Hidden Webs and Small Bowel Obstruction: Non-steroidal Anti-inflammatory Drug (NSAID)-Induced Diaphragmatic Strictures

Diaphragm disease is an uncommon manifestation of non-steroidal anti-inflammatory drug (NSAID)-associated enteropathy, in which thin, concentric fibrotic septa constrict the small bowel lumen, most often in the distal ileum. Because the septa are typically <2 mm thick and radiolucent, patients are frequently misdiagnosed with adhesive small bowel obstruction (SBO) and may undergo unnecessary laparotomy. We present a case of an 89-year-old man with prolonged, high-dose ibuprofen use for degenerative knee pain who developed complete SBO. CT enterography showed a distal-ileal transition point, and exploratory laparotomy revealed three circumferential diaphragms 30 cm proximal to the ileocecal valve. Microscopic examination of multiple luminal narrowings revealed radially arranged submucosal fibrovascular proliferation lined by mucosa with scattered acute injury and repair changes, characteristic of NSAID-related diaphragm disease. Segmental resection relieved the obstruction, and the patient recovered uneventfully following permanent cessation of NSAIDs.