The Ulster Medical Journal, Volume 69, No. 2, pp. 175-176, November 2000. ... Hospital, Glenshane Road, Londonderry. C The Ulster Medical Society, 2000.
The Ulster Medical Journal, Volume 69, No. 2, pp. 175-176, November 2000.
Case Report
Aspirin-related small bowel diaphragm disease identified during emergency laparotomy S M Crowther, J G W Matthews Accepted 22 March 2000
Small bowel diaphragm disease is a rare complication of NSAID and aspirin ingestion. We report a case diagnosed following emergency laparotomy for an associated jejunal perforation. CASE REPORT A 67-year-old man presented as an emergency admission with a 4 hour history of severe central abdominal pain. This was initially colicky and subsequently sharp and constant in nature with no other associated features. He had no history of peptic ulcer disease, nor of any similar pain previously. Of note, his medication included aspirin NS 75 mgs mane. On examination the patient was distressed but haemodynamically stable and apyrexic. His abdomen was rigid with maximal guarding and rebound tenderness in the epigastrium and central abdomen. Bowel sounds were present and hernial orifices intact. The patient's white cell count was mildly elevated at 11.6 x 109 per L3 but all other blood investigations including serum amylase were within normal limits. A presumptive diagnosis of a perforated peptic ulcer was made and following fluid resuscitation a laparotomy was performed. Approximately 200 mls of turbid free fluid was found, principally in the upper abdomen. Both stomach and duodenum were intact; however, an isolated segment of inflamed jejunum approximately 10 to 12 centimetres in length was identified. Midway along this section of bowel a perforation was noted. The remainder ofthe small bowel appeared normal and no other intraabdominal pathology was identified. A small bowel resection was performed and closed with an end to end anastomosis prior to copious saline lavage and a post operative course of antibiotics. Recovery was uneventful and the patient was discharged eight days later.
Histopathology of the resected segments confirmed perforation with surrounding transmural inflammation with necrosis of the mucosa and muscle wall with fibrin deposition on the serosal aspect. There was no evidence of vasculitis away from the perforation and no evidence of malignancy. Of interest, however, was the presence of several diaphragmatic strictures in which there was a proliferation of the mucosa with a central fibrovascular sub-mucosal core and some inflammation at the tip. These diaphragms within the lumen of the bowel wall were acting to cause a decrease in its diameter. At subsequent outpatient review eight weeks following admission the patient had made a full recovery, having had his aspirin therapy stopped whilst an inpatient. DISCUSSION
The damaging effects of NSAIDs and aspirin on upper GI mucosa have long been recognised, contributing to ulceration and perforation.' Less well recognised is the occurrence of damage to small bowel mucosa distal to the duodenum and with the common usage of enterically coated and slow release preparations, even the large bowel may be involved representing a distal shift in NSAID toxicity.2 A much less common complication of NSAID and aspirin ingestion is diaphragm disease. This Coleraine Hospital, Mountsandel Road, Coleraine, Co. Londonderry. S M Crowther, MB, MRCS(Eng), Senior House Officer. J G W Matthews, FRCS(Eng), MCh, Consultant Surgeon.
Correspondence to Mr Crowther, Altnagelvin Area Hospital, Glenshane Road, Londonderry. C The Ulster Medical Society, 2000.
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is the formation of thin circumferential mucosal diaphragms within the lumen of the bowel. This usually affects the small bowel but large bowel diaphragms have been reported rarely.3 The exact patho-physiological basis for the formation of these diaphragms is unclear but due to the stricturing of the bowel lumen which they produce it would seem from reported cases that they would most commonly present clinically with an obstructive picture.4 Inflammation and ulceration however can also be present. In this case the patient proceeded to laparotomy with a presumptive diagnosis of perforated duodenal ulceration. The interesting features of the case were, firstly the finding of an isolated jejunal perforation in an otherwise healthylooking small bowel, and, secondly, the discovery of the associated diaphragm disease. As there were no clinical features or findings at laparotomy to suggest significant small bowel obstruction, it may be that the dual pathologies are merely synchronous and that the perforation and associated inflammation were not directly caused by the mucosal diaphragms. However, we were unable to find any report of diaphragm disease of the small bowel having been previously diagnosed following emergency laparotomy for an acute abdomen caused by perforation. NSAID and salicylate ingestion can therefore, in addition to being responsible for recognised gastric and duodenal inflammation and perforation, cause more distal gastro-intestinal pathology. In addition, it can also be the cause of intestinal lumenal stricturing secondary to mucosal diaphragms. This also implicates this family of drugs as a rare cause of intestinal obstruction.
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4. McGonigal A, Moffat D F, Lindop G B, Gilchrist W J. Nonsteroidal anti-inflammatory drug associated diaphragm disease. Postgrad Med 1997; 73: 505-6.
