gms | German Medical Science

Background: According to current studies NSAIDs-induced colopathy is an underestimated but serious clinical entity that can cause a series of significant symptoms ranging from diarrhea to rectal haemorrhage, and usually develops up to 20 months after initiation of NSAIDs treatment. In order to contribute to more effective treatment of NSAIDs-induced enteropathy, we present a case of a NSAID-induced simultaneous upper gastrointestinal bleeding (GIB) and colonic microangiopathic ischemic necrosis.

Materials and methods: A 65 year old male patient was admitted in our Emergency Department due to upper abdominal pain and massive upper GI Bleeding after chronic abuse of Ibuprofen. The duodenal bleeding was managed with adrenalin injection after emergency gastroscopy but two days later the patient deteriorated clinically, and developed an acute abdomen with signs of peritonitis especially on the left abdomen. An emergency laparotomy revealed an acute microischemic colitis and necrosis of the left hemicolon along with patch-like microischemias of the rest large bowel and of the small bowel. A left hemicolectomy, and Hartmann’s procedure was performed. After 24hrs a programmed second look laparotomy presented restored bowel perfusion. Two days later an emergency re-laparotomy due to hemodynamic instability because of re-upper GIB was necessary. Duodenal incision and ligation of the gastroduodenal artery stopped the massive duodenal ulcera bleeding. The further hospitalization was uncomplicated and the patient was discharged from hospital on the 30^th postoperative day.

Conclusion: Upper GI-ulcera/bleeding is the most common NSAID-induced complication. Colonic micorangiopathy can be manifested with subtle clinical symptoms such as diarrhea or tenesmus which regress after termination of the NSAID-therapy. Few cases of large bowel necrosis under NSAID-therapy are reported. This is the first report of a concomitant NSAID-induced upper GIB and acute colonic necrosis leading to the necessity of emergency operation. In most cases the upper GIB can be treated by endoscopic hemosthasis. Patients with history of NSAID-usage complaining of non-specific lower abdominal pain should undergo a colonoscopy to detect early microischemic mucosal alterations. In case of upper hemodynamic relevant GIB with hemorrhagic shock the development of severe microischemic necrosis of the colonic wall leading to acute abdomen should be considered. In this case the Hartmann operation can be performed and a programed second look operation after 24-48hrs should evaluate the remaining bowel circulation and the need for further resection.

For early identification of bowel microangiopathy in patients with history of upper GI-complications due to NSAID, a routine colonoscopy in addition to gastroscopy should be conducted.