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  • • Damage to the small intestinal mucosa due to NSAIDs or radiation exposure

    • Ensuing inflammation can result in mucosal ulceration, diarrhea, and GI bleeding

    • Late complications of NSAID and radiation enteropathy include stricture and obstruction

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Epidemiology

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NSAID Enteropathy

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  • • NSAIDs increase intestinal permeability, leading to mucosal inflammation

    • Enteropathy, with subclinical intestinal inflammation and occult blood loss, develops in 70% of patients who have taken NSAIDs for > 6 months

    • Mucosal ulceration or transmural inflammation and fibrosis with circumferential strictures develop in < 1%

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Radiation Enteropathy

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  • • Injury to blood vessels in the bowel wall leads to endothelial proliferation and fibrosis that obliterates the vessel lumen producing chronic intestinal ischemia

    • Incidence of bowel injury is dose-related

    • -5% after 4500 cGy

      -30% after 6000 cGy

    • Fixed loops of small bowel in the radiation field increases the risk of intestinal complications

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Symptoms and Signs

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  • • Nausea and vomiting

    • Abdominal pain

    • GI bleeding

    • Diarrhea, which may be bloody

    • Abdominal tenderness

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Laboratory Findings

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  • • Anemia

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Imaging Findings

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  • Abdominal x-ray

    • -If obstruction is present, dilated loops of bowel proximal to the obstruction with air-fluid levels and thickened bowel wall

      -Free air suggests perforation

    Upper GI contrast radiography: Narrowed, stenotic segment of bowel

    CT scan

    • -Dilated bowel with bowel wall edema proximal to the obstruction with narrowed, stenotic bowel at the site of obstruction

      -Free air suggests perforation

    Endoscopy

    • -Inflamed mucosa

      -May identify the strictured segment of bowel

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  • • Strictures, either inflammatory (NSAID enteropathy) or ischemic (radiation enteropathy) can present as a late complication and result in obstruction or perforation

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Rule Out

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  • • Crohn disease

    • Ischemia

    • TB

    • Lymphoma

    • Primary or recurrent carcinoma

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  • • Abdominal x-ray

    • GI contrast radiography

    • CT scan

    • Endoscopy

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When to Admit

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  • • Obstruction

    • Perforation

    • Bleeding

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NSAID Enteropathy

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  • • Discontinue drug

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Radiation Enteropathy

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  • • Symptoms may appear as early as 1 month or as late as 30 years after completion of therapy

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Surgery

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  • • Resection indicated for complications

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Indications

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  • • Obstruction

    • Perforation

    • Bleeding

    • Abscess

    • Fistula

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Complications

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  • • Obstruction

    • Perforation

    • Bleeding

    • Abscess

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Prognosis

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  • • Good for NSAID enteropathy after medication is discontinued

    • Symptoms are usually minor and transient with radiation enteropathy

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References

Graham DY et al: Visible small-intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol 2005;3:55.  [PubMed: 15645405]
Jain G et al: Chronic radiation enteritis: a ten-year ...

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