NSAID enteropathy: appearance at CT and MR enterography in the age of multi-modality imaging and treatment

CT and MR enterography and capsule endoscopy are increasingly used as routine diagnostic tests for patients with potential small bowel disorders and obscure gastrointestinal bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used drugs that disrupt prostaglandin synthesis and result in a variety of localized complications within the small bowel ranging from ulcer formation to characteristic circumferential strictures, or diaphragms. NSAID enteropathy encompasses this spectrum of acute and chronic inflammatory sequelae, and is associated with typical findings at capsule endoscopy and surgery. Herein we review the typical clinical presentation of NSAID enteropathy, in addition to its endoscopic appearances, focusing on imaging findings at cross-sectional enterography. Multiple, short-segment strictures are the hallmarks of imaging diagnosis. Strictures may have minimal hyperenhancement or wall thickening, but these findings are typically symmetric and circumferential with respect to the bowel lumen. Multifocal Crohn’s strictures, and occasionally radiation-induced strictures or adhesions, will mimic NSAID diaphragms. Multi-phase or multi-sequence imaging at CT and MR enterography increase diagnostic confidence in stricture presence. Strategies for subsequent workup and therapy after enterography are also discussed. Given the frequent use of NSAIDs and typical appearance of these strictures, knowledge of characteristic imaging findings can be particularly useful when evaluating patients with anemia and recurrent small bowel obstruction.