Introduction: The chronic use of NSAIDs has many well-established effects on the digestive system, specifically within the upper GI tract. One uncommon complication of chronic NSAID use is the formation of diaphragm-like strictures, characterized by the circumferential narrowing of mucosal membranes. These diaphragm-like strictures are most encountered in the small intestine, and there exists a limited number of cases reporting occurrence of such lesions within the colon. Our case highlights one such example and the importance of considering NSAID-induced colopathy as a causative factor for iron deficiency anemia.
Case Description/Methods: A 69-year-old female with history of chronic low back pain, and long-term use of diclofenac 75 mg twice daily, presented to the hospital with a hemoglobin of 6.2 g/dL discovered on outpatient lab work. Additional labs showed iron saturation 5% and ferritin 2 ng/ml at that time, consistent with iron deficiency anemia. She endorsed dyspnea on exertion, fatigue and lightheadedness for one month duration and denied symptoms of overt GI bleeding. The patient had a colonoscopy five years prior to presentation which revealed several benign polyps and diverticulosis with no strictures. EGD and colonoscopy were subsequently pursued. EGD showed mild erosive gastritis and colonoscopy revealed 5 diaphragm-like strictures with ulcerative edges located in the ascending and proximal transverse colon [see images] requiring CRE balloon dilation up to 15 mm to allow passage of the scope. The ileocecal valve could not be traversed due to significant narrowing. Biopsy of the diaphragm lesions showed benign colonic mucosa with chronic architectural distortion and ulcer bed. NSAID-induced colopathy was suspected to be the cause of anemia, for which she was counseled to discontinue NSAID use.
Discussion: NSAID-induced diaphragm-like strictures are encountered most often in the small intestine, specifically at the ileum. Colonic diaphragm disease (CDD) remains a lesser recognized entity and their prevalence remains unknown, occurring predominantly in the proximal ascending colon. Poor recognition of NSAID-induced colopathy has led to misdiagnosis with conditions such as Crohn's disease. Therefore, in providing another example of this rarer finding, it is one aim of this case report to encourage NSAID-induced colopathy to be considered in differential diagnosis for iron deficiency anemia among different other GI pathologies.
