1
|
Sachdeva K, Agarwal S, Kumar P, Mathew D, Kurrey L, Vuyyuru SK, Kante B, Sahu P, Mundhra S, Virmani S, Mouli P, Dhingra R, Sharma R, Das P, Makharia G, Kedia S, Ahuja V. Revised Algorithmic Approach to Differentiate Between Nonspecific and Specific Etiologies of Chronic Terminal Ileitis. Am J Gastroenterol 2023; 118:2052-2060. [PMID: 37216605 DOI: 10.14309/ajg.0000000000002334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 12/29/2022] [Accepted: 04/27/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Chronic isolated terminal ileitis (TI) may be seen in Crohn's disease (CD) and intestinal tuberculosis (ITB) in addition to other etiologies that may be managed symptomatically. We developed a revised algorithm to distinguish patients with a specific etiology from a nonspecific etiology. METHODS Patients with chronic isolated TI followed up from 2007 to 2022 were retrospectively reviewed. A specific (ITB or CD) diagnosis was made based on standardized criteria, and other relevant data were collected. Using this cohort, validation of a previously suggested algorithm was conducted. Furthermore, based on the results of a univariate analysis, a multivariate analysis with bootstrap validation was used to develop a revised algorithm. RESULTS We included 153 patients (mean age 36.9 ± 14.6 years, males-70%, median duration-1.5 years, range: 0-20 years) with chronic isolated TI of whom 109 (71.2%) received a specific diagnosis (CD-69, ITB-40). On multivariate regression and validation statistics with a combination of clinical, laboratory, radiological, and colonoscopic findings, an optimism corrected c-statistic of 0.975 and 0.958 was obtained with and without histopathological findings, respectively. Revised algorithm, based on these, showed sensitivity, specificity, positive and negative predictive values, and overall accuracy of 98.2% (95% CI: 93.5-99.8), 75.0% (95% CI: 59.7-86.8), 90.7% (95% CI: 85.4-94.2), 94.3% (95% CI: 80.5-98.5) and 91.5%(95% CI:85.9-95.4), respectively. This was more sensitive and specific than the previous algorithm (accuracy 83.9%, sensitivity 95.5%, and specificity 54.6%). DISCUSSION We developed a revised algorithm and a multimodality approach to stratify patients with chronic isolated TI into specific and nonspecific etiologies with an excellent diagnostic accuracy, which could potentially avoid missed diagnosis and unnecessary side effects of treatment.
Collapse
Affiliation(s)
- Karan Sachdeva
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Peeyush Kumar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - David Mathew
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kurrey
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Sudheer K Vuyyuru
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Kante
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Pabitra Sahu
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Mundhra
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Shubi Virmani
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Pratap Mouli
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Rajan Dhingra
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
2
|
Gupta S, Allegretti JR. Mimics of Crohn's Disease. Gastroenterol Clin North Am 2022; 51:241-269. [PMID: 35595413 DOI: 10.1016/j.gtc.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 02/21/2023]
Abstract
Crohn's disease is a chronic inflammatory disease that can affect any portion of the gastrointestinal tract. Associated symptoms can vary based on the severity of disease, extent of involvement, presence of extraintestinal manifestations, and development of complications. Diagnosis is based on a constellation of findings. Many diseases can mimic Crohn's disease and lead to diagnostic conundrums. These include entities associated with the gastrointestinal luminal tract, vascular disease, autoimmune processes, various infections, malignancies and complications, drug- or treatment-induced conditions, and genetic diseases. Careful consideration of possible causes is necessary to establish the correct diagnosis.
Collapse
Affiliation(s)
- Sanchit Gupta
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 850 Boyslton Street, Suite 201, Chestnut Hill, MA 02467, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Jessica R Allegretti
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 850 Boyslton Street, Suite 201, Chestnut Hill, MA 02467, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| |
Collapse
|
3
|
Baiomi A, Abbas H, Mehershahi S, Daniel M. Non-Steroidal Anti-Inflammatory Drugs: A Rare Cause of Colonic Mass. Case Rep Gastroenterol 2021; 15:395-399. [PMID: 33976617 PMCID: PMC8077422 DOI: 10.1159/000511748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 04/30/2020] [Accepted: 09/18/2020] [Indexed: 11/30/2022] Open
Abstract
NSAIDs (non-steroidal anti-inflammatory drugs) are one of the most used medications worldwide. Every day they are used by more than 30 million Americans. Here, we report a rare and interesting case of a 63-year-old woman with a history of NSAID use who presented to our emergency room with lower abdominal pain. Computed tomography (CT) scan of the abdomen with intravenous contrast revealed focal mucosal thickening in the cecum which was highly suspicious for colonic malignancy. She had a colonoscopy which showed two masses and ulcers in the right colon, pathology was negative for malignancy and showed inflammation consistent with NSAID colopathy.
Collapse
Affiliation(s)
- Ahmed Baiomi
- Department of Medicine, BronxCare Health System, Bronx, New York, USA
- Division of Gastroenterology, BronxCare Health System, Bronx, New York, USA
- *Ahmed Baiomi, Division of Gastroenterology, Department of Medicine, Bronxcare Health System, Bronx, NY 10457 (USA),
| | - Hafsa Abbas
- Department of Medicine, BronxCare Health System, Bronx, New York, USA
- Division of Gastroenterology, BronxCare Health System, Bronx, New York, USA
| | - Shehriyar Mehershahi
- Department of Medicine, BronxCare Health System, Bronx, New York, USA
- Division of Gastroenterology, BronxCare Health System, Bronx, New York, USA
| | - Myrta Daniel
- Department of Medicine, BronxCare Health System, Bronx, New York, USA
- Division of Gastroenterology, BronxCare Health System, Bronx, New York, USA
| |
Collapse
|
4
|
Chawla S, Kaur A, Yadav N, Sharma S. Unusual case of recurrent intestinal obstruction. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2021. [DOI: 10.4103/mjdrdypu.mjdrdypu_23_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/04/2022] Open
|
5
|
Lim DH, Jung K, Lee SB, Park IK, Cha HJ, Park JH, Kim BG, Jung SW, In Du Jeong, Kim JH, Kim SE, Moon W, In Park M, Park SJ. Non-steroidal anti-inflammatory drug-induced enteropathy as a major risk factor for small bowel bleeding: a retrospective study. BMC Gastroenterol 2020; 20:178. [PMID: 32513198 PMCID: PMC7282042 DOI: 10.1186/s12876-020-01329-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 02/20/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background Small bowel (SB) bleeding accounts for 5% of all gastrointestinal (GI) bleeding cases and 80% of obscure GI bleeding cases. Although angioectasia is the common etiology of SB bleeding, nonsteroidal anti-inflammatory drug (NSAID)-induced SB lesions are also reported as a major cause in studies from Eastern countries. Herein, we assessed the frequency of occurrence of NSAID-induced SB lesions in Korean patients with obscure GI bleeding. Methods We retrospectively analyzed medical records of all consecutive patients aged ≥18 years who underwent capsule endoscopy from March 2018 to February 2019 at Ulsan University Hospital and Kosin University Gospel Hospital. Results Of the 83 subjects (all Korean; mean age ± standard deviation: 59 ± 18 years; age range: 18–84 years; men: n = 52; women: n = 31), 55 (66.2%) had stool with clear blood and 28 (33.8%) had normal stool with iron deficiency anemia. The detection rate of SB bleeding and lesions using capsule endoscopy was 72.3% (60 of 83 patients). A significantly higher frequency (40 of 51) of ulcerative/erosive lesions than other causes was observed in patients with inactive bleeding but visible SB lesions. As a result, NSAID-induced enteropathy accounted for 30.1% of 83 patients with obscure GI bleeding (25 of the all 60 SB bleeding cases). Conclusions Contrary to what is reported for patients in Western countries, this study in Korean patients showed an improved diagnostic yield of capsule endoscopy for obscure GI bleeding and that NSAID-induced enteropathy was the most common etiology of SB bleeding. Aggressive small intestine examination is required for patients with unexplained GI bleeding.
Collapse
Affiliation(s)
- Doo-Ho Lim
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Seung Bum Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea.
| | - In Kyu Park
- Department of General Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Hee Jeong Cha
- Department of Pathology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Jae Ho Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Byung Gyu Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Seok Won Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - In Du Jeong
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| |
Collapse
|
6
|
Bielsa-Fernández M, Tamayo-de la Cuesta J, Lizárraga-López J, Remes-Troche J, Carmona-Sánchez R, Aldana-Ledesma J, Avendaño-Reyes J, Ballesteros-Amozorrutia M, De Ariño M, de Giau-Triulzi L, Flores-Rendón R, Huerta-Guerrero H, González-González J, Hernández-Guerrero A, Murcio-Pérez E, Jáquez-Quintana J, Meixueiro-Daza A, Nogueira-de Rojas J, Rodríguez-Hernández H, Santoyo-Valenzuela R, Solorzano-Olmos S, Uscanga-Domínguez L, Zamarripa-Dorsey F. Consenso mexicano sobre diagnóstico, prevención y tratamiento de la gastropatía y enteropatía por antiinflamatorios no esteroideos. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:190-206. [DOI: 10.1016/j.rgmx.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Academic Contribution Register] [Received: 09/02/2019] [Revised: 10/27/2019] [Accepted: 11/27/2019] [Indexed: 02/07/2023]
|
7
|
Szeto CC, Sugano K, Wang JG, Fujimoto K, Whittle S, Modi GK, Chen CH, Park JB, Tam LS, Vareesangthip K, Tsoi KKF, Chan FKL. Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut 2020; 69:617-629. [PMID: 31937550 DOI: 10.1136/gutjnl-2019-319300] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 07/01/2019] [Revised: 12/06/2019] [Accepted: 12/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications. OBJECTIVE To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs. METHODS Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations. RESULTS Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases. CONCLUSION NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.
Collapse
Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong
| | - Kentaro Sugano
- Jichi Medical University, Shimotsuke, Tochigi, Japan.,Asian Pacific Association of Gastroenterology (APAGE), Tochigi, Japan
| | - Ji-Guang Wang
- Shanghai Institute of Hypertension, Shanghai, Shanghai, China.,Asia Pacific Society of Hypertension (APSH), Shanghai, China
| | - Kazuma Fujimoto
- Saga University, Saga, Japan.,Asia-Pacific Society for Digestive Endoscopy (APSDE), Saga, Japan
| | - Samuel Whittle
- The University of Adelaide, Adelaide, South Australia, Australia.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Gopesh K Modi
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Samarpan Kidney Institute and Research Center, Bhopal, India
| | - Chen-Huen Chen
- National Yang-Ming University, Taipei, Taiwan.,Pulse of Asia (PoA), Taipei, Taiwan
| | - Jeong-Bae Park
- Pulse of Asia (PoA), Taipei, Taiwan.,JB Lab and Clinic and Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Kriengsak Vareesangthip
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Mahidol University, Nakorn Pathom, Thailand
| | | | | |
Collapse
|
8
|
Bielsa-Fernández M, Tamayo-de la Cuesta J, Lizárraga-López J, Remes-Troche J, Carmona-Sánchez R, Aldana-Ledesma J, Avendaño-Reyes J, Ballesteros-Amozorrutia M, De Ariño M, de Giau-Triulzi L, Flores-Rendón R, Huerta-Guerrero H, González-González J, Hernández-Guerrero A, Murcio-Pérez E, Jáquez-Quintana J, Meixueiro-Daza A, Nogueira-de Rojas J, Rodríguez-Hernández H, Santoyo-Valenzuela R, Solorzano-Olmos S, Uscanga-Domínguez L, Zamarripa-Dorsey F. The Mexican consensus on the diagnosis, treatment, and prevention of NSAID-induced gastropathy and enteropathy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020. [DOI: 10.1016/j.rgmxen.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Academic Contribution Register] [Indexed: 12/15/2022]
|
9
|
Statement on Best Practices in the Use of Pathology as a Diagnostic Tool for Celiac Disease: A Guide for Clinicians and Pathologists. Am J Surg Pathol 2019; 42:e44-e58. [PMID: 29923907 DOI: 10.1097/pas.0000000000001107] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 12/14/2022]
Abstract
Small intestinal biopsy interpretation has been the cornerstone for the diagnosis of celiac disease for over 50 years. Despite the existence of sensitive and specific serological tests, duodenal mucosal biopsies continue to be obtained in the vast majority of patients in whom a diagnosis of celiac disease is being considered. The accurate evaluation of these biopsies requires coordination and information sharing between the gastroenterologist, laboratory, and pathologist in order to optimize tissue sampling, preparation and interpretation. This document, a collaboration between the Rodger C. Haggitt Gastrointestinal Pathology Society and the North American Association for the Study of Celiac Disease, is intended to provide clinicians and pathologists with a summary of best practices in the use of endoscopy and biopsy for patients with suspected celiac disease. The authors present a comprehensive and critical appraisal of the literature with respect to the topics of endoscopic findings, best methods for the obtaining biopsies, completing the pathology form and pathologic assessment, including evaluating intraepithelial lymphocytes and villous architecture. A discussion of conditions with overlapping pathologic findings in duodenal mucosal biopsies is presented. In order to provide additional guidance for challenging situations, the authors include an appendix containing practical suggestions. This review may be utilized in interdisciplinary discussions to optimize care for patients with possible celiac disease.
Collapse
|
10
|
Overt Gastrointestinal Bleeding Secondary to Nonsteroidal Anti-Inflammatory Drug-Induced Jejunal Diverticular Ulcer. ACG Case Rep J 2018; 5:e52. [PMID: 30038924 PMCID: PMC6053547 DOI: 10.14309/crj.2018.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 12/01/2017] [Accepted: 05/02/2018] [Indexed: 12/22/2022] Open
|
11
|
Shin SJ, Noh CK, Lim SG, Lee KM, Lee KJ. Non-steroidal anti-inflammatory drug-induced enteropathy. Intest Res 2017; 15:446-455. [PMID: 29142512 PMCID: PMC5683975 DOI: 10.5217/ir.2017.15.4.446] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 02/16/2017] [Revised: 05/05/2017] [Accepted: 05/07/2017] [Indexed: 12/18/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are well known to be associated with serious upper gastrointestinal complications, such as peptic ulcer, bleeding, perforation, and obstruction. Recently, attention has been mainly focused on the small bowel injuries caused by NSAIDs, and new endoscopic techniques such as capsule endoscopy and double balloon endoscopy can help in detecting such injuries. This article reviewed the epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of small bowel injuries caused by NSAIDs. Small bowel injures by NSAIDs might occur with a similar frequency and extent as those observed in the upper gastrointestinal tract. The pathogenesis of NSAID-induced enteropathy is complex and not clearly understood. The various lesions observed in the small bowel, including petechiae, reddened folds, loss of villi, erosions, and ulcers can be detected by capsule endoscopy. A drug that could prevent or treat NSAID-induced enteropathy has not yet been developed. Therefore, further investigations should be performed to elucidate the pathogenesis of such enteropathy and develop suitable preventive and treatment strategies.
Collapse
Affiliation(s)
- Sung Jae Shin
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Choong-Kyun Noh
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
12
|
Toshniwal J, Chawlani R, Thawrani A, Sharma R, Arora A, Kotecha HL, Goyal M, Kirnake V, Jain P, Tyagi P, Bansal N, Sachdeva M, Ranjan P, Kumar M, Sharma P, Singla V, Bansal R, Shah V, Bhalla S, Kumar A. All ileo-cecal ulcers are not Crohn’s: Changing perspectives of symptomatic ileocecal ulcers. World J Gastrointest Endosc 2017; 9:327-333. [PMID: 28744345 PMCID: PMC5507824 DOI: 10.4253/wjge.v9.i7.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 01/27/2017] [Revised: 05/06/2017] [Accepted: 06/07/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigated clinical, endoscopic and histopathological parameters of the patients presenting with ileocecal ulcers on colonoscopy.
METHODS Consecutive symptomatic patients undergoing colonoscopy, and diagnosed to have ulcerations in the ileocecal (I/C) region, were enrolled. Biopsy was obtained and their clinical presentation and outcome were recorded.
RESULTS Out of 1632 colonoscopies, 104 patients had ulcerations in the I/C region and were included in the study. Their median age was 44.5 years and 59% were males. The predominant presentation was lower GI bleed (55, 53%), pain abdomen ± diarrhea (36, 35%), fever (32, 31%), and diarrhea alone (9, 9%). On colonoscopy, terminal ileum was entered in 96 (92%) cases. The distribution of ulcers was as follows: Ileum alone 40% (38/96), cecum alone 33% (32/96), and both ileum plus cecum 27% (26/96). The ulcers were multiple in 98% and in 34% there were additional ulcers elsewhere in colon. Based on clinical presentation and investigations, the etiology of ulcers was classified into infective causes (43%) and non-infective causes (57%). Fourteen patients (13%) were diagnosed to have Crohn’s disease (CD).
CONCLUSION Non-specific ileocecal ulcers are most common ulcers seen in ileo-cecal region. And if all infections are clubbed together then infection is the most common (> 40%) cause of ulcerations of the I/C region. Cecal involvement and fever are important clues to infective cause. On the contrary CD account for only 13% cases as a cause of ileo-cecalulcers. So all symptomatic patients with I/C ulcers on colonoscopy are not Crohn’s.
Collapse
|
13
|
Yamamoto H, Ogata H, Matsumoto T, Ohmiya N, Ohtsuka K, Watanabe K, Yano T, Matsui T, Higuchi K, Nakamura T, Fujimoto K. Clinical Practice Guideline for Enteroscopy. Dig Endosc 2017; 29:519-546. [PMID: 28370422 DOI: 10.1111/den.12883] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 12/11/2022]
Abstract
Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.
Collapse
Affiliation(s)
| | - Haruhiko Ogata
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
| | - Takayuki Matsumoto
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Naoki Ohmiya
- Japan Gastroenterological Endoscopy Society
- Japanese Association for Capsule Endoscopy
| | - Kazuo Ohtsuka
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Kenji Watanabe
- Japanese Society of Gastroenterology
- Japanese Association for Capsule Endoscopy
| | - Tomonori Yano
- Japan Gastroenterological Endoscopy Society
- Japanese Association for Capsule Endoscopy
| | - Toshiyuki Matsui
- Japan Gastroenterological Endoscopy Society
- Japanese Gastroenterological Association
| | - Kazuhide Higuchi
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
| | - Tetsuya Nakamura
- Japan Gastroenterological Endoscopy Society
- Japanese Society of Gastroenterology
| | | |
Collapse
|
14
|
A Curious Case of Intestinal Diaphragm Disease Unmasked by Perforation of a Duodenal Ulcer. Case Rep Med 2017; 2017:5048345. [PMID: 28523070 PMCID: PMC5385904 DOI: 10.1155/2017/5048345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 11/04/2016] [Accepted: 02/19/2017] [Indexed: 12/22/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs are a common cause of intestinal injury. A variety of NSAID-induced injuries may occur including ulcers, erosions, colitis, strictures, and diaphragm disease. Diaphragm disease refers to the development of multiple thin, concentric, stenosing strictures in the intestine. Strictures occur most often in the midintestine and are thought to be pathognomonic of NSAID damage. They can lead to intermittent or complete bowel obstruction. Diagnosis may be elusive as there is nothing specific about NSAID-induced injury at endoscopy and histology is also nonspecific. Even at laparotomy, the diagnosis of diaphragm disease may be missed as the serosa may appear normal and strictures can be difficult to palpate. While most NSAID-induced lesions tend to resolve quickly following withdrawal of the offending drug, diaphragm-like strictures usually require intervention such as stricturoplasty or surgical resection of the involved segment of bowel. Here we report the case of a 60-year-old male patient who presented with iron deficiency anaemia and recurrent subacute bowel obstruction. Following endoscopy and repeated CT scanning of his abdomen, he was diagnosed with Crohn's disease. He was treated with 5-ASAs and immune suppression until a perforated duodenal ulcer resulted in emergency laparotomy and the subsequent discovery of multiple intestinal diaphragms attributable to long-standing NSAID use.
Collapse
|
15
|
Tachecí I, Kopáčová M, Rejchrt S, Bureš J. Non-steroidal Anti-inflammatory Drug Induced Injury to the Small Intestine. ACTA MEDICA (HRADEC KRÁLOVÉ) 2016. [DOI: 10.14712/18059694.2016.56] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Academic Contribution Register] [Indexed: 10/20/2022]
Abstract
Non-steroidal anti-inflammatory drug (NSAIDs) induced enteropathy represents an important complication of one of the most commonly used drugs worldwide. Due to previous diagnostics difficulties the real prevalence of this disease was underestimated for a long time. The pathogenesis of NSAID-enteropathy is more multifactorial and complex than formerly assumed but has still not been fully uncovered. A combination of the local and systemic effect plays an important role in pathogenesis. Thanks to novel enteroscopy methods (wireless capsule endoscopy, double balloon enteroscopy), small bowel lesions are described in a substantial section of NSAID users although most are clinically asymptomatic. The other non-invasive tests (small bowel permeability, faecal calprotectin, scintigraphy using faecal excretion of 111-indium-labelled leukocytes etc.) proposed for diagnostics are not generally used in clinical practice, mainly because of their non-specificity. Despite intensive research into possible treatment, the main measure for patients with NSAID-enteropathy is still withdrawal of NSAIDs. Double balloon enteroscopy plays an important role in the treatment of complications (bleeding, strictures).
Collapse
|
16
|
Singh DP, Borse SP, Nivsarkar M. Clinical importance of nonsteroidal anti-inflammatory drug enteropathy: the relevance of tumor necrosis factor as a promising target. Transl Res 2016; 175:76-91. [PMID: 27083387 DOI: 10.1016/j.trsl.2016.03.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 01/12/2016] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 12/13/2022]
Abstract
The pathogenesis of nonsteroidal anti-inflammatory drug (NSAID) enteropathy is still unclear, and consequently, there is no approved therapeutic strategy for ameliorating such damage. On the other hand, molecular treatment strategies targeting tumor necrosis factor (TNF) exerts beneficial effects on NSAID-induced intestinal lesions in rodents and rheumatoid arthritis patients. Thus, TNF appears to be a potential therapeutic target for both the prevention and treatment of NSAID enteropathy. However, the causative relationship between TNF and NSAID enteropathy is largely unknown. Currently approved anti-TNF agents are highly expensive and exhibit numerous side effects. Hence, in this review, the pivotal role of TNF in NSAID enteropathy has been summarized and plant-derived polyphenols have been suggested as useful alternative anti-TNF agents because of their ability to suppress TNF activated inflammatory pathways both in vitro and in vivo.
Collapse
Affiliation(s)
- Devendra Pratap Singh
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India; Registered Ph.D Scholar (External) at Institute of Pharmacy, NIRMA University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India
| | - Swapnil P Borse
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India; Registered Ph.D Scholar (External) at Institute of Pharmacy, NIRMA University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India
| | - Manish Nivsarkar
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India.
| |
Collapse
|
17
|
Yamawaki H, Mihara H, Suzuki N, Nishizono H, Uchida K, Watanabe S, Tominaga M, Sugiyama T. Role of transient receptor potential vanilloid 4 activation in indomethacin-induced intestinal damage. Am J Physiol Gastrointest Liver Physiol 2014; 307:G33-40. [PMID: 24789205 DOI: 10.1152/ajpgi.00105.2013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 01/31/2023]
Abstract
Gastrointestinal ulcers and bleeding are serious complications of nonsteroidal anti-inflammatory drug (NSAID) use. Although administration of antibiotics and Toll-like receptor 4 knockdown mitigate NSAID-induced enteropathy, the molecular mechanism of these effects is poorly understood. Intestinal hyperpermeability is speculated to trigger the initial damage due to NSAID use. Transient receptor potential vanilloid 4 (TRPV4) is a nonselective cation channel expressed throughout the gastrointestinal tract epithelium that is activated by temperature, extension, and chemicals such as 5,6-epoxyeicosatrienoic acid (5,6-EET). The aim of this study was to investigate the possible role of TRPV4 in NSAID-induced intestinal damage. TRPV4 mRNA and protein expression was confirmed by RT-PCR and immunochemistry, respectively, in mouse and human tissues while TRPV4 channel activity of the intestinal cell line IEC-6 was assessed by Ca(2+)-imaging analysis. TRPV4 activators or the NSAID indomethacin significantly decreased transepithelial resistance (TER) in IEC-6 cells, and indomethacin-induced TER decreases were inhibited by specific TRPV4 inhibitors or small-interfering RNA TRPV4 knockdown, as well as by the epoxygenase inhibitor N-(methylsulfonyl)-2-(2-propynyloxy)-benzenehexanamide, which decreased 5,6-EET levels. In TRPV4 knockout mice, indomethacin-induced intestinal damage was significantly reduced compared with WT mice. Taken together, these results show that TRPV4 activation in the intestinal epithelium caused epithelial hyperpermeability in response to NSAID-induced arachidonic acid metabolites and contributed to NSAID-induced intestinal damage. Thus, TRPV4 could be a promising new therapeutic target for the prevention of NSAID-induced intestinal damage.
Collapse
Affiliation(s)
- Hidemoto Yamawaki
- Department of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Hiroshi Mihara
- Department of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Nobuhiro Suzuki
- Department of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Hirofumi Nishizono
- Division of Animal Experimental Laboratory, Life Science Research Center, University of Toyama, Toyama, Japan
| | - Kunitoshi Uchida
- Division of Cell Signaling, Okazaki Institute for Integrative Bioscience (National Institute for Physiological Sciences), National Institutes of Natural Sciences, Okazaki, Japan; and
| | - Shiro Watanabe
- Division of Nutritional Biochemistry, Institute of Natural Medicines, University of Toyama, Japan
| | - Makoto Tominaga
- Division of Cell Signaling, Okazaki Institute for Integrative Bioscience (National Institute for Physiological Sciences), National Institutes of Natural Sciences, Okazaki, Japan; and
| | - Toshiro Sugiyama
- Department of Gastroenterology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan;
| |
Collapse
|
18
|
Maehata Y, Esaki M, Morishita T, Kochi S, Endo S, Shikata K, Kobayashi H, Matsumoto T. Small bowel injury induced by selective cyclooxygenase-2 inhibitors: a prospective, double-blind, randomized clinical trial comparing celecoxib and meloxicam. J Gastroenterol 2012; 47:387-93. [PMID: 22170412 DOI: 10.1007/s00535-011-0501-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 08/10/2011] [Accepted: 10/24/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Selective cyclooxygenase (COX)-2 inhibitors are less harmful to the small bowel mucosa than non-selective anti-inflammatory drugs. We aimed to compare the severity of small bowel mucosal injury in healthy volunteers induced by two selective COX-2 inhibitors, celecoxib and meloxicam, in a randomized, double-blind trial, using capsule endoscopy (CE). METHODS Twenty-nine healthy subjects were randomized to take either celecoxib (200 mg twice daily) or meloxicam (10 mg once daily) for 2 weeks. The incidence and the number of small bowel mucosal injuries (bleeding, ulcers, and erosions) observed by CE were compared between the two groups. RESULTS The overall incidence of small bowel mucosal injury was not different between the celecoxib group (6 of 14 subjects, 42.9%) and the meloxicam group (4 of 15 subjects, 26.7%, P = 0.45). In subjects with positive CE findings, the number of ulcers was greater in the meloxicam group than in the celecoxib group (P = 0.02), while such a trend was not found with regard to erosions (P = 0.52). The distribution of mucosal lesions within the small bowel was similar in the two groups. CONCLUSIONS Selective COX-2 inhibitors are not completely safe for the small bowel. The mucosal lesions may be less severe with celecoxib than with meloxicam.
Collapse
Affiliation(s)
- Yuji Maehata
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Kochhar GS, Sanaka MR, Vargo JJ. Therapeutic management options for patients with obscure gastrointestinal bleeding. Therap Adv Gastroenterol 2012; 5:71-81. [PMID: 22282709 PMCID: PMC3263978 DOI: 10.1177/1756283x11409280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 02/04/2023] Open
Abstract
Obscure gastrointestinal bleeding (OGIB) is one of the most challenging disorders faced by gastroenterologists because of its evasive nature and difficulty in identifying the exact source of bleeding. Recent technological advances such as video capsule endoscopy and small bowel deep enteroscopy have revolutionized the diagnosis and management of patients with OGIB. In this paper, we review the various diagnostic and therapeutic options available for the management of patients with OGIB.
Collapse
Affiliation(s)
- Gursimran S. Kochhar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - John J. Vargo
- Department of Gastroenterology and Hepatology Digestive Disease Institute Cleveland Clinic 9500 Euclid Avenue, Desk A-30 Cleveland, OH, USA
| |
Collapse
|
20
|
Park SC, Chun HJ, Kang CD, Sul D. Prevention and management of non-steroidal anti-inflammatory drugs-induced small intestinal injury. World J Gastroenterol 2011; 17:4647-53. [PMID: 22180706 PMCID: PMC3237301 DOI: 10.3748/wjg.v17.i42.4647] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 03/15/2011] [Revised: 04/21/2011] [Accepted: 04/28/2011] [Indexed: 02/06/2023] Open
Abstract
Non-steroidal anti-inflammatory drug (NSAID)-induced small bowel injury is a topic that deserves attention since the advent of capsule endoscopy and balloon enteroscopy. NSAID enteropathy is common and is mostly asymptomatic. However, massive bleeding, stricture, or perforation may occur. The pathogenesis of small intestine injury by NSAIDs is complex and different from that of the upper gastrointestinal tract. No drug has yet been developed that can completely prevent or treat NSAID enteropathy. Therefore, a long-term randomized study in chronic NSAID users is needed.
Collapse
|
21
|
Double-contrast barium enteroclysis as a patency tool for nonsteroidal anti-inflammatory drug-induced enteropathy. Dig Dis Sci 2011; 56:3247-53. [PMID: 21567189 DOI: 10.1007/s10620-011-1742-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 03/30/2011] [Accepted: 04/26/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evaluating small bowel patency is recommended for capsule endoscopy in patients suspected of nonsteroidal anti-inflammatory drug-induced (NSAID) enteropathy. AIMS The aim of this investigation was to examine whether radiography is a candidate of patency tool in NSAID enteropathy. METHODS We reviewed double-contrast barium enteroclysis in 21 patients with NSAID enteropathy diagnosed either by capsule endoscopy or balloon-assisted endoscopy. The endoscopic findings were classified into circular ulcers, linear ulcers and small mucosal defects. The radiographic signs of the corresponding endoscopic findings were retrieved and the depiction rate was calculated. RESULTS Of the 21 patients, endoscopy detected circular ulcers, linear ulcers, and small ulcers in 12, 3 and 12 patients, respectively. Small bowel radiography depicted circular narrowing as pseudo-folds in 10 patients (83%) and linear ulcers as eccentric rigidity in 2 patients (67%). However, radiography was able to depict small mucosal defects in only 3 patients (17%). Two of 5 patients with pseudo-folds experienced retention of the capsule. CONCLUSION "Pseudo-folds" is a sign corresponding to circular ulcer in NSAID enteropathy, which may be predictive of capsule retention.
Collapse
|
22
|
Sunada K, Yamamoto H, Yano T, Sugano K. Advances in the diagnosis and treatment of small bowel lesions with Crohn's disease using double-balloon endoscopy. Therap Adv Gastroenterol 2011; 2:357-66. [PMID: 21180582 DOI: 10.1177/1756283x09343542] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 12/14/2022] Open
Abstract
With the recent development of double-balloon endoscopy (DBE) and capsule endoscopy (CE), it has become possible to observe the entire small bowel endoscopically. DBE enables us to make detailed observations and at the same time takes biopsy samples. Single-balloon endoscopy (SBE), which has a balloon only at the tip of the overtube, has also been introduced. Since DBE and SBE are similar in the concept of insertion method, a general term 'balloon-assisted endoscopy' (BAE) is used when referring to these methods. Characteristic small bowel lesions observed with BAE in Crohn's disease are aphthoid ulcers, round ulcers, irregular ulcers and longitudinal ulcers. These ulcers tend to be located on the mesenteric side of the small bowel. Since BAE can determine the location (mesenteric or antimesenteric side) of the ulceration, it is useful in distinguishing Crohn's disease from other diseases that have ulcers in the small bowel. Strictures are a major clinical problem in the course of Crohn's disease. Traditionally, surgery was the main choice for small bowel strictures. In some cases, strictures located in distal ileum or proximal jejunum have been dilated using standard enteroscopes. DBE now enables balloon dilatation to be performed endoscopically even in the deep small bowel.
Collapse
Affiliation(s)
- Keijiro Sunada
- Department of Internal Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | | | | | | |
Collapse
|
23
|
Hirata Y, Kataoka H, Shimura T, Mizushima T, Mizoshita T, Tanida S, Kamiya T, Joh T. Incidence of gastrointestinal bleeding in patients with cardiovascular disease: buffered aspirin versus enteric-coated aspirin. Scand J Gastroenterol 2011; 46:803-9. [PMID: 21501103 DOI: 10.3109/00365521.2011.568522] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Aspirin-induced enteropathy is increasing, but whether the type of aspirin affects the gastrointestinal (GI) bleeding, especially small intestine, is unclear. The incidence of GI bleeding for buffered aspirin and enteric-coated aspirin was evaluated in patients receiving long-term low-dose aspirin (LDA) for cardiovascular (CV) diseases. METHODS This retrospective cohort study assessed overt GI bleeding, decreased hemoglobin levels suspecting small bowel blood loss, and CV death in patients taking LDA for more than 1 year (LDA group) and in patients not taking LDA (control group). The LDA group was divided into two subgroups, patients taking either buffered aspirin (buffered subgroup) or enteric-coated aspirin (enteric subgroup), and their outcomes were compared. RESULTS A total of 1402 patients (LDA group 701, control group 701; median follow-up duration 1778 ± 747 days) were assessed. The incidences of overt GI bleeding and decreased hemoglobin were 3.9% and 1.4% in LDA group, respectively, significantly higher than the control group (p < 0.01; p < 0.01). In the LDA group, 3% died during the follow-up period. Ten (3.7%) in the buffered subgroup (n = 267) and 17 (3.9%) in the enteric subgroup (n = 434) developed GI bleeding (p = 0.92). One (0.3%) in the buffered subgroup and nine (2%) in the enteric subgroup developed decreased hemoglobin (p = 0.06, log-rank test). CONCLUSIONS The type of aspirin does not affect the incidence of overt GI bleeding and decreased hemoglobin, but enteric-coated aspirin may be associated with an increased incidence of decreased hemoglobin.
Collapse
Affiliation(s)
- Yoshikazu Hirata
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Patel P, Tobi M. Dieulafoy-like lesion bleeding: in the loop. Gastroenterol Hepatol (N Y) 2011; 7:271-274. [PMID: 21857828 PMCID: PMC3127032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 05/31/2023]
Affiliation(s)
- Pragnesh Patel
- Geriatrics Division, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | - Martin Tobi
- Section of Gastroenterology, Philadelphia VA Medical Center and Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
25
|
Abstract
The effects of drugs on the gastrointestinal tract are diverse and depend on numerous factors. Diagnosis is centered on histologic findings, with mostly nonspecific patterns of injury that must be interpreted in the correct clinical context. Nonsteroidal antiinflammatory drugs are a common cause of drug-induced gastrointestinal injury, with effects primarily in the gastric mucosa but also throughout the gastrointestinal tract. Another common class of drugs causing a variety of pathologic findings in the gut is chemotherapeutic agents. This article discusses the differential diagnosis of the various patterns of injury, including ischemic damage, and the histologic findings specific for certain drugs.
Collapse
Affiliation(s)
- Ilyssa O Gordon
- Department of Pathology, University of Chicago Medical Center, 5841 South Maryland Avenue, MC 6101, Chicago, IL 60637, USA
| | - Vani Konda
- Section of Gastroenterology, Department of Medicine, University of Chicago Medical Center, 5841 South Maryland Avenue, MC 4076, Chicago, IL 60637, USA
| | - Amy E Noffsinger
- Department of Pathology, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0529, USA.
| |
Collapse
|
26
|
Abstract
Occult gastrointestinal bleeding, defined as bleeding that is unknown to the patient, is the most common form of gastrointestinal bleeding and can be caused by virtually any lesion in the gastrointestinal tract. Patients with occult gastrointestinal bleeding include those with fecal occult blood and iron-deficiency anemia (IDA). In men and postmenopausal women, IDA should be considered to be the result of gastrointestinal bleeding until proven otherwise. Indeed, the possibility of gastrointestinal tract malignancy in these patients means that gastrointestinal evaluation is nearly always indicated. Obscure gastrointestinal bleeding is defined as obvious bleeding from a difficult to identify source and is always recurrent. This form of bleeding accounts for approximately 5% of all cases of clinically evident gastrointestinal bleeding and is most commonly caused by bleeding from the small intestine. Capsule endoscopy and deep enteroscopy have had a major impact on the way that patients with occult and, in particular, obscure bleeding are managed. In this Review the causes, diagnostic evaluation and treatment of occult and obscure gastrointestinal bleeding are discussed.
Collapse
|
27
|
Abstract
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for analgesic, anti-inflammatory and, in the case of aspirin, for anti-thrombotic actions. The serious gastrointestinal side-effects associated with these drugs are of concern and pose a significant obstacle to their use. This review discusses the pathogenic mechanisms by which the conventional acidic NSAIDs induce gastrointestinal toxicity, with particular emphasis on non-prostaglandin effects. Methods of assessment of NSAID-induced enteropathy are reviewed, with particular emphasis on the use of functional measurement of NSAID-induced changes in the gastrointestinal tract. The advances in our knowledge of the pathogenesis of these effects have resulted in the development of a range of novel NSAIDs. Where functional assessment of the effects of NSAIDs has been employed, it appears to be more useful as an indicator of early-stage changes rather than a predictor of the effects of long-term NSAID exposure. Successful pharmaceutical strategies now offer considerable promise for reducing the severity of NSAID damage to the gastrointestinal tract. The utility of intestinal permeability measurements for selection and assessment of these strategies is discussed.
Collapse
Affiliation(s)
- Majella E Lane
- Department of Pharmaceutics, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Mi-Jeong Kim
- Gastrointestinal, Pulmonary and Metabolic Drug Division, Department of Drug Evaluation, Korea Food and Drug Administration, 5 Nokbun-dong, Eunpyung-Ku, Seoul 122-704, South Korea
| |
Collapse
|
28
|
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are well known to cause gastroduodenal mucosal lesions as an adverse effect. Recently, the serious problem of NSAID-induced small intestinal damage has become a topic of great interest to gastroenterologists, since capsule endoscopy and balloon enteroscopy are available for the detection of small intestinal lesions. Such lesions have been of great concern in clinical settings, and their treatment and prevention must be devised as soon as possible. The prevalence of NSAIDs-induced small intestinal injury is higher than had been expected. Recent studies show that more than 50% of patients taking NSAIDs have some mucosal damage in the small intestine. The gross appearance of NSAID-induced enteropathy varies, appearing variously as diaphragm-like strictures, ulcers, erosions, and mucosal redness. To investigate NSAID-induced enteropathy, and to rule out other specific enteropathies, other useful methods (in addition to capsule endoscopy and balloon enteroscopy) include such modalities as radiological examination of the small intestine, the permeability test, scintigraphy or the fecal excretion test using (111)Indium-labeled white blood cells, and measurement of the fecal calprotectin concentration. Diaphragm-like strictures and bleeding from mucosal breaks may be treatable with interventional enteroscopy. Misoprostol, metronidazole, and sulfasalazine are frequently used to treat NSAID-induced enteropathy, but have undesirable effects in some cases. In the experimental model, we confirmed that several existing drugs for gastroduodenal ulcers prevented indomethacin-induced small intestinal injury. Such drugs may be useful for preventing the adverse effects of NSAIDs not only in the stomach but also in the small intestine. We hope to examine these drugs in future clinical studies.
Collapse
|
29
|
Abstract
Subclinical gut inflammation has been described in up to two-thirds of patients with spondyloarthropathies (SpA). Arthritis represents an extra-intestinal manifestation of several gastrointestinal diseases, including inflammatory bowel disease (IBD), Whipple’s disease, Behcet’s disease, celiac disease, intestinal bypass surgery, parasitic infections of the gut and pseudomembranous colitis. Moreover about two-thirds of nonsteroidal anti-inflammatory drug users demonstrate intestinal inflammation. Arthritis may manifest as a peripheral or axial arthritis. The spondyloarthropathy family consists of the following entities: ankylosing spondylitis, undifferentiated spondyloarthritis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with IBD, juvenile onset spondyloarthritis. This topic reviews the major gastrointestinal manifestations that can occur in patients with SpA and in nonsteroidal anti-inflammatory drugs users.
Collapse
|
30
|
Hayashi Y, Yamamoto H, Taguchi H, Sunada K, Miyata T, Yano T, Arashiro M, Sugano K. Nonsteroidal anti-inflammatory drug-induced small-bowel lesions identified by double-balloon endoscopy: endoscopic features of the lesions and endoscopic treatments for diaphragm disease. J Gastroenterol 2009; 44 Suppl 19:57-63. [PMID: 19148795 DOI: 10.1007/s00535-008-2277-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 06/12/2008] [Accepted: 08/12/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) occasionally induce small-bowel injury. However, the clinical features have only been partially clarified. The aim of this study was to clarify the clinical features of the disease and evaluate the effectiveness of endoscopic balloon dilation therapy for diaphragm disease, using double-balloon endoscopy (DBE). METHODS This is a retrospective case study using our DBE database. Our inclusion criteria required patients to meet all the following criteria: (1) history of NSAID use; (2) endoscopic findings of erosion and/or ulcer and/or typical diaphragm-like strictures; (3) improvement in clinical findings (signs and symptoms) and/or endoscopic findings by cessation of NSAIDs, except for diaphragm disease; and (4) exclusion of other causes (e.g., malignant tumor, inflammatory bowel disease, and infectious disease). The clinical records of patients were investigated. RESULTS Eighteen patients were included. Sixteen patients showed ulcerative lesions, and the remaining 2 patients showed diaphragm diseases. For localized lesions, 12 patients evidenced lesions in the ileum, 5 patients had lesions in the duodenum and/or jejunum, and 1 had lesions in both intestines. The ulcerative lesions were multiple with various morphologies that were located unrelated to mesenteric or antimesenteric sides. The endoscopic balloon dilations were performed safely, and all patients improved with regard to their symptoms. CONCLUSIONS Symptomatic NSAID-induced small-bowel injuries exhibit a variety of patterns of ulcerative lesions as observed in the ileum in many cases. The endoscopic balloon dilation appears to be a safe and effective treatment for diaphragm disease.
Collapse
Affiliation(s)
- Yoshikazu Hayashi
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, 329-0498, Japan
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Adler DH, Phillips JA, Cogan JD, Iverson TM, Stein JA, Brenner DA, Morrow JD, Boutaud O, Oates JA, Boutaud O, Oates JA. The enteropathy of prostaglandin deficiency. J Gastroenterol 2009; 44 Suppl 19:1-7. [PMID: 19148786 PMCID: PMC2799331 DOI: 10.1007/s00535-008-2253-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 06/28/2008] [Accepted: 07/07/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Small intestinal ulcers are frequent complications of therapy with nonsteroidal anti-inflammatory drugs (NSAIDs). We present here a genetic deficiency of eicosanoid biosynthesis that illuminates the mechanism of NSAID-induced ulcers of the small intestine. METHODS Eicosanoids and metabolites were measured by isotope dilution with mass spectrometry. cDNA was obtained by reverse transcription and sequenced following amplification with RT-PCR. RESULTS We investigated the cause of chronic recurrent small intestinal ulcers, small bowel perforations, and gastrointestinal blood loss in a 45-year-old man who was not taking any cyclooxygenase inhibitor. Prostaglandin metabolites in urine were significantly depressed. Serum thromboxane B2 (TxB2) production was 4.6% of normal controls (P<0.006), and serum 12-HETE was 1.3% of controls (P<0.005). Optical platelet aggregation with simultaneous monitoring of ATP release demonstrated absent granule secretion in response to ADP and a blunted aggregation response to ADP and collagen, but normal response to arachidonic acid (AA). LTB4 biosynthesis by ionophore-activated leukocytes was only 3% of controls, and urinary LTE4 was undetectable. These findings suggested deficient AA release from membrane phospholipids by cytosolic phospholipase A2-alpha (cPLA2-alpha), which regulates cyclooxygenase- and lipoxygenase-mediated eicosanoid production by catalyzing the release of their substrate, AA. Sequencing of cPLA2-alpha cDNA demonstrated two heterozygous nonsynonymous single-base-pair mutations: Ser111Pro (S111P) and Arg485His (R485H), as well as a known single nucleotide polymorphism (SNP), Lys651Arg (K651R). CONCLUSIONS Characterization of this cPLA2-alpha deficiency provides support for the importance of prostaglandins in protecting small intestinal integrity and indicates that loss of prostaglandin biosynthesis is sufficient to produce small intestinal ulcers.
Collapse
Affiliation(s)
- David H. Adler
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University. 536 RRB, Vanderbilt Medical Center, Nashville, Tennessee 37232, USA, Phone: (615) 343-4847, Fax: (615) 322-5303,
| | - John A. Phillips
- Department of Pediatrics, Division of Medical Genetics, DD 2205 MCN, Vanderbilt Medical Center, Nashville, Tennessee 37232, USA, Phone: (615) 322-7601, Fax: (615) 343-9951,
| | - Joy D. Cogan
- Department of Pediatrics, Division of Medical Genetics, DD 2205 MCN, Vanderbilt Medical Center, Nashville, Tennessee 37232, USA, Phone: (615) 322-7601, Fax: (615) 343-9951,
| | - Tina M. Iverson
- Department of Pharmacology, Vanderbilt University, 461 PRB, Vanderbilt Medical Center, Nashville, Tennessee 37232, USA, Phone: (615) 322-7817, Fax: (615) 343-6532,
| | - Jeffrey A. Stein
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University, Irving Pavillion, Rm 521, 161 Fort Washington Ave, New York, New York 10032, USA, Phone: (212) 305-5444, Fax: (212) 305-3542,
| | - David A. Brenner
- University of California, San Diego, Room 1318A, Biomedical Sciences Building, School of Medicine, 9500 Gilman Drive, La Jolla, California 92093, Phone: (858) 534-1501, Fax: (858) 822-0084,
| | - Jason D. Morrow
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University. 536 RRB, Vanderbilt Medical Center, Nashville, Tennessee 37232, USA, Phone: (615) 322-4785, Fax: (615)343-9659,
| | - Olivier Boutaud
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University. 536 RRB, Vanderbilt Medical Center, Nashville, Tennessee 37232, USA, Phone: (615) 343-7398, Fax: (615) 322-5303,
| | - John A. Oates
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University. 536 RRB, Vanderbilt Medical Center, Nashville, Tennessee 37232, USA, Phone: (615) 343-4847, Fax: (615) 322-5303,
| | | | | |
Collapse
|
32
|
ROBERT MARIEE. Inflammatory Disorders of the Small Intestine. SURGICAL PATHOLOGY OF THE GI TRACT, LIVER, BILIARY TRACT, AND PANCREAS 2009:321-354. [DOI: 10.1016/b978-141604059-0.50016-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Academic Contribution Register] [Indexed: 01/03/2025]
|
33
|
|
34
|
Matsumoto T, Kudo T, Esaki M, Yano T, Yamamoto H, Sakamoto C, Goto H, Nakase H, Tanaka S, Matsui T, Sugano K, Iida M. Prevalence of non-steroidal anti-inflammatory drug-induced enteropathy determined by double-balloon endoscopy: a Japanese multicenter study. Scand J Gastroenterol 2008; 43:490-6. [PMID: 18365915 DOI: 10.1080/00365520701794121] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Capsule endoscopy has shown that non-steroidal anti-inflammatory drugs (NSAIDs) can damage the small intestine. The aim of this study was to determine the prevalence of NSAIDs enteropathy in subjects indicated for double-balloon endoscopy (DBE). MATERIAL AND METHODS The Japanese Study Group for Double-Balloon Endoscopy (JSG-DBE) established a database for the practical use of DBE in the Japanese population during a 2-year period from 2004 to 2005. Using this database, we identified subjects who had been taking NSAIDs within a month prior to DBE (NSAIDs group) and those free from NSAIDs use (control group). The clinical background and DBE findings were compared between the two groups. RESULTS Among 1035 patients registered in the JSG-DBE database, 61 subjects were classified as the NSAIDs group and 600 served as the control group. Patients in the NSAIDs group were older (62+/-18 versus 51+/-19 years, p<0.0001) and gastrointestinal bleeding was a more frequent indication for DBE (79% versus 44%, p<0.001) compared with in the control group. Non-specific mucosal breaks were detected by DBE in 31 patients in the NSAIDs group (51%) and 29 patients in the control group (5%, p <0.0001). Aspirin was less frequently prescribed and cardiovascular disease was a less frequent indication for NSAIDs use in patients with mucosal breaks than in those without breaks. CONCLUSIONS In the cases indicated for enteroscopy, NSAIDs enteropathy occurred in half of the patients taking NSAIDs. Aspirin seems to be less harmful to the small intestine than other NSAIDs.
Collapse
Affiliation(s)
- Takayuki Matsumoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Matsumoto T, Iida M, Matsui T, Yao T. Chronic nonspecific multiple ulcers of the small intestine: a proposal of the entity from Japanese gastroenterologists to Western enteroscopists. Gastrointest Endosc 2007; 66:S99-107. [PMID: 17709045 DOI: 10.1016/j.gie.2007.01.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 12/05/2006] [Accepted: 01/04/2007] [Indexed: 02/08/2023]
Affiliation(s)
- Takayuki Matsumoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | | | | |
Collapse
|
36
|
Sunada K, Yamamoto H, Hayashi Y, Sugano K. Clinical importance of the location of lesions with regard to mesenteric or antimesenteric side of the small intestine. Gastrointest Endosc 2007; 66:S34-8. [PMID: 17709028 DOI: 10.1016/j.gie.2007.02.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 01/22/2007] [Accepted: 02/17/2007] [Indexed: 02/08/2023]
Affiliation(s)
- Keijiro Sunada
- Division of Gastroenterology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | | | | | | |
Collapse
|
37
|
|
38
|
Shih SC, Chang CW. Nonsteroidal Anti-inflammatory Drug-related Gastrointestinal Bleeding in the Elderly. INT J GERONTOL 2007. [DOI: 10.1016/s1873-9598(08)70022-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 11/30/2022] Open
|
39
|
Abstract
PURPOSE OF REVIEW The small intestine may be a more common site for nonsteroidal antiinflammatory drug toxicity than the gastroduodenal mucosa. Two-thirds of regular nonsteroidal antiinflammatory drug users develop subclinical small bowel enteropathy. This review highlights this emerging issue in patients requiring antiinflammatory drugs. RECENT FINDINGS Nonsteroidal antiinflammatory drug enteropathy is a stepwise process involving direct mucosal toxicity, mitochondrial damage, breakdown of intercellular integrity, enterohepatic recirculation and neutrophil activation by luminal contents including bacteria. Unlike upper gastrointestinal toxicity, cyclooxygenase-mediated mechanisms are probably less important. Newer imaging modalities such as capsule endoscopy studies demonstrate nonsteroidal antiinflammatory drug-induced small bowel erosions, but the clinical implications are unclear. SUMMARY Nonsteroidal antiinflammatory drug toxicity to the small intestine is common. Useful research tools have been developed to indirectly measure intestinal inflammation and permeability, but these are not generally available to the clinician, although enteroscopy and capsule endoscopy can be illuminating. Anaemia or hypoalbuminaemia are useful indications of nonsteroidal antiinflammatory drug enteropathy. Cessation of the drug would be the preferred option, alternatively there are experimental data to support the use of sulphasalazine and metronidazole. Animal models are unravelling new mechanisms for mucosal toxicity beyond the cyclooxygenase model, including mucosal oxidative injury and nitric oxide mediated pathways.
Collapse
Affiliation(s)
- Paul J Fortun
- University of Nottingham, Queens Medical Centre, Nottingham, UK.
| | | |
Collapse
|
40
|
Abstract
Pain is a leading cause of morbidity worldwide, with published data showing its prevalence as high as 50% for chronic pain in the European population. This prevalence is likely to continue to rise, particularly in elderly people with comorbid conditions and complex aetiologies of pain. There is thus a rapidly growing demand for safe and effective pain management. Management of mild-to-moderate pain has traditionally been based upon the use of non-steroidal anti-inflammatory drugs (NSAIDs) and the synthetic non-opioid analgesic paracetamol (acetaminophen), the latter of which acts centrally, inhibiting brain cyclo-oxygenase (COX) and nitric oxide synthase. Both the NSAIDs and paracetamol are effective for mild-to-moderate pain and are widely recommended and used. However, NSAIDs may not be tolerated due to gastrointestinal (GI) symptoms and can result in potentially fatal peptic ulceration and bleeding. Selective COX-2 inhibitors were developed to reduce the GI side effects and complications, but large-scale studies have highlighted another serious potential effect of anti-inflammatory drugs: cardiovascular events. Both the European Medicines Agency (EMEA) and the Food and Drugs Administration (FDA) in the US have issued advice to apply cautions and restrictions when prescribing COX-2 inhibitors, particularly for patients at increased cardiovascular risk and for long-term use. The FDA also applied cardiovascular warnings with regard to nonselective NSAIDs. Both the EMEA and the FDA have recommended using the lowest effective dose for the shortest duration. These concerns and warnings have left physicians seeking safe alternatives to anti-inflammatory drugs for both short- and long-term uses in many patients. These developments have generated a climate of uncertainty in the absence of official guidance on the selection of alternative analgesic regimens. Amongst the possible strategies, combinations of drugs that provide analgesic efficacy at reduced individual doses may confer the optimal risk-benefit ratio for pain management in the long term or in patients at increased cardiovascular risk. Weak opioids devoid of serious organ-damaging effects combined with paracetamol may well be safer for long-term therapy. Fixed-dose combinations of paracetamol with weak opioids, such as codeine, dextropropoxyphene or tramadol are currently available. Paracetamol plus tramadol is an effective and safe multimodal analgesic regimen for the management of both acute and chronic moderate-to-severe pain. Re-evaluating the role of weak opioids, such as tramadol, and combinations in pain management may prove a valuable option for prescribers seeking alternatives to anti-inflammatory drugs.
Collapse
Affiliation(s)
- Richard M Langford
- Anaesthetics Laboratory, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
| |
Collapse
|