Ulcerative ileitis encountered at ileo-colonoscopy: likely role of nonsteroidal agents.
OBJECTIVE
Ileoscopy is increasingly practiced, but it is unclear what diagnostic and management decisions should ensue if ulcerations are encountered.


METHODS
The lead author identified 40 patients with ulcerative ileitis during 1900 consecutive ileoscopies in a community practice. We analyzed the clinical, endoscopic, and histopathologic findings in these patients and related them to drug usage.


RESULTS
Although most patients were asymptomatic, ileitis likely contributed to blood loss in 14 and to right lower quadrant pain in one. Endoscopy revealed multiple, discrete, fibrin-covered ulcerations in the prevalvular segment with patches of erythematous stippling, normal intervening mucosa, and occasional mucosal scars or webs. Histologic findings included focal superficial neutrophilic infiltrates, edema, mucosal hemorrhage, lymphatic dilatation, fibromuscular hyperplasia, prominence of the muscularis mucosae, and antral and Paneth cell metaplasia. Granulomas, fissure ulcers, and apoptosis were notably absent. No specific disease process developed in a median follow-up of 3.2 years. Thirty-three patients admitted recently taking nonsteroidal anti-inflammatory drugs (NSAIDs), notably: enteric-coated aspirin at 325 mg/day or less (19), selective cyclooxygenase-2 inhibitors (5), and nonacetylated salicylates (3). Three fourths of nonsteroidal users were taking agents with low or intermediate gastroduodenal toxicity. Lesions disappeared after drug withdrawal, and reappeared on resumption.


CONCLUSIONS
Ileoscopy during colonoscopy may identify an ulcerative ileitis. This lesion likely contributes to gastrointestinal blood loss and other clinical manifestations, and likely is caused by NSAID use, including those usually associated with low toxicity or at low doses. Features of NSAID-ileitis overlap with Crohn's ileitis, but differentiation of the 2 entities is critical for appropriate management.
Lengeling
Randall W
RW
Gastroenterology Section, Dubuque Internal Medicine, PC, Dubuque, Iowa 52001, USA. Rwltiucases@aol.com
Mitros
Frank A
FA
Brennan
John A
JA
Schulze
Konrad S
KS
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects*; D003113:Colonoscopy; D005260:Female; D006801:Humans; D007079:Ileitis / Q000139:chemically induced / Q000175:diagnosis* / Q000473:pathology; D007082:Ileum / Q000187:drug effects / Q000473:pathology; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D014456:Ulcer / Q000139:chemically induced / Q000473:pathology
D000894:Anti-Inflammatory Agents, Non-Steroidal