B0671 - Small Bowel Diaphragm Disease Presenting With Iron Deficiency Anemia and Abdominal Pain

Dhir Gala, BS¹, Vikash Kumar, MD², Mili Shah, BS¹, Han Chen Tom Tsou, BS³, Josef Khoury, MS³, Stephen Wonnacott, MS¹, Paul Toomey, MD^4
1American University of the Caribbean School of Medicine, Brooklyn, NY; ²The Brooklyn Hospital Center, Brooklyn, NY; ³Ross University School of Medicine, Basseterre, Saint George Basseterre, Saint Kitts and Nevis; ⁴Epsom and St. Helier University Hospitals, London, England, United Kingdom

Introduction: Small bowel diaphragm disease (SBDD) is a rare condition characterized by circumferential strictures causing intermittent or complete small bowel obstruction, as well as unexplained abdominal pain or occult gastrointestinal bleeding commonly secondary to chronic NSAID use.

Case Description/Methods: A 50-year-old male with no past medical or surgical history presents with intermittent recurring hypogastric abdominal pain with occasional vomiting and chronic fatigue. His lab work was significant for microcytic anemia secondary to iron deficiency. Previous EGD and colonoscopy one month before to identify the cause of iron deficiency anemia were normal. CT scan of abdomen/pelvis showed moderately dilated small bowel loops involving the distal jejunum and proximal ileum suggestive of an incomplete closed-loop partial obstruction without an obvious cause (Figure 1A). MRI ruled out suspected small bowel adenocarcinoma or any other significant cause of bowel obstruction. A video capsule endoscopy could not be completed because the patency capsule did not pass through as seen on XR (Figure 1B). A diagnostic and therapeutic laparoscopy was performed, where a careful inspection of the small bowel from the ileocecal valve to the duodenojejunal flexure showed three distinct areas of congested appearing, thickened, narrowed small bowel within the ileum were observed (Figure 1C) with associated mesenteric lymphadenopathy. The diseased segment of the small bowel with the associated mesenteric vessels was removed followed by hand-sewn end-to-end anastomosis. Histology of the resected small bowel showed ulceration with elongated mucosal folds and submucosal fibrosis confirming the diagnosis of SBDD. Postoperatively, the patient improved clinically, and repeat anemia workup showed significant improvement (Table 1).







Discussion: The most common presentation of SBDD includes a history of extensive NSAID use, anemia, and obstructive symptoms. Imaging can potentially be used to diagnose SBDD pre-operatively. The best diagnostic and therapeutic intervention for diaphragm disease is laparoscopy which will show dilations and strictures in the affected bowel segment. Definitive treatment consists of resection and strictureplasty of the affected small bowel. SBDD should be considered as a differential in patients with chronic abdominal pain, obstructive symptoms, and iron deficiency anemia regardless of history of NSAID use.




Disclosures:


Dhir Gala, BS¹, Vikash Kumar, MD², Mili Shah, BS¹, Han Chen Tom Tsou, BS³, Josef Khoury, MS³, Stephen Wonnacott, MS¹, Paul Toomey, MD⁴. B0671 - Small Bowel Diaphragm Disease Presenting With Iron Deficiency Anemia and Abdominal Pain, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.