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Re: Diagnosis of NSAID enteropathy using Capsule Endoscopy - United Kingdom pilot data

Dear Editor,

We read with interest the review by Adebayo and Bjarnason on non- steroidal anti-inflammatory drug enteropathy. The article cites capsule endoscopy (CE) as an important tool to diagnose intestinal damage caused by NSAID (1). The diagnosis of NSAID induced enteropathy prior to CE was limited, as visualization of the small bowel using other modalities was often suboptimal (2). In addition, patient’s symptoms may be mild, non specific or absent. However, presently there is a paucity of international data evaluating the role of CE for the recognition of NSAID induced small intestinal damage (2). A small number of studies (Table 1.0 (3-5)) and case reports (6-7) have suggested that the prevalence of NSAID enteropathy (including diaphragm disease) is between 55%-71%. We would like to share our United Kingdom (UK) experience in the use of capsule endoscopy to detect NSAID enteropathy. Our aim was to assess the prevalence of small bowel (SB) injury in patients taking long term NSAID’s and to evaluate the role of gastrointestinal (GI) symptoms in predicting the presence of enteropathy. We conducted a pilot study on 22 patients with arthritis (either osteoarthritis or rheumatoid) who had been on conventional NSAID’s for a minimum of three months duration. Patients with obstructive symptoms or previous gastrointestinal (GI) surgery were excluded. The presence of other GI symptoms and all drug ingestions were noted. 18 other patients who underwent CE for functional disorders/ diarrhoea in our unit were used as controls.

Nine patients were symptomatic with heartburn (n=6) and abdominal pain (n=3). Evidence of intestinal injury throughout the small bowel was seen in 50% of our patients: multiple erosions (n=9), ulcers (n=2) and red spots (n=4) compared to 17% of controls (p<0.05).The presence of NSAID induced enteropathy detected by CE was poorly correlated with GI symptoms; 36%, p<0.1). Intestinal damage was also independent of proton pump inhibitor use.

We strongly agree with Adebayo & Bjarnason that CE is a useful tool to detect the high prevalence of NSAID induced macroscopic small bowel injury. Our study has shown that symptoms are poorly correlated with the presence of enteropathy. The clinical relevance of the small bowel findings in these patients have yet to be established. Larger studies are needed to correlate and quantify small bowel injury detected by CE with the presence of anaemia, obscure GI bleeding and small bowel perforations.

References

1. Adebayo D, Bjarnason I. Is non-steroidal anti-inflammaory drug (NSAID) enteropathy clinically more important than NSAID gastropathy? Postgrad Med J 2006;82:186-91.

2. Chutkan R, Toubia N. Effect of nonsteroidal anti-inflammatory drugs on the gastrointestinal tract: diagnosis by wireless capsule endoscopy. Gastrointest Endosc Clin N Am 2004;14:67-85.

3. Goldstein JL, Eisen GM, Lewis B, Gralnek IM, Zlotnick S, Fort JG. Video capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omeprazole, and placebo. Clin Gastroenterol Hepatol 2005;3:133-41.

4. Maiden L, Thjodleifsson B, Theodors A, Gonzalez J, Bjarnason I. A quantitative analysis of NSAID-induced small bowel pathology by capsule enteroscopy. Gastroenterology 2005;128:1172-8.

5. Graham DY, Opekun AR, Willingham FF, Qureshi WA. Visible small- intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol 2005;3:55-9.

6. Yousfi MM, De Petris G, Leighton JA, Sharma VK, Pockaj BA, Jaroszewski DE, Heigh RI, Ramzan NN, Fleischer DE. Diaphragm disease after use of nonsteroidal anti-inflammatory agents: first report of diagnosis with capsule endoscopy. J Clin Gastroenterol 2004;38:686-91.

7. Manetas M, O'Loughlin C, Kelemen K, Barkin JS. Multiple small-bowel diaphragms: a cause of obscure GI bleeding diagnosed by capsule endoscopy. Gastrointest Endosc 2004;60:848-51.

Table 1 Studies using capsule endoscopy to detect NSAID induced enteropathy.