Diaphragm disease diagnosed by capsule endoscopy: a single center's experience

Aims Diaphragm disease is a rare entity characterized by the presence of multiple rings in the small bowel that narrow the lumen. The symptoms are variable: iron-deficiency anemia, bleeding, obstruction, alteration of the intestinal habit or acute abdomen due to perforation. It is usually associated with high doses of non-steroidal anti-inflammatory drugs (NSAIDs). Capsule endoscopy or enteroscopy are usually required to diagnose it, as diaphragms are often overlooked in imaging tests.

The aim is to analyze the cases of diaphragm disease diagnosed by capsule endoscopy, its causes, and evolution.

Methods Retrospective descriptive study of capsule procedures performed in our hospital and review of previous literature.

Results We reviewed 434 explorations, finding 3 cases of diaphragm disease (0.69%).

• Case 1: a 54-year-old woman with chronic anemia. Normal upper endoscopy and colonoscopy. The capsule shows diaphragms from the middle jejunum. Incomplete examination without retention. The patient takes NSAIDs, improving after stopping them. The capsule is repeated with the persistence of residual diaphragms.

• Case 2: a 59-year-old man with malabsorptive syndrome and polyneuropathy. Upper endoscopy shows atrophic gastritis with metaplasia, H. pylori negative. Normal colonoscopy. The capsule shows jejunal diverticula, multiple ulcerated and friable diaphragms from the jejunum. Incomplete examination without retention. The patient does not consume NSAIDs. Positive bacterial overgrowth test. After treatment, better response to supplementation, without clinical improvement.

• Case 3: a 61-year-old woman with chronic anemia and transfusional requirements. Upper endoscopy shows chronic gastritis H. pylori negative. Normal colonoscopy. The capsule shows ulcerated and friable diaphragms from the jejunum. Incomplete examination. The capsule was not expelled after 14 days according to the patient, but she rejected abdominal radiography. She consumes NSAIDs. Irregular follow-up due to alcoholism. [1] [2] [3]

Conclusions The main cause of diaphragm disease is NSAIDs. In previous series, it has been described in up to 2% of patients under long treatment. Other reported causes include potassium intake, celiac disease, eosinophilic gastroenteritis, and radiation damage. We present an idiopathic case.

1. In our series, all patients undergo the capsule for chronic anemia, without symptoms. According to the previous series, the most common presentation is chronic anemia and signs of intestinal obstruction.

2. Diaphragm disease is a major cause of incomplete capsule exploration. In none of our cases, the procedure is complete. In addition, the risk of retention is also high, in the previous series up to 70%.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Kelly ME, McMahon LE, Jaroszewski DE. et al. Small-bowel diaphragm disease: seven surgical cases. Arch Surg 2005; 140 (12) 1162-1166
• 2 Slesser AAP, Wharton R, Smith GV. et al. Systematic review of small bowel diaphragm disease requiring surgery. Colorectal Dis 2012; 14 (07) 804-813
• 3 Ullah S, Ajab S, Rao R. et al. Diaphragm disease of the small intestine: an interesting case report. Int J Surg Pathol 2015; 23 (04) 322-324

Publication History

Article published online:
15 April 2024