Indian J Gastroenterol DOI 10.1007/s12664-014-0531-6

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Small bowel diaphragm disease Arulprakash Sarangapani & Arun Thangaraj & V. Baskaran & Vikas D. Kohli & George M. Chandy

# Indian Society of Gastroenterology 2015

Small bowel diaphragm disease (DD) is a relatively rare clinical entity described first in 1988 by Lang et al. [1], characterized by short length circumferential lesions involving

predominantly small intestine resulting in multiple stenosis of the lumen. The most common cause is believed to be the use of nonsteroid antiinflammatory drugs (NSAIDs) [2]. Inhibi-

A. Sarangapani (*) : A. Thangaraj : V. Baskaran : V. D. Kohli : G. M. Chandy MIOT Advanced Center for Gastrointestinal and Liver Diseases, MIOT International, 4/112, Mount Poonamalle Road, Manapakkam, Chennai 600 089, India e-mail: [email protected]

tion of cyclooxygenase-1 causing reduction in villous microcirculation combines with inhibitory action on the cellular oxidative processes of the epithelial cells to induce increased mucosal permeability which allows luminal aggressors

Indian J Gastroenterol

(enteral bacteria, their products, and bile) to gain access to the mucosa and cause inflammation with expression of inducible nitric oxide synthase. Reactive oxygen species from neutrophils and injured endothelial cells add to the damage. Clinical presentations vary from vague intermittent abdominal discomfort to frank small intestinal obstruction, chronic iron deficiency anemia to gastrointestinal bleed. Diagnosis of DD is complicated, not only by the ambiguity of the symptoms, but also by the fact that most investigations are inconclusive. Radiographic studies with contrast media are notoriously inaccurate for the diagnosis of DD. They either do not show the diaphragms or show them so indistinctly that they are misinterpreted as exaggerated plicae circulares. Newer modalities like enteroscopy and capsule endoscopy aid the diagnosis. The typical histology is focal chronic injury of

mucosa with inflammatory infiltrate, neurovascular/muscular hamartoma-like changes, and submucosal fibrosis. Treatment is by surgical resection or stricturoplasty/balloon dilatation, based on the involved portion of intestine and discontinuation of offending NSAIDs. Lang et al. have reported a symptom recurrence rate as high as 50 % after resection for DD [1].

References 1. Lang J, Price AB, Levi AJ, Burke M, Gumpel JM, Bjarnason I. Diaphragm disease: pathology of disease of the small intestine induced by non-steroidal anti-inflammatory drugs. J Clin Pathol. 1988;41:516–6. 2. Whittle BJR. Mechanisms underlying intestinal injury induced by antiinflammatory COX inhibitors. Eur J Pharmacol. 2004;500:427–39.

Small bowel diaphragm disease.

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