculitis. This appears to be the first case of a fatal form of NMVH, presenting with abdominal cocoon and associated with vasculitis.
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Affiliation(s)
| | - Suvradeep Mitra
- 1 All India Institute of Medical Sciences, Bhubaneswar, India
| | | | - Suvendu Purkait
- 1 All India Institute of Medical Sciences, Bhubaneswar, India
| | - Pankaj Kumar
- 1 All India Institute of Medical Sciences, Bhubaneswar, India
| | - Suprava Naik
- 1 All India Institute of Medical Sciences, Bhubaneswar, India
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Grattan BJ, Bennett T, Starks MR. Diaphragm Disease: NSAID-Induced Small Bowel Stricture. Case Rep Gastroenterol 2018; 12:327-330. [PMID: 30022924 PMCID: PMC6047552 DOI: 10.1159/000489301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/17/2018] [Indexed: 01/26/2023] Open
Abstract
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is ubiquitous. However, it remains an oftentimes under-recognized risk factor for the development of strictures and small bowel obstruction. Herein we describe the case of a 63-year-old female with a prolonged course of abdominal pain and occult anemia found to have a diaphragmatic stricture in the small bowel related to chronic NSAID use.
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Affiliation(s)
- Bruce J Grattan
- University of New England College of Osteopathic Medicine, Biddeford, Maine, USA
| | - Tracy Bennett
- Department of Surgery, Saint Joseph Hospital, Bangor, Maine, USA
| | - Michael R Starks
- Department of Surgery, Saint Joseph Hospital, Bangor, Maine, USA
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Yang CS, Park JY, Choi HR, Kim D. Nonsteroidal anti-inflammatory drugs induced diaphragm disease: a report of 3 cases and literature review. Ann Surg Treat Res 2018; 94:279-283. [PMID: 29732361 PMCID: PMC5931940 DOI: 10.4174/astr.2018.94.5.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/01/2017] [Accepted: 09/07/2017] [Indexed: 11/30/2022] Open
Abstract
Multiple strictures of small bowel induced by nonsteroidal anti-inflammatory drugs (NSAIDs), were known as diaphragm disease. The purpose of these case reports is to present 3 cases of diaphragm disease of small bowel and summarize the clinical features of this disease entity. A 34-year-old man, a 63-year-old man, and a 66-year-old woman were admitted to Daegu Catholic University Medical Center because of recurrent intestinal obstructions. Two of these patients had taken heavy NSAIDs use. Capsule endoscopy was performed in all cases and the all capsules were retained by circumferential strictures of the ileum. Segmental resection of the strictures was performed in 2 patients and 1 underwent just enterotomy and capsule removal. In conclusion, clinicians should be aware that diaphragm disease might be a cause of small bowel obstruction especially in patients receiving long term NSAIDs therapy.
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Affiliation(s)
- Chun-Seok Yang
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ji Y Park
- Department of Pathology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Hye Ryeon Choi
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Daedong Kim
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
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35
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Park J, Jeon SR, Kim JO, Kim HG, Lee TH, Cho JH, Ko BM, Lee JS, Lee MS. Rebleeding rate and risk factors in nonsteroidal anti-inflammatory drug-induced enteropathy. J Dig Dis 2018; 19:279-287. [PMID: 29696804 DOI: 10.1111/1751-2980.12600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Limited evidence is available on rebleeding due to nonsteroidal anti-inflammatory drugs (NSAIDs)-induced enteropathy. Previous studies have primarily analyzed endoscopic findings. Therefore, there is a need to evaluate their clinical implications for patients. This study aimed to evaluate the rebleeding rate and its related risk factors in patients with NSAIDs-induced enteropathy. METHODS Of 402 patients with obscure gastrointestinal bleeding who were evaluated with capsule endoscopy, 49 were diagnosed with NSAIDs-induced enteropathy. The clinical characteristics of the patients were retrospectively analyzed. The Charlson comorbidity index was used to stratify the comorbidities. For patients who used additional drugs that influenced their tendency to bleeding, the odds ratio was calculated and used for a quantitative comparison. RESULTS The rebleeding rate in patients with NSAIDs-induced enteropathy was 20.4%, within a mean duration of 23.4 months. Age ≥65 years (hazard ratio [HR] 8.628, 95% confidence interval [CI] 1.152-64.625), no additional use of mucoprotective agents (HR 11.712, 95% CI 1.278-76.098) and the continuation of NSAIDs after the first bleeding episode (HR 9.861, 95% CI 1.395-98.344) were independently related to rebleeding due to NSAIDs-induced enteropathy. The underlying comorbidities, drug-related rebleeding risk scores and therapeutic use of proton pump inhibitors were not significantly different (P = 0.209, 0.212 and 0.720, respectively). CONCLUSIONS Approximately one-fifth of patients with NSAIDs-induced enteropathy showed rebleeding within 2 years. A careful long-term follow-up should be offered to elderly patients with NSAIDs-induced enteropathy who need continuous NSAID treatment without the additional use of mucoprotective medications.
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Affiliation(s)
- Junseok Park
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Seong Ran Jeon
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Jin-Oh Kim
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Hyun Gun Kim
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Tae Hee Lee
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Jun-Hyung Cho
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Bong Min Ko
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Joon Seong Lee
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Moon Sung Lee
- Digestive Disease Center, Institute for Digestive Research, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, South Korea
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36
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So HF, Bloomfield I. Small Bowel Obstruction due to Non-steroidal Anti-inflammatory Drug-induced Diaphragm Disease: A Case Report. Cureus 2018; 10:e2350. [PMID: 29796362 PMCID: PMC5959315 DOI: 10.7759/cureus.2350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Small bowel obstruction (SBO) is a common illness encountered by general surgeons. However, obstruction caused by diaphragm disease induced by non-steroidal anti-inflammatory drug (NSAID) is exceedingly rare. The diagnosis is challenging as the signs and symptoms are neither sensitive nor specific. We report the case of a 59-year-old male who presented with SBO secondary to this uncommon condition. We hope to raise awareness of this unusual entity.
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Srinivasan A, De Cruz P. Review article: a practical approach to the clinical management of NSAID enteropathy. Scand J Gastroenterol 2017; 52:941-947. [PMID: 28587496 DOI: 10.1080/00365521.2017.1335769] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Co-prescription of acid suppressive therapy, together with advances in small bowel imaging techniques, have shifted the burden of NSAID-related toxicity from gastro-duodenal to more distal small bowel injury. Due to predominantly subclinical disease, NSAID enteropathy remains under-recognised, with an incidence of 53-80% amongst healthy short-term users, and a prevalence of 50-71% following long-term (>3 months) use. Despite their distinct pathogenesis, those at risk of NSAID-related gastro-duodenal and small bowel complications share several risk factors. Clinical complications of NSAID enteropathy such as protein-losing enteropathy, small bowel strictures and diaphragm disease, confer significant morbidity, and are often irreversible. Small bowel prophylaxis has proven of modest efficacy after short-term, high-dose NSAID use in asymptomatic patients. While selective COX-2 inhibitors are associated with fewer gastro-duodenal complications relative to non-selective NSAIDs, their comparative benefit in protecting against small bowel enteropathy remains unclear. Prophylaxis should be considered in those at high risk of small bowel complications, as treatment options for established disease remain limited; however, the optimal agent remains unclear. We propose a clinical algorithm that may help prevent, monitor, investigate, and manage the sequelae of NSAID-induced small bowel toxicity.
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Affiliation(s)
- Ashish Srinivasan
- a Department of Gastroenterology , Austin Health , Melbourne , Australia
| | - Peter De Cruz
- a Department of Gastroenterology , Austin Health , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia
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Ciccia F, Guggino G, Ferrante A, Raimondo S, Bignone R, Rodolico V, Peralta S, Van Tok M, Cannizzaro A, Schinocca C, Ruscitti P, Cipriani P, Giacomelli R, Alessandro R, Dieli F, Rizzo A, Baeten D, Triolo G. Interleukin-9 Overexpression and Th9 Polarization Characterize the Inflamed Gut, the Synovial Tissue, and the Peripheral Blood of Patients With Psoriatic Arthritis. Arthritis Rheumatol 2017; 68:1922-31. [PMID: 26895441 DOI: 10.1002/art.39649] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 02/16/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To investigate the expression and tissue distribution of Th9-related cytokines in patients with psoriatic arthritis (PsA). METHODS Quantitative gene expression analysis of Th1, Th17, and Th9 cytokines was performed in intestinal biopsy samples obtained from patients with PsA, HLA-B27-positive patients with ankylosing spondylitis (AS), patients with Crohn's disease (CD), and healthy controls. Expression and tissue distribution of interleukin-23 (IL-23), IL-17, IL-22, IL-9, and IL-9 receptor (IL-9R) were evaluated by immunohistochemistry and confocal microscopy. Flow cytometry was used to study the frequency of Th9 cells among peripheral blood, lamina propria, and synovial fluid mononuclear cells. The functional relevance of IL-9R expression on epithelial cells was assessed in functional in vitro studies. Th9 cells in synovial tissue from patients with PsA were also studied. RESULTS Subclinical gut inflammation in PsA patients was characterized by a clear Th17 and Th22, but not Th1, polarized immune response. Unlike AS and CD, a strong and significant up-regulation of IL-9 was observed in PsA gut, especially among infiltrating mononuclear cells, high endothelial venules, and Paneth cells. IL-9-positive mononuclear cells were demonstrated to be in large part Th9 cells. IL-9 overexpression was accompanied by significant Paneth cell hyperplasia. Paneth cells strongly overexpressed IL-9R, and stimulation of epithelial cells, isolated from PsA patients, with IL-9 resulted in overexpression of α-defensin 5 and IL-23p19. Peripheral and synovial expansion of α4β7+ Th9 cells was also observed in patients with PsA. Increased expression of IL-9 and IL-9R was also found in synovial tissue. CONCLUSION Strong IL-9/Th9 polarization seems to be the predominant immunologic signature in patients in PsA.
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Affiliation(s)
| | | | | | | | | | | | | | - Melissa Van Tok
- Academic Medical Center and University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | - Aroldo Rizzo
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Dominique Baeten
- Academic Medical Center and University of Amsterdam, Amsterdam, The Netherlands
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A Curious Case of Intestinal Diaphragm Disease Unmasked by Perforation of a Duodenal Ulcer. Case Rep Med 2017; 2017:5048345. [PMID: 28523070 PMCID: PMC5385904 DOI: 10.1155/2017/5048345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/19/2017] [Indexed: 12/22/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs are a common cause of intestinal injury. A variety of NSAID-induced injuries may occur including ulcers, erosions, colitis, strictures, and diaphragm disease. Diaphragm disease refers to the development of multiple thin, concentric, stenosing strictures in the intestine. Strictures occur most often in the midintestine and are thought to be pathognomonic of NSAID damage. They can lead to intermittent or complete bowel obstruction. Diagnosis may be elusive as there is nothing specific about NSAID-induced injury at endoscopy and histology is also nonspecific. Even at laparotomy, the diagnosis of diaphragm disease may be missed as the serosa may appear normal and strictures can be difficult to palpate. While most NSAID-induced lesions tend to resolve quickly following withdrawal of the offending drug, diaphragm-like strictures usually require intervention such as stricturoplasty or surgical resection of the involved segment of bowel. Here we report the case of a 60-year-old male patient who presented with iron deficiency anaemia and recurrent subacute bowel obstruction. Following endoscopy and repeated CT scanning of his abdomen, he was diagnosed with Crohn's disease. He was treated with 5-ASAs and immune suppression until a perforated duodenal ulcer resulted in emergency laparotomy and the subsequent discovery of multiple intestinal diaphragms attributable to long-standing NSAID use.
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Marginean EC. The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. Arch Pathol Lab Med 2017; 140:748-58. [PMID: 27472233 DOI: 10.5858/arpa.2015-0451-ra] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
CONTEXT -There is an ever-growing armamentarium of pharmacologic agents that can cause gastrointestinal (GI) mucosal injury, the most common symptoms being diarrhea, constipation, nausea, and vomiting. These are often self-limiting and without serious sequelae, but some symptoms are of greater concern, like drug-induced mucosal ulceration that can manifest as GI hemorrhage, stricture formation, and even perforation. Histologically, there is significant overlap between drug-induced injuries and various disease entities. A single type of medication may cause multiple patterns of injury, which can involve the entire GI tract or just some parts of it. OBJECTIVE -To review the most common drug-induced injury patterns affecting the colon, which may be recognized by the surgical pathologist on colonic mucosal biopsies. This review does not address the injuries occurring in the upper GI tract. DATA SOURCES -A PubMed review of English-language literature, up to December 2015, on drug-induced injury of GI tract was performed. CONCLUSIONS -There are numerous drugs that damage the colonic mucosa. The most common drugs are included in this review according to their histologic pattern of injury. It is important for the pathologist to keep in mind that a single drug type can induce many histologic patterns of mucosal injury that can mimic many disease entities. Although there are some histologic clues helpful in the diagnosis of drug-induced colonic injury, correlation with clinical history and especially medication history is essential to improve diagnostic accuracy.
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Affiliation(s)
- Esmeralda Celia Marginean
- From the Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Ontario, Canada
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41
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Xue Y, Farris AB, Quigley B, Krasinskas A. The Impact of New Technologic and Molecular Advances in the Daily Practice of Gastrointestinal and Hepatobiliary Pathology. Arch Pathol Lab Med 2017; 141:517-527. [PMID: 28157407 DOI: 10.5858/arpa.2016-0261-sa] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The practice of anatomic pathology, and of gastrointestinal pathology in particular, has been dramatically transformed in the past decade. In addition to the multitude of diseases, syndromes, and clinical entities encountered in daily clinical practice, the increasing integration of new technologic and molecular advances into the field of gastroenterology is occurring at a fast pace. Application of these advances has challenged pathologists to correlate newer methodologies with existing morphologic criteria, which in many instances still provide the gold standard for diagnosis. This review describes the impact of new technologic and molecular advances on the daily practice of gastrointestinal and hepatobiliary pathology. We discuss new drugs that can affect the gastrointestinal tract and liver, new endoluminal techniques, new molecular tests that are often performed reflexively, new imaging techniques for evaluating hepatocellular carcinoma, and modified approaches to the gross and histologic assessment of tissues that have been exposed to neoadjuvant therapies.
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Affiliation(s)
| | | | | | - Alyssa Krasinskas
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
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42
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Tachecí I, Kopáčová M, Rejchrt S, Bureš J. Non-steroidal Anti-inflammatory Drug Induced Injury to the Small Intestine. ACTA MEDICA (HRADEC KRÁLOVÉ) 2016. [DOI: 10.14712/18059694.2016.56] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Non-steroidal anti-inflammatory drug (NSAIDs) induced enteropathy represents an important complication of one of the most commonly used drugs worldwide. Due to previous diagnostics difficulties the real prevalence of this disease was underestimated for a long time. The pathogenesis of NSAID-enteropathy is more multifactorial and complex than formerly assumed but has still not been fully uncovered. A combination of the local and systemic effect plays an important role in pathogenesis. Thanks to novel enteroscopy methods (wireless capsule endoscopy, double balloon enteroscopy), small bowel lesions are described in a substantial section of NSAID users although most are clinically asymptomatic. The other non-invasive tests (small bowel permeability, faecal calprotectin, scintigraphy using faecal excretion of 111-indium-labelled leukocytes etc.) proposed for diagnostics are not generally used in clinical practice, mainly because of their non-specificity. Despite intensive research into possible treatment, the main measure for patients with NSAID-enteropathy is still withdrawal of NSAIDs. Double balloon enteroscopy plays an important role in the treatment of complications (bleeding, strictures).
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Ueno Y, Nakamura M, Watanabe O, Yamamura T, Funasaka K, Ohno E, Miyahara R, Kawashima H, Goto H, Hirooka Y. COX-2 inhibitory NSAID-induced multiple stenosis in the small intestine diagnosed by double-balloon endoscopy. NAGOYA JOURNAL OF MEDICAL SCIENCE 2016; 78:323-8. [PMID: 27578916 PMCID: PMC4995278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
The patient was a 72 year old man who had been given non-steroidal anti-inflammatory drug (NSAID) for two years. He repeatedly developed small intestinal ileus; therefore, he underwent several imaging examinations, but the cause was not identified. He subsequently underwent a double-balloon endoscopy (DBE). The membranous stenoses were detected in the jejunum, and the biopsy specimens were taken during the DBE. The membranous stenoses in the gastrointestinal tract were characteristic of NSAID-induced enteropathy, and he was endoscopically and histopathologically diagnosed with NSAID-induced small intestinal disorder. NSAID administration was withdrawn, and the balloon dilation was conducted for small intestinal stenosis. After that, no small intestinal ileus developed again. Some studies were conducted on the mechanism of NSAID-induced small intestinal dysfunction, but the drug that was administered to the patient was a highly selective NSAID for cyclooxygenase (COX)-2, and there are few studies that reported a dysfunctional mechanism induced by this drug. In the tissue sampled by DBE, apoptotic bodies were found; therefore, it was suggested that the stenoses in this case were caused by the COX-2 inhibitor from the relationship between COX-2 inhibition and apoptosis. Further studies are necessary to investigate the mechanism of NSAID enteropathy.
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Affiliation(s)
- Yasuaki Ueno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Osamu Watanabe
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Takeshi Yamamura
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
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Sumner D, Sahota J, Schofield J. Recurrence of an NSAID-induced diaphragmatic disease of the small intestine. BMJ Case Rep 2016; 2016:bcr-2016-215023. [PMID: 27170609 DOI: 10.1136/bcr-2016-215023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 74-year-old woman was referred to the surgical team from clinic, reporting of a 1-week history of vomiting and abdominal distension on a background of previous large bowel resection for a flare up of diverticulitis with a suspicion of diaphragm disease of the small intestine diagnosed at the same time. She was initially managed conservatively owing to the likely diagnosis of adhesion(s) leading to small bowel obstruction, but a CT of the abdomen a day later revealed a recurrence of diaphragmatic disease of the small bowel causing an obstruction, most likely due to chronic non-steroidal anti-inflammatory drug use. She was taken to theatre for an emergency laparotomy and small bowel resection due to previous resections, from which she made a good recovery; she was discharged from hospital 8 days later.
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Affiliation(s)
- Daniel Sumner
- Department of General Surgery, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, UK
| | - Jagjit Sahota
- Department of General Surgery, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, UK
| | - John Schofield
- Histopathology Department, Maidstone Hospital, Maidstone, Kent, UK
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Clinical Features, Diagnosis, and Treatment Strategies of Gastrointestinal Diaphragm Disease Associated with Nonsteroidal Anti-Inflammatory Drugs. Gastroenterol Res Pract 2016; 2016:3679741. [PMID: 27118967 PMCID: PMC4826940 DOI: 10.1155/2016/3679741] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/07/2016] [Indexed: 12/22/2022] Open
Abstract
Background. To demonstrate the clinical features, diagnosis, and treatment of nonsteroidal anti-inflammatory drug- (NSAID-) induced diaphragm disease (DD). Methods. A literature search between January 1973 and August 2015 was undertaken. The clinical data of patients with NSAID-induced DD were recorded and analyzed. Results. 159 patients were included. The ratio of male to female was 1 : 2.3; the mean age was 65 ± 11 years. The most common clinical manifestations were gastrointestinal bleeding and obstruction. 121 (84%) patients took traditional NSAIDs. The durations of NSAIDs use ranged from 2 to 300 months. A majority (59.7%) of DD were seen in the small bowel, were seen secondly in the colon (30.2%), and were mainly located in the ileum (57.9%) and right colon (91.7%), respectively. 80% of patients had multiple diaphragms. 41.5% of small bowel DD were diagnosed preoperatively by capsule endoscopy and/or double-balloon enteroscopy, 52.1% at laparotomy. Nearly 75% of patients underwent surgery, endoscopic balloon dilation was performed in 22 patients, and NSAIDs were withdrawn in 53 patients. Conclusions. NSAID-induced DD is relatively rare. The small bowel is most commonly involved. Preoperative diagnosis of small bowel DD is relatively difficult. Discontinuation of the NSAIDs is recommended, surgical resection is the main treatment presently, and endoscopic balloon dilation should be considered as an alternative therapy.
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Frye JM, Hansel SL, Dolan SG, Fidler JL, Song LMWK, Barlow JM, Smyrk TC, Flicek KT, Hara AK, Bruining DH, Fletcher JG. NSAID enteropathy: appearance at CT and MR enterography in the age of multi-modality imaging and treatment. ACTA ACUST UNITED AC 2016; 40:1011-25. [PMID: 25666969 DOI: 10.1007/s00261-015-0367-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
CT and MR enterography and capsule endoscopy are increasingly used as routine diagnostic tests for patients with potential small bowel disorders and obscure gastrointestinal bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used drugs that disrupt prostaglandin synthesis and result in a variety of localized complications within the small bowel ranging from ulcer formation to characteristic circumferential strictures, or diaphragms. NSAID enteropathy encompasses this spectrum of acute and chronic inflammatory sequelae, and is associated with typical findings at capsule endoscopy and surgery. Herein we review the typical clinical presentation of NSAID enteropathy, in addition to its endoscopic appearances, focusing on imaging findings at cross-sectional enterography. Multiple, short-segment strictures are the hallmarks of imaging diagnosis. Strictures may have minimal hyperenhancement or wall thickening, but these findings are typically symmetric and circumferential with respect to the bowel lumen. Multifocal Crohn's strictures, and occasionally radiation-induced strictures or adhesions, will mimic NSAID diaphragms. Multi-phase or multi-sequence imaging at CT and MR enterography increase diagnostic confidence in stricture presence. Strategies for subsequent workup and therapy after enterography are also discussed. Given the frequent use of NSAIDs and typical appearance of these strictures, knowledge of characteristic imaging findings can be particularly useful when evaluating patients with anemia and recurrent small bowel obstruction.
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Affiliation(s)
- Judson M Frye
- Department of Radiology, Mayo Clinic Health System, La Crosse, WI, USA
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Abstract
Many drugs and chemical agents can cause enteritis and colitis, producing clinical gastrointestinal side effects, the most common of which are diarrhoea, constipation, nausea and vomiting. Significant histological overlap exists between some patterns of medication or chemical injury and various disease entities. A particular medication may cause multiple patterns of injury and may mimic common entities such as coeliac disease, Crohn's disease, infectious enteritis and colitis. Thus, given the common absence of specific histopathological features, the diagnosis often relies upon thorough clinicopathological correlation. This review concentrates on selected examples of medication-induced injury of the intestinal tract in which the pathology can be recognized, particularly on biopsies, with a focus on newly described medication-induced gastrointestinal effects.
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Affiliation(s)
- Aoife J McCarthy
- Department of Histopathology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Maresso KC, Tsai KY, Brown PH, Szabo E, Lippman S, Hawk ET. Molecular cancer prevention: Current status and future directions. CA Cancer J Clin 2015; 65:345-83. [PMID: 26284997 PMCID: PMC4820069 DOI: 10.3322/caac.21287] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 05/26/2015] [Accepted: 05/28/2015] [Indexed: 12/20/2022] Open
Abstract
The heterogeneity and complexity of advanced cancers strongly support the rationale for an enhanced focus on molecular prevention as a priority strategy to reduce the burden of cancer. Molecular prevention encompasses traditional chemopreventive agents as well as vaccinations and therapeutic approaches to cancer-predisposing conditions. Despite challenges to the field, we now have refined insights into cancer etiology and early pathogenesis; successful risk assessment and new risk models; agents with broad preventive efficacy (eg, aspirin) in common chronic diseases, including cancer; and a successful track record of more than 10 agents approved by the US Food and Drug Administration for the treatment of precancerous lesions or cancer risk reduction. The development of molecular preventive agents does not differ significantly from the development of therapies for advanced cancers, yet it has unique challenges and special considerations given that it most often involves healthy or asymptomatic individuals. Agents, biomarkers, cohorts, overall design, and endpoints are key determinants of molecular preventive trials, as with therapeutic trials, although distinctions exist for each within the preventive setting. Progress in the development and evolution of molecular preventive agents has been steadier in some organ systems, such as breast and skin, than in others. In order for molecular prevention to be fully realized as an effective strategy, several challenges to the field must be addressed. Here, the authors provide a brief overview of the context for and special considerations of molecular prevention along with a discussion of the results from major randomized controlled trials.
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Affiliation(s)
- Karen Colbert Maresso
- Program Manager, Division of Cancer Prevention & Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kenneth Y Tsai
- Assistant Professor, Department of Dermatology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Powel H Brown
- Chair, Department of Clinical Cancer Prevention, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eva Szabo
- Chair, Lung and Upper Aerodigestive Cancer Research Group, Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Scott Lippman
- Director, Moores Cancer Center, University of California, San Diego, San Diego, CA
| | - Ernest T Hawk
- Vice President and Division Head, Boone Pickens Distinguished Chair for Early Prevention of Cancer, Division of Cancer Prevention & Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX
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49
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Crothers JW, Zenali M. Neuromuscular and Vascular Hamartoma of the Small Intestine: An Exuberant Reparative Process Secondary to Chronic Inflammation. Int J Surg Pathol 2015; 23:673-6. [PMID: 26275621 DOI: 10.1177/1066896915600518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The term Neuromuscular and Vascular Hamartoma (NMVH) was initially coined by Fernando and McGovern in 1982 in their report of 2 cases. Whether this lesion is truly hamartomatous or represents a "burnt-out" phase of varying chronic pathologies has been debated since that time. Examples of NMVH-like proliferations have been reported in the setting of diaphragm disease, Crohn's disease, radiation, and ischemia. Herein we present the case of a 73-year-old female with partial small bowel obstruction and a past surgical history significant for cholecystectomy and abdominal hysterectomy. A computed tomography scan revealed an ill-defined mass with the same density as muscle extending into the mesentery, worrisome for malignancy and generating the differential of lymphoma versus metastatic disease. Upon laparotomy, a 2.5 cm, constrictive, predominantly mural-based mass was identified. The more proximal bowel was dilated, and there were dense serosal adhesions. Grossly, the transmural lesion had a tan-yellow cobweb-like cut surface and the overlying mucosa was flattened. Histologically, the lesion contained fascicles of smooth muscle, irregularly spaced large nerve bundles, and thick-walled vasculature in a haphazard arrangement within a hypocellular fibroadipose stroma. No stigmata of Crohn's disease were observed, and the uninvolved enteric tissue was unremarkable. The patient's medical history was negative for chronic nonsteroidal anti-inflammatory use and was otherwise unremarkable. This case of an NMVH-like lesion is presented as a reminder of benign mass-forming lesions causing bowel obstruction and suggests that such lesions may develop secondary to a chronic inflammatory process.
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Affiliation(s)
| | - Maryam Zenali
- University of Vermont College of Medicine, Burlington, VT, USA
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50
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Sarantitis I, Gerrard AD, Teasdale R, Pettit S. Small bowel diaphragm disease mimicking malignancy. BMJ Case Rep 2015; 2015:bcr-2015-210174. [PMID: 26174729 DOI: 10.1136/bcr-2015-210174] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) can produce diaphragm disease where multiple strictures develop in the small bowel. This typically presents with anaemia and symptoms of small bowel obstruction. The strictures develop as a result of circumferential mucosal ulceration with subsequent contraction of rings of scar tissue. We report a case of a 47-year-old woman with a 6-month history of NSAIDs abuse who presented with subacute small bowel obstruction 1 year after stopping NSAIDs. CT and MRI showed multiple ileal strictures with florid locoregional lymphadenopathy. A malignant diagnosis such as lymphoma was considered likely as florid mesenteric lymphadenopathy has not been previously reported in diaphragm disease. Laparotomy with small bowel resection was therefore performed. Histology showed diaphragm disease with the enlarged mesenteric nodes having reactive features. Gross locoregional lymphadenopathy should not deter a diagnosis of diaphragm disease in cases of multiple small bowel strictures where there is a strong history of NSAIDs use.
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Affiliation(s)
| | | | - Rebecca Teasdale
- Department of Surgery, Blackpool Victoria Hospital, Blackpool, UK
| | - Stephen Pettit
- Department of Surgery, Blackpool Victoria Hospital, Blackpool, UK
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