chronic nsaid use: small bowel injury waqar qureshi, md, facp, facg associate professor of medicine...

Chronic NSAID Use: Small Chronic NSAID Use: Small Bowel InjuryBowel Injury

Waqar Qureshi, MD, FACP, FACGWaqar Qureshi, MD, FACP, FACG

Associate Professor of MedicineAssociate Professor of Medicine

Chief of EndoscopyChief of Endoscopy

Baylor College of Medicine/VAMCBaylor College of Medicine/VAMC

Houston, TexasHouston, Texas

The occasional finding of intestinal blood loss

or anemia in the setting of normal upper and

lower endoscopy led to the realization that:

• NSAID-induced small intestinal ulceration and bleeding were clinically important

Hedenbro JL, et al. Gastrointest Endosc 1988;34:247-251

Upadhyay R, et al. Ann Rheum Dis 1990;49:359-362

NSAIDs and the Small IntestineNSAIDs and the Small Intestine

A Controlled Study of NSAID-induced A Controlled Study of NSAID-induced Small Bowel Injury Using VCESmall Bowel Injury Using VCE

Methods:

• 41 ambulatory subjects (mean age = 49.5 y) with various types of arthritides (OA/RA/gout/non-specific) were enrolled

• 21 subjects took NSAIDs daily (>3 mo duration)

• 20 took acetaminophen alone or nothing.

The Pill CameraThe Pill Camera

1. Optical dome1. Optical dome2. Lens holder2. Lens holder3. Lens3. Lens4. Illuminating LEDs (light 4. Illuminating LEDs (light emitting diodes)emitting diodes)5. CMOS image sensor5. CMOS image sensor6. Battery6. Battery7. ASIC (Application Specific7. ASIC (Application Specific Integrated Circuit) transmitterIntegrated Circuit) transmitter 8. Antenna8. Antenna

1. Optical dome1. Optical dome2. Lens holder2. Lens holder3. Lens3. Lens4. Illuminating LEDs (light 4. Illuminating LEDs (light emitting diodes)emitting diodes)5. CMOS image sensor5. CMOS image sensor6. Battery6. Battery7. ASIC (Application Specific7. ASIC (Application Specific Integrated Circuit) transmitterIntegrated Circuit) transmitter 8. Antenna8. Antenna

Dimensions: Height: 11mm Length: 26mmWeight: 3.7gm

Small Bowel Ulcer

NSAID Ulceration

Blood in Terminal Ileum

A Controlled Study of NSAID-induced A Controlled Study of NSAID-induced Small Bowel Injury Using VCESmall Bowel Injury Using VCE

Results:

any injury (p<0.001)

• Severe damage was associated with high dose indomethacin, naproxen, and ibuprofen use.

NSAID users Controls

Any injury 71% 10%

Severe injury 20% 0%

ConclusionsConclusionsSymptoms and signs of ill-health among chronic

NSAID users are often attributed to the underlying

disease

Possible evidence of NSAID enteropathy includes:

• Dyspepsia that does not respond to PPI

• Vague abdominal pain that eludes diagnosis or treatment

• Iron deficiency anemia

• Hypoalbuminemia

• VCE is a useful tool for diagnosing NSAID-induced small intestinal mucosal injury

• VCE should be considered in patients on NSAIDs with unexplained symptoms

• Prospective comparisons of NSAIDs or other drugs and the GI tract

NSAID-induced Small Bowel Injury NSAID-induced Small Bowel Injury ConclusionsConclusions

THE END