Vol 44 # 2 June 2012 - Kma.org.kw

June 2012
KUWAIT MEDICAL JOURNAL 144
Fig. 2: Histopathological analysis of intra-luminal diaphragm
within the small bowel consisting of prominent hyperplastic folds
with intervening stromal cells
Fig. 1: Plain supine abdominal radiograph which demonstrates
dilated small bowel consistent with small bowel obstruction
was found at the point of transition with a patent,
but very narrow lumen. Similar constrictions were
noted throughout the length of the small bowel but
the patency of the lumen was not compromised at
these areas. A wedge resection of the affected area of
small bowel was performed and stapled side-to-side
anastomosis using the TLC 75 (Ethicon, UK) device was
fashioned. He made a good post-operative recovery
and was discharged home four days after surgery.
Histopathological examination of the resected
specimen revealed the presence of an intra-luminal
diaphragm within the small bowel consisting of
prominent hyperplastic folds with intervening stromal
cells, consistent with diaphragm disease of the small
bowel (Fig. 2). The diaphragm consisted of significant
fibrosis, which was confined to the submucosal layer
with minimal mucosal ulceration. This was confirmed
on both hematoxylin and eosin staining and Van
Gieson’s staining. There was a slightly greater density
of neutrophil polymorphs and lymphocytes at the areas
of mucosal ulceration. There was no evidence of any
other pathology; in particular, there was no evidence
of Crohn’s disease, malignancy or other inflammatory
bowel disease and specific immune-histochemistry
stains were not performed.
DISCUSSION
DD was first described in 1988 [1] as circumferential
mucosal lesions forming “diaphragms” within the
small bowel. The small bowel is most commonly
affected although similar lesions have been reported
in the colon [2] . Histologically, diaphragms are similar
to the normal plicae circulares in the small bowel but
with submucosal fibrosis, and occasional mucosal
ulceration and villous atrophy [1] .
There is a clear association between DD and
long-term NSAID use and NSAIDs are known to
affect enterocytes directly by increasing intestinal
permeability [3] , which might allow bacterial invasion
of the bowel wall with secondary inflammation. DD
in the absence of NSAID use is very rare although
unknown NSAID ingestion was possible in these
cases [2,4] . In this case, given the long term management
of chronic leg pain, formal documentation of
analgesics prescribed both in the community and
hospital settings was available and we are confident
that there was no prior NSAID use. We are unsure as
to the etiology of diaphragm disease in this case and,
on histopathological analysis, there was no chronic
inflammation or ulceration, suggesting that systemic
factors may have a role.
Radiological investigations, as in this case, can
be misleading and can often overlook intra-luminal
diaphragms. The diagnosis is usually confirmed on
histopathological analysis although can be suspected
from other imaging techniques such as capsule
endoscopy, small bowel enteroscopy, small bowel
contrast studies or enteroclysis. The tendency for
objects to be retained within diaphragm compartments
themselves may also be useful for diagnosis [5] .
Progressive obstruction caused by diaphragm
disease requires surgical resection of the affected bowel
and strictuloplasty-type operations are of no benefit
given the circumferential nature of the disease. There
is no current guidance on the management of other
diaphragms found at surgery. In this case, resection
was not possible given the length of bowel that was
affected and as such an intra-operative decision to
leave bowel that had a patent lumen was taken and