Nonceliac diaphragm disease of the duodenum: DISCUSSION
The differential diagnosis of small intestinal ulceration and stricture formation is extensive. This is generally classified into broad groups such as congenital, mechanical, inflammatory, vascular, neoplastic and miscellaneous. Most formations are self-evident from clinical history and are rare. Granulomatous disease, especially with broad-based strictures, raises the possibility of Crohn’s disease or an infection such as tuberculosis. Congenital duodenal stenoses, including webs and rings, may occur and are evident soon after birth. Occasionally, they may be associated with Down’s syndrome. Post-traumatic strictures that simulate Crohn’s disease rarely have been described in the ileum, but stricture of the duodenum and jejunum has been recorded in association with physical child abuse. Ischemic strictures may develop in the more distal small intestine, are usually broad-based and typically have iron-laden macrophages. Ulceration in the small intestine may be related to celiac disease, sometimes with intestinal lymphoma. Strictures have also been associated with celiac disease, particularly in the duodenum. Drug-induced strictures and diaphragm-like changes have been reported with a number of medications, including potassium chloride, ASA and other nonsteroidal anti- inflammatory medications. Usually, these occur in the distal small intestine and colon rather than the duodenum. In spite of careful, clinical and pathological evaluation, the cause of some small intestinal strictures remain unexplained. Some of these differ from the changes seen in the present case because the strictures are broad-based and often require surgical resection to resolve symptoms. In contrast, the diaphragm-like strictures seen in the present patient were quite distinctive and multiple; they usually involve the distal small intestine or colon. Pathological features of diaphragm disease, as previously detailed in this journal, also seem quite specific and, in some instances, appear to be directly related to medication use. In the present patient, no specific cause could be defined.
Little information is available on the effects of different dietary factors in the the pathogenesis of gastroduodenal disease. Nevertheless, prior epidemiological and experimental animal studies from India have suggested that environmental, particularly dietary factors, may be important in the pathogenesis of duodenal ulcer disease. Moreover, studies from Bombay have demonstrated pathologic effects of spices, including chili powder, on the mucosa of the upper gastrointestinal tract. The prevalence of most duodenal diseases in India, however, is not well defined; for example, most duodenal strictures have been attributed to prior ulcer disease or tuberculosis. Even in these patients, however, it may be speculated that some caustic dietary factor could be important. It is known, for example, that salicylates, including ASA and other salicylate-like compounds, may be found in a variety of foods. Whether these would be present in sufficient amounts in the Indian diet to cause any toxic effects in the upper gastrointestinal tract is not known. Further studies are needed to determine whether dietary factors, including those associated with ethnic diets, play a role in the pathogenesis of duodenal disease, including ulcers or strictures, in South Asians.
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