Gastroenterology

Gastroenterology

Volume 128, Issue 5, May 2005, Pages 1172-1178
Gastroenterology

Clinical-alimentary tract
A Quantitative Analysis of NSAID-Induced Small Bowel Pathology by Capsule Enteroscopy

https://doi.org/10.1053/j.gastro.2005.03.020Get rights and content

Background & Aims: Conventional acidic nonsteroidal anti-inflammatory drugs frequently cause small bowel inflammation. Diagnosis is largely based on assay of surrogate markers of inflammation in stool, such as fecal calprotectin. However, stool markers are not widely available and the precise nature of this inflammation is uncertain. We used wireless capsule enteroscopy to quantitate and assess the nature of the small bowel damage caused by nonsteroidal anti-inflammatory drugs when taken on a short-term basis. Methods: Forty healthy volunteers underwent a baseline capsule enteroscopy and fecal calprotectin test. After taking diclofenac slow-release 75 mg twice a day (with omeprazole 20 mg twice a day for gastroprotection) for a total of 14 days, both investigations were repeated. Results: After drug treatment, 30 subjects (75%) had increased repeat fecal calprotectin concentrations above the upper limit of normal. Capsule enteroscopy showed new pathology in 27 subjects (68%). The commonest lesions were mucosal breaks, seen in 16 (40%), which were seen to be bleeding in 2 (5%); reddened folds in 14 (35%); petechiae or red spots in 13 (33%); denuded mucosa in 8 (20%); and blood in the lumen without a visualized source in 3 (8%). Fifteen of the 27 subjects had more than one lesion concurrently. Conclusions: This study provides both biochemical and direct evidence of macroscopic injury to the small intestine in 68%–75% of volunteers resulting from 2 weeks’ ingestion of slow-release diclofenac.

Section snippets

Materials and Methods

Forty healthy volunteers (23 men and 17 women; mean age, 35 years; range, 21–61 years), mostly hospital staff, from London, England, and Reykjavik, Iceland, were recruited for this study. The main exclusion criteria included recent (in the past month) NSAID or aspirin intake, history of regular NSAID or aspirin use, NSAID hypersensitivity, pregnancy, alcohol or substance misuse, and any serious central nervous system, psychiatric, cardiovascular, respiratory, musculoskeletal, and intestinal

Capsule Enteroscopy

The baseline capsule study was incomplete in 2 volunteers. All 40 repeat studies were complete. Baseline capsule images showed that 3 volunteers had incidental lymphangiectasiae and a further 3 each had a single angiodysplastic lesion. No other pathology was seen.

After 2 weeks of treatment with diclofenac and omeprazole, 27 of the 40 volunteers (68%) had demonstrable pathology not previously seen at baseline as shown in Table 1. Fifteen volunteers (38%) had more than one category of lesion

Discussion

This study shows a high prevalence of NSAID-induced enteropathy, as shown by elevated fecal calprotectin concentrations, after a fortnight’s ingestion of diclofenac and omeprazole in volunteers. The capsule enteroscopy shows that the macroscopic morphologic correlates of this damage are abnormalities ranging from subtle reddening of mucosal folds to that of discrete erosions and ulcers and occasional bleeding.

It is not in doubt that conventional NSAIDs cause small bowel damage in humans.5 This

References (26)

  • C. Scarpignato et al.

    Towards a GI safer antiinflammatory therapy

    Gastroenterol Int

    (1999)
  • F.E. Silverstein et al.

    Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: a randomised controlled trial. Celecoxib Long-term Arthritis Study

    JAMA

    (2000)
  • F.E. Silverstein et al.

    Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs

    Ann Intern Med

    (1995)
  • Cited by (453)

    View all citing articles on Scopus

    Supported by an unconditional grant from Pfizer. B.T. and I.B. have received honoraria for lectures and research grants from a number of companies that produce anti-inflammatory drugs.

    View full text