Gastroenterology  1993 Jun;104(6):1832-47 

Side effects of nonsteroidal anti-inflammatory drugs on the small and large

intestine in humans.

Bjarnason I, Hayllar J, MacPherson AJ, Russell AS.

Department of Clinical Biochemistry, King's College School of Medicine and

Dentistry, London, England.

BACKGROUND: It is not widely appreciated that nonsteroidal anti-inflammatory

drugs (NSAIDs) may cause damage distal to the duodenum. We reviewed the adverse

effects of NSAIDs on the large and small intestine, the clinical implications

and pathogenesis. METHODS: A systematic search was made through Medline and

Embase to identify possible adverse effects of NSAIDs on the large and small

intestine. RESULTS: Ingested NSAIDs may cause a nonspecific colitis (in

particular, fenemates), and many patients with collagenous colitis are taking

NSAIDs. Large intestinal ulcers, bleeding, and perforation are occasionally due

to NSAIDs. NSAIDs may cause relapse of classic inflammatory bowel disease and

contribute to serious complications of diverticular disease (fistula and

perforation). NSAIDs may occasionally cause small intestinal perforation,

ulcers, and strictures requiring surgery. NSAIDs, however, frequently cause

small intestinal inflammation, and the associated complications of blood loss

and protein loss may lead to difficult management problems. The pathogenesis of

NSAID enteropathy is a multistage process involving specific biochemical and

subcellular organelle damage followed by a relatively nonspecific tissue

reaction. The various possible treatments of NSAID-induced enteropathy

(sulphasalazine, misoprostol, metronidazole) have yet to undergo rigorous

trials. CONCLUSIONS: The adverse effects of NSAIDs distal to the duodenum

represent a range of pathologies that may be asymptomatic, but some are life

threatening.