How Capsule Endoscopy Has Illumened the Prevalence of NSAID-Related Distal Small Intestinal Ulceration
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EDITORIAL
How Capsule Endoscopy Has Illumened the Prevalence of NSAID‑Related Distal Small Intestinal Ulceration Foong Way David Tai1 Accepted: 6 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
The commonly prescribed analgesic and anti-inflammatory medications termed nonsteroidal anti-inflammatory drugs (NSAIDs) induce gastroduodenal ulcerations that in turn are well recognized as the basis for upper gastrointestinal (GI) bleeding and perforation. Though these complications are effectively treated and prevented by the use of protonpump inhibitors (PPIs), less well appreciated are the ulcerating effects of NSAIDs on the small intestine distal to the second part of the duodenum. Due to the inhibition of the inducible enzyme cyclooxygenase (COX)-2, NSAIDs reduce the production of mucosal prostaglandin E2, a substance responsible for the regulation of the small intestinal microcirculation and the integrity of the mucus barrier [1], while alterations of small intestinal microbiota homeostasis favoring Gram-negative bacteria increase the susceptibility to ulceration in experimental models [2]. The spectrum of endoscopic features of NSAIDs range from mucosal breaks such as erosions and ulcerations to erythema and denuded areas of mucosa [3]. In this issue of Digestive Diseases and Sciences, Lee and collaborators report on the effects of NSAIDs on small intestinal injuries as visualized with wireless capsule endoscopy [4]. In this retrospective single-center study, they analyzed the risk factors associated with the presence of erosive lesions in the small intestines by examining 309 capsule endoscopy examinations performed over a 5-year period. In a blinded fashion, Lee and colleagues re-reviewed videos adjudicated by a committee of three experienced experts. Lee et al. reported that 45% of patients investigated mostly for suspected gastrointestinal bleeding had erosions or ulcers, while in comparison in only 36 patients or 11.6% of complete capsule examinations, a pathological diagnosis associated with intestinal ulceration such as Crohn’s disease, * Foong Way David Tai [email protected] 1
Academic Department of Gastroenterology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
tuberculosis, or Behçet’s syndrome had been given. Patients with definite or suspected erosive lesions with no established cause were then compared with other subjects who had no evidence of erosive lesions. Frequent NSAID ingestion within 2 weeks of capsule endoscopy was present in 14% of this subset. The authors concluded that idiopathic erosions or ulcers as visualized with capsule endoscopy was statistically associated with the use of NSAIDs after adjusting for age and gender (odds ratio 4.2, 95% confidence interval 1.9–9.5). Among patients with definite erosive lesions, as determined by agreement of at least two of three blinded reviewers, over half had a history of NSAID ingestion. Idiopathic small intestinal mucosal breaks are common; prospective trials examining the effects of NSAID
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