Small bowel diaphragm disease--strictures associated with non-steroidal anti-inflammatory drugs.

"Diaphragm disease" is a recently described entity seen in patients taking non-steroidal anti-inflammatory drugs in which strictures or diaphragms develop in the small intestine.' A case of intermittent small bowel obstruction is reported, in which the cause was a combination of such diaphragms and herniation of the small bowel through a mesenteric defect. CASE REPORT. A 62-year-old woman, who had had rheumatoid arthritis for 20 years, was investigated over a period of three years from 1988 for episodes of central crampy abdominal pain. These attacks were usually precipitated by eating and lasted for two to three hours post-prandially. They were occasionally associated with vomiting but always settled spontaneously. Her rheumatoid arthritis had been treated for 12 years with simple analgesics alone, including aspirin, but in 1987 she was started on azapropazone 600 mgs twice daily and piroxicam 20 mgs at night. There was no other past medical history of note. Upper gastro-intestinal endoscopy, barium meal and barium enema were normal. An ultrasound scan showed gallstones, and cholecystectomy was performed in 1990. Laparotomy findings at this time were normal. However, her symptoms failed to resolve; further investigation which included small bowel barium series, colonoscopy, ERCP and CT scanning gave normal results. She presented again in March 1991 with an acute episode of abdominal pain and vomiting. Plain abdominal X-ray showed small bowel obstruction, and laparotomy was undertaken. At operation, a 38 cm loop of ileum was herniating through an adjacent 20 cm defect in the distal small bowel mesentery. The bowel was macro-scopically normal and moved freely in and out of the defect. However, several strictures could be felt along the loop of bowel and this segment was therefore resected. The defect in the mesentery was closed.