EP904 - NSAID-Induced Colopathy; An Uncommon Case of Persistent Disease Requiring Right Colectomy

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Purpose/Background: NSAIDs are common over the counter analgesics. Their side effects are well studied and include NSAID-induced colopathy, a rare phenomenon occurring after prolonged NSAID use. It has a variety of clinical presentations and management includes ruling out malignancy and stopping NSAIDs. Surgery is reserved for obstruction, perforation, or strictures. There are multiple reports on this disease but a paucity of literature on prolonged persistence despite being off NSAIDs. In our case we aim to provide further awareness to this disease and its management by describing an atypical case in which NSAID colopathy persisted for months despite NSAID cessation, leading to right colectomy.

Methods/Interventions: A healthy 42-year-old female underwent hemorrhoidectomy and took ibuprofen for weeks due to pain. She developed abdominal pain, prompting a CT which demonstrated a thickened cecal base. Colonoscopy demonstrated a large, fibrotic, ulcerated cecal mass. Histopathology revealed benign tissue. The concerning gross appearance and inconclusive pathology led to repeat colonoscopy and biopsy, both without change. She was evaluated by Colorectal Surgery, asymptomatic and off ibuprofen, and felt to have NSAID-induced colopathy. She was instructed to remain off NSAIDs and a CT was later obtained to evaluate for resolution, but again showed cecal thickening. Repeat colonoscopy was unchanged from prior. At this point the mass persisted for five months despite no NSAID use and there was concern for occult cancer. She underwent a laparoscopic right colectomy. Pathology demonstrated a firm cecal mass. The cecal pouch was obliterated with a large necrotic ulcerated mass present. The mass and nine lymph nodes were negative for malignancy. Findings were compatible with subacute NSAID-induced colopathy. She was discharged on postoperative day three and had an uneventful recovery.

Results/Outcomes: The side effect profile of NSAIDs is well studied. They inhibit prostaglandin synthesis, leading to disruption of bowel epithelium, causing ulcers, bleeding, strictures, and in severe cases obstruction and perforation. These processes more commonly involve the small bowel, but increasing use of NSAIDS has led to more literature on their colonic effects. Symptoms include anemia, abdominal pain, weight loss, or change in bowel habits. The nonspecific symptoms make NSAID colopathy challenging to diagnose as it can mimic inflammatory bowel disease, ischemic colitis, and cancer. Careful history taking is critical in identifying this diagnosis. Colonoscopy is usually the first opportunity for tissue biopsy and analysis. Histopathology often demonstrates acute inflammation and ischemic-type necrosis. Management involves ruling out other diseases and cessation of NSAIDs. Surgery is reserved for symptomatic strictures or perforation, as described in some reports. Ongoing inflammation months after NSAID cessation is not reported in the literature, making prolonged disease more concerning and our patient’s presentation particularly unique. Her course continued off NSAIDs for 5 months - most courses resolve by 2-3 months. There are no guidelines for when to surgically intervene for persistent inflammatory disease.

Conclusion/Discussion: NSAID-induced colopathy is an uncommon disease in which surgery is reserved for emergencies, strictures, and in our case persistent inflammation. Further awareness and contributions to the literature are needed for this diagnosis as there are no set guidelines on how to best mitigate the risks of persistent disease.