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Figure A: Shows long segment narrowing of terminal ileum (see arrow).

Figure B: Shows multiple discrete ulcers varying in size from 5 to 10 mm at terminal ileum (see arrows).

Figure C: Shows acute ulcer, infectious ileitis is suggestive, no organism or granuloma is seen.

   A45-year-old male presented with the chief complaint of abdominal colicky pain at the epigastric region that had lasted 3 weeks. He had a past history of chronic rhinitis, back pain and headache and had been taking Ibuprofen 1.2-1.4 gm orally for 1 year without a physician’s prescription. He was investigated for a complete workup including CBC, whole chemistry blood tests which were unremarkable. Gastroscopy revealed mild gastritis. No Helicobacter pylori (H. pylori) was found. A computed tomography (CT) of the whole abdomen, with intravenous and oral contrast, and an ultrasonic scan of the whole abdomen were performed. The initial report was unremarkable. He was treated symptomatically for gastritis but his condition was getting worse. His acute pain and sleeplessness brought him back for a reinvestigation to determine a more definite diagnosis. All the data from previous investigations were reviewed and repeated, a non-contrast CT of the whole abdomen was performed on axial, sagittal, coronal and oblique and a reconstruction of the small bowel was performed very precisely. The finding reveals a long segment narrowing of the terminal ileum (Figure A). The differential diagnoses of stenosis of terminal ileum include Crohn’s disease, radiation fibrosis, ischemic ileitis, potassium chloride tablets, adhesion band from previous abdominal surgery, lymphoma, metastatic seeding, carcinoid or primary adenocarcinoma.¹ Colonoscopy reveals edematous wall of terminal ileum and multiple discrete ulcers varying in size from 5 to 10 mm at terminal ileum (Figure B). The section reveals acute ulcer, infectious ileitis is suggestive, no organism or granuloma is seen (Figure C). The findings are consistent with terminal ileal stenosis from drug abuse. We conclude that the cause of the ileal ulcer is likely due to Ibuprofen. Ibuprofen is a nonsteroidal anti- inflammatory drug (NSAID) which is useful as an analgesic and antipyretic and the dosage for adults is 1-3.2 gm daily (maximum 3.2 gm daily). This patient took 1-4 gm daily for 1 year for headache relief and chronic rhinitis. Ibuprofen causes an increased risk of serious gastrointestinal GI adverse events² including bleeding, ulceration and perforation of the stomach or intestine which can be fatal. These events can occur at any time during use and without warning symptoms. Especially elderly patients are at greater risk for serious GI events. He was treated by stopping Ibuprofen. Antacid drugs and symptomatic drugs were prescribed, and eventually his abdominal pain subsided and the patient returned to a healthy condition within a week’s time.