Introduction Diaphragm disease is characterised by strictures that mainly occur in the small intestine, resulting from the use of non-steroidal anti-inflammatory drugs. It may present with vague gastrointestinal symptoms or as a surgical emergency requiring laparotomy. Most cases are diagnosed retrospectively at laparotomy. Laparoscopy and various radiological imaging modalities are often inconclusive. Capsule endoscopy effectively diagnoses diaphragm disease pre-operatively. Following withdrawal of the offending NSAID, surgical resection, strictureplasty and double balloon enteroscopy have all been used as potential treatments. Specific drug treatment of small bowel diaphragm disease has not been described. We present a case series of three patients who were diagnosed with Diaphragm disease at capsule endoscopy and responded to Budesonide therapy.
Methods Case notes of three patients with a confirmed diagnosis of Diaphragm Disease were analysed, with respect to presenting symptoms, duration of symptoms, investigations, treatment and follow-up.
Results Three female patients between the ages of 56 and 72 presented with gastrointestinal symptoms, including abdominal pain, nausea, vomiting, bloating and loose stool. Symptoms were present from a range of two months to four years before their presentation to secondary care. All patients had a history of regular NSAID use and were investigated with gastroscopy, colonoscopy and CT abdomen, all of which were normal. Small bowel MRI was also normal in two patients (Fig.1). Capsule endoscopy in all patients demonstrated characteristic features of diaphragm disease (Fig.2). All patients received a tapering dose of Budesonide, starting at a dose of 9mg. A symptomatic response was observed in all patients. One patient has now been started on Azathioprine to maintain long term remission. Two remain on reducing doses of steroid with a significant improvement in symptoms.
Conclusion Diaphragm disease is an under recognised clinical entity that can present in a variety of ways. It can be difficult to diagnose with routine endoscopy or conventional radiology. Capsule endoscopy appears to be the most sensitive test. Clinicians should have a high index of suspicion for this condition, particularly in the context of NSAID use and chronic gastrointestinal symptoms. Budesonide appears to be an effective therapy for Diaphragm Disease, and it seems likely that long-term therapy with azathioprine can maintain remission. However this is an observational study with a small number of patients. Further research is required to validate this as successful, viable, evidence based treatment option.
Disclosure of Interest None Declared.