Ibuprofen belly: A case of small bowel stricture due to non-steroidal anti-inflammatory drug abuse in the setting of codeine dependence

To the Editor

We report a case of non-steroidal anti-inflammatory drug (NSAID)-induced small bowel stricture in the setting of dependence on combination analgesics (codeine/ibuprofen).

NSAID-induced colonic strictures are rare but increasingly reported in the literature (Eis et al., 1998; Gopal and Katon, 1999; Mulcahy and O’Donoghue, 2002). Codeine dependence is a recognized risk of long-term use (Ford and Good, 2007; Rossi, 2010). The prevalence of codeine-based analgesic abuse in Australia is unknown. However, the 2007 Australian National Drug Strategy Household Survey (Australian Institute of Health and Welfare, 2008) indicated that over half a million Australians use analgesics for non-medical purposes. Literature on the serious consequences of using over-the counter opioids is mainly confined to case descriptions (Frei et al., 2010). Individuals who take high doses of codeine due to dependence are at risk of harm from the accompanying simple analgesic found in many over-the-counter preparations.

Mr R is a 35-year-old unemployed man who presented to the emergency department of a regional tertiary hospital with a 3-month history of abdominal pain, acutely worse over 24 h, against the background of codeine and ibuprofen abuse. The pain was associated with an acute onset of nausea and vomiting, and with chronic constipation and anorexia. On examination, he was a thin man with a grossly distended, tympanic abdomen. Imaging of the abdomen revealed a small bowel obstruction, and he underwent an exploratory laparotomy and small bowel resection.

The histology report described a segment of small bowel in which there was a fibrous stricture. No specific underlying pathology could be identified. Adjacent to the stricture, the mucosa demonstrated reactive and inflammatory changes with considerable distortion to the villous architecture. The pathologist noted that this was in keeping with a history of NSAID abuse.

The post-operative course was complicated by delirium, which started on day 3 and fluctuated over 4 days. Mr R required multiple code black interventions for aggressive and violent behaviour. The consultation-liaison psychiatry team became involved. The patient’s delirium was considered to be due to ketamine use (patient-controlled ketamine analgesia initiated by other clinicians) and codeine withdrawal.

Further history revealed that he had commenced an over-the-counter codeine/ibuprofen combination analgesic following a dental extraction in 2003. Over the ensuing 10 years, it had developed increased salience, leading to the termination of his employment as a labourer and the loss of his relationship with his partner. Prior to admission, he reported taking up to 90 tablets of codeine/ibuprofen per day (450–1153 mg codeine and 18,000 mg ibuprofen depending on the strength of the preparation).

Mr R grew up in a large regional city. He lived with his grandparents due to his parents’ intravenous drug use and went to many schools across the state. He denied any other substance abuse. He had previously attempted to cease codeine consumption but the withdrawal symptoms had dissuaded him. He reported that he was initially unaware that codeine was addictive. He pursued community drug and alcohol services on discharge from hospital.

Misuse of codeine/ibuprofen analgesics is emerging in the literature as a cause of significant morbidity. Legislative changes around dispensing these products may be warranted.