Selected Articles from the Journal Abdominal Surgery
Subacute Small Bowel Obstruction due to Ileal Diaphragm Disease – Case Report and Literature Review
Shankar Raman, M.D., M.S., MRCS
John M. Cosgrove, M.D., FACS
Pradeep S. Basnyat, FRCS*
From the Departments of Surgery at Bronx-Lebanon
Physical examination and imaging studies do not add usually significant data to the diagnosis, but patients deteriorating condition requires exploratory laparotomy. Even intraoperatively, a thorough examination of the intestines is necessary to find the lesion. Limited resection followed by discontinuation of NSAIDs is curative. We present a case of DD in a 78-year old male who became symptomatic after the discontinuation of NSAID and discuss the management of the disease.
Physical examination revealed visible intestinal peristalsis and borborygmi in an emaciated virgin abdomen. No masses were palpable. A CT scan demonstrated dilated small bowel loops without a definitive transition zone. A colonoscopy performed up to the cecum was unremarkable. Upper gastrointestinal endoscopy showed erythematous gastric mucosa and was negative for Helicobacter pylori. Among the radiographic studies, a small bowel series revealed dilated bowels, but no definite point of obstruction. The patients’ hemoglobin level was 10 g/dl; his hematocrit level was 31% and his albumin level was 3.1 g/dl. The rest of the laboratory values, including tumor markers were unremarkable.
The patient’s deteriorating condition prompted a laparotomy at which the jejunum and a proximal ileum were found to be dilated. A narrowing with stricture formation was noted at about 4 cm of the mid ileum, but there was no palpable mass. A 10 cm segment of ileum was resected and a primary anastomosis was done. The narrowed segment of resected ileum had a diaphragm-like stricture (FIG 1). Histopathologic examination showed a circumferential mucosal ulceration with sub mucosal fibrosis around the stricture. No granulomas were seen. The gross and microscopic appearance of the resected segment was consistent with the classical picture of NSAIDs inducted stricture. At two-year follow-up, the patient appeared to be cured.
The diagnosis of DD is complicated, not only by the ambiguity of the symptoms, but also by the fact that most complete investigations are inconclusive. At times, the diaphragms can appear as exaggerated plica ciculares and they are not seen or interpreted properly on imaging studies10. Recently, Yousufi et al11 pointed out that capsule endoscopy can diagnose this disorder. However, this procedure carries the risk of the capsule becoming incarcerated into the diaphragm thus, necessitating immediate surgery. The definitive diagnosis is usually made intra operatively, after an exhaustive work-up has failed to diagnose the condition. Even at laparotomy, the bland serosal appearance of bowel makes it difficult for surgeons to identify the diseased segment of the intestine. For the same reason, laparoscopy has a limited role12.Meticulous palpation of the entire length of the bowels and intraoperative enteroscopy are helpful means of locating the affected segment of the intestine. However, the risks associated with intraoperative enteroscopy include enterotomies, small bowel inflation and mesenteric tears12. Occasionally, strictures can be visible externally, as in our case. Once found, the diaphragms can be managed by limited resection of strictureplasty. As in Crohn’s disease, strictureplasty is useful in setting of multiple strictures or when the small bowel length needs to be optimized. The exact mechanism of DD has not been elucidated thus far.
Microscopically, diaphragm disease is characterized by the presence of sub mucosal fibrosis and the granulomas differentiate this subset of intestinal strictures from Crohn’s disease and tuberculosis. In DD, a disorganized arrangement of neural, vascular and smooth muscle elements resembling hamartoma can be present1. Although the surgical treatment of DD is potentially curative, Lang, et al reported symptoms recurrence rate of 50%1.
Awareness and a high index of suspicion are necessary
when ambiguous obstructive symptoms occur in a patient
taking, or previously on NSAIDs.
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9. Bjarnason I. Zanelli G, Smith T, et al. Non-steroidal anti-inflammatory drug-induced intestinal inflammation in humans. Gastroenterology. 1987;93:480-489.
10. Scholz FJ, Heiss FW, Roberts PL, Thomas C. Diaphragm like strictures of the small bowel associated with the use of non-steroidal anti-inflammatory drugs. Am J Roentgenol. 1994;162:49-50.
11. Yousufi MM, DePetris G, Leighton JA, et al. Diaphragm disease after use of non-steroidal anti-inflammatory agents: First report of diagnosis with capsule endoscopy. J Clin Gastroenterol. 2004;38:686-691.
12. Kelly ME, McMahon LE, Jaroszewski DE, Yousfi MM, DePetris G, Swain JM. Small-bowel diaphragm disease: Seven surgical cases. Arch Surg. 2005 Dec; 140(12):1162-1166.
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