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Chronic NSAID Use: Small Chronic NSAID Use: Small Bowel InjuryBowel Injury
Waqar Qureshi, MD, FACP, FACGWaqar Qureshi, MD, FACP, FACG
Associate Professor of MedicineAssociate Professor of Medicine
Chief of EndoscopyChief of Endoscopy
Baylor College of Medicine/VAMCBaylor College of Medicine/VAMC
Houston, TexasHouston, Texas
The occasional finding of intestinal blood loss
or anemia in the setting of normal upper and
lower endoscopy led to the realization that:
• NSAID-induced small intestinal ulceration and bleeding were clinically important
Hedenbro JL, et al. Gastrointest Endosc 1988;34:247-251
Upadhyay R, et al. Ann Rheum Dis 1990;49:359-362
NSAIDs and the Small IntestineNSAIDs and the Small Intestine
A Controlled Study of NSAID-induced A Controlled Study of NSAID-induced Small Bowel Injury Using VCESmall Bowel Injury Using VCE
Methods:
• 41 ambulatory subjects (mean age = 49.5 y) with various types of arthritides (OA/RA/gout/non-specific) were enrolled
• 21 subjects took NSAIDs daily (>3 mo duration)
• 20 took acetaminophen alone or nothing.
The Pill CameraThe Pill Camera
1. Optical dome1. Optical dome2. Lens holder2. Lens holder3. Lens3. Lens4. Illuminating LEDs (light 4. Illuminating LEDs (light emitting diodes)emitting diodes)5. CMOS image sensor5. CMOS image sensor6. Battery6. Battery7. ASIC (Application Specific7. ASIC (Application Specific Integrated Circuit) transmitterIntegrated Circuit) transmitter 8. Antenna8. Antenna
1. Optical dome1. Optical dome2. Lens holder2. Lens holder3. Lens3. Lens4. Illuminating LEDs (light 4. Illuminating LEDs (light emitting diodes)emitting diodes)5. CMOS image sensor5. CMOS image sensor6. Battery6. Battery7. ASIC (Application Specific7. ASIC (Application Specific Integrated Circuit) transmitterIntegrated Circuit) transmitter 8. Antenna8. Antenna
Dimensions: Height: 11mm Length: 26mmWeight: 3.7gm
Small Bowel Ulcer
NSAID Ulceration
Blood in Terminal Ileum
A Controlled Study of NSAID-induced A Controlled Study of NSAID-induced Small Bowel Injury Using VCESmall Bowel Injury Using VCE
Results:
any injury (p<0.001)
• Severe damage was associated with high dose indomethacin, naproxen, and ibuprofen use.
NSAID users Controls
Any injury 71% 10%
Severe injury 20% 0%
ConclusionsConclusionsSymptoms and signs of ill-health among chronic
NSAID users are often attributed to the underlying
disease
Possible evidence of NSAID enteropathy includes:
• Dyspepsia that does not respond to PPI
• Vague abdominal pain that eludes diagnosis or treatment
• Iron deficiency anemia
• Hypoalbuminemia
• VCE is a useful tool for diagnosing NSAID-induced small intestinal mucosal injury
• VCE should be considered in patients on NSAIDs with unexplained symptoms
• Prospective comparisons of NSAIDs or other drugs and the GI tract
NSAID-induced Small Bowel Injury NSAID-induced Small Bowel Injury ConclusionsConclusions
THE END