Cyclooxygenase 2 selective inhibitor induced bowel stricture: a case report

Several reports have mentioned the role of non-steroidal anti-inflammatory drugs (NSAID) in inducing diaphragm disease and strictures in the small and large bowel. To our knowledge, there is no such report in patients treated with cyclooxygenase 2 (COX2) selective inhibitors. We report the case of a 55 year old man with a past history of axial spondylarthropathy, successfully treated with NSAID from 1975 to 2001; from February 2001, he was treated with celecoxib 400 mg per day for three weeks and then 200 mg/day for two years. He had previous abdominal surgery (appendicectomy) in 1965. He presented with a 24 hour history of central abdominal pain with persistent vomiting. Clinical and radiological examination confirmed small bowel obstruction. At laparoscopy, a distal ileal obstruction was identified. Coelioscopic laparotomy was then performed, showing evidence of bowel wall stricture; 10 cm of the distal ileum was spared. Macroscopic and microscopic examination of the resected specimen was consistent with a diagnosis of stricture on submucosal ulceration of the small bowel. This condition is known to be associated with long term use of NSAID. The COX-2 specific inhibitors have been developed in order to improve the gastrointestinal safety of therapy with NSAID. In various clinical trials, COX-2 selective inhibitors have been shown to have similar efficacy to NSAID, with a concomitant association with fewer endoscopic ulcers and serious lower gastrointestinal events. This case suggests that COX-2 selective inhibitors can induce bowel wall ulcerations, followed by submucosa fibrosis, which may cause strictures or diaphragm-like disease.