Mayo Clio Proc, May 1995, Vol 70

nonhemorrhagic stroke; a ventilation/perfusion scan showeda high probability of pulmonary embolism. A correct optionindicated was to begin intravenous heparin therapy to in­crease the activated partial thromboplastin time to 11/2 timesthe normal value and start warfarin therapy the same day. Ibelieve, however, that it is important, especially for teachingpurposes, to consider the option of obtaining a computedtomographic scan of the head. Possibly, a cerebral computedtomographic scan was obtained only during the initial as­sessment of the patient, results of which showed no acutehemorrhage. Thus, the patient's hemiplegia would havebeen regarded as due to a nonhemorrhagic cause. Consider­ing the clinical entity of hemorrhagic transformation of acerebrovascular accident is important. This well-describedentity can occur in previously ischemic brain tissue within10 days after an initial ischemic event.

The initiation of anticoagulant therapy in the presence ofa cerebral hemorrhagic event would be devastating. In myopinion and from my clinical experience, the option of per­forming imaging studies of the head should therefore beconsidered as a first step before instituting anticoagulanttherapy in such a situation.

Martin A. Schaeffer, M.D.DuBois Regional Medical CenterDuBois, Pennsylvania

In response: I agree entirely with Dr. Schaeffer's concernsthat a stroke may not demonstrate hemorrhage for at least 48hours. Thus, obtaining a computed tomographic scan beforeinitiation of long-term anticoagulant therapy would beappropriate.

Edward C. Rosenow III, M.D.Mayo Clinic RochesterRochester, Minnesota

Treatment of Nonsteroidal Anti-InflammatoryDrug-Induced Enteropathy

To the Editor: In the case report by Kwo and Tremaine onnonsteroidal anti-inflammatory drug-induced enteropathy,which was published in the January 1995 issue of the MayoClinic Proceedings (pages 55 to 61), I question their decisionto perform laparotomy in their patient who had persistentanemia. Their article had several references that substanti­ated the effects of nonsteroidal anti-inflammatory drugs onthe small bowel. In the conclusion, they recommenddiscontinuation of the use of nonsteroidal anti-inflammatorydrugs in patients with iron deficiency anemia who have

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normal findings on assessment of the upper and lower gas­trointestinal tract. In light of these facts, why did theysubject their patient to laparoscopy and bowel resectionrather than discontinue the use of ibuprofen and monitor thepatient's response?

Douglas W. Kirtley, M.D.Lewis-Gale ClinicRoanoke, Virginia

In response: We thank Dr. Kirtley for his interest in our casereport of a woman with severe iron deficiency anemia, whohad been hospitalized numerous times. Laparotomy wasdone because an angiogram demonstrated angiodysplasia inthe cecum, and no other source for the bleeding could bedetected. We did not expect to find the multiple strictures inthe distal ileum. In fact, this case occurred before the so­called diaphragm disease had been reported by Bjarnasonand colleagues. I In addition, the patient had been takingibuprofen, a nonsteroidal agent that had not previously beenassociated with drug-induced enteropathy. In light of ourcurrent knowledge, we certainly agree that discontinuing theuse of ibuprofen and monitoring the patient's responsewould be a reasonable course of action.

Paul Y. Kwo, M.D.William J. Tremaine, M.D.Mayo Clinic RochesterRochester, Minnesota

REFERENCE1. Bjarnason I, Price AB, Zanelli G, Smethurst P, Burke M,

Gumpel JM, et al. Clinicopathological features of nonsteroidalantiinflammatory drug-induced small intestinal strictures.Gastroenterology 1988; 94:1070-1074

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