Diaphragm Disease of the Small Bowel Presenting With Intussusception

Abstract

Diaphragm disease of the small bowel is an uncommon condition with nonspecific symptoms, which causes strictures of the small bowel associated with non-steroidal anti-inflammatory drug (NSAID) use. Due to the nature of the disease process and the strictures it can form, patients often present with a clinical picture suggestive of small bowel obstruction, and the true diagnosis is not confirmed until histopathological examination. In this article, we present the case of a 73-year-old female with chronic NSAID use and gastrointestinal complaints who had undergone multiple endoscopic procedures which failed to identify the cause of her symptoms. Further investigation with video capsule endoscopy and CT enterography led to a diagnosis of intussusception believed to be caused by a small bowel mass. Retention of the video capsule endoscope prompted the decision to undertake diagnostic laparoscopy with push endoscopy and direct visualization of a string of small bowel strictures in the area of intussusception. This characteristic appearance of the bowel was then confirmed by pathology as diaphragm disease lesions. Diagnosis of this disorder is difficult due to its rarity and common symptoms that make other disease processes seem more probable. Early diagnosis can prompt counseling on cessation of NSAID use and interventions to decrease the risk of complications that may require surgical intervention. Physicians should be able to recognize diaphragm disease of the small bowel as a differential in patients presenting with obstructive bowel symptoms and even rare cases of intussusception in the setting of chronic NSAID use.

Keywords: chronic ulcerations; diaphragm disease; enterography and endoscopy; intussusception; nsaid abuse; obstruction; small bowel; strictures.

Figure 1. Intraoperative photo of intussusception

Figure 2. Video capsule endoscope retrieved intraoperatively

Figure 3. Endoscopic photos of small bowel diaphragm stricture