Capsule endoscopic diagnosis of nonsteroidal antiinflammatory drug-induced enteropathy

Background. Case reports have linked nonsteroidal antiinflammatory drugs (NSAIDs) to a variety of lesions in the small and large bowel including bleeding, protein loss, strictures, increased intestinal permeability, and NSAID enteropathy. We here review the use of wireless capsule endoscopy to quantitate and assess the nature of the small bowel damage caused by NSAIDs when taken short term and in patients on long-term NSAIDs and COX-2 inhibitors. Methods. Forty healthy volunteers underwent a baseline capsule endoscopy. After taking diclofenac slow-release 75 mg twice a day for a total of 14 days, both investigations were repeated. A further 120 patients on long-term NSAIDs (more than 3 months) and 40 on COX-2 inhibitors underwent a capsule endoscopy study. Sixty healthy patients acted as controls. Small bowel damage was categorized and quantitated. Results. Short-term diclofenac: Capsule endoscopy demonstrated new pathology in 27 (68%) of subjects. The most common lesions were mucosal breaks, seen in 16 (40%), which were seen to be bleeding in 2 (5%). Long-term NSAIDs: The main pathology was related to mucosal breaks (29%); 3% had free luminal blood and 2% had strictures. The damage seen in 50% of patients on selective COX-2 inhibitors did not differ significantly (P < 0.5) from that seen with NSAIDs. Conclusions. Capsule endoscopy demonstrates evidence of macroscopic injury to the small intestine, in up to 68% of volunteers, resulting from 2 weeks ingestion of slow-release diclofenac. Long-term use of NSAIDs and COX-2 inhibitors causes comparable small bowel damage (50%-68%).