Profuse diarrhea after misoprostol use in a patient with a history of Crohn's disease

OBJECTIVE: To report a case of profuse diarrhea after misoprostol use in a patient with a history of Crohn's disease and to discuss the role of eicosanoids in Crohn's disease. DATA SOURCES: Patient medical records, case reports, review articles identified by MEDLINE, and personal communication with the physician, patient, and manufacturer. DATA EXTRACTION: From interviews, the manufacturer, and pertinent published sources by one author and reviewed by the others. DATA SYNTHESIS: A 55-year-old woman presented to clinic complaining of multiple joint pains. Her medical history was significant for peptic ulcer disease, hypertension, and Crohn's disease in remission since May 1989. Her joint pains were treated with ibuprofen 600 mg po qid and misoprostol 200 micrograms po qid (after meals and at bedtime). Following the administration of three doses of ibuprofen and misoprostol, the patient experienced abdominal cramps, pain, and voluminous, watery diarrhea for two days. Upon discontinuation of the ibuprofen and misoprostol, all of her gastrointestinal symptoms resolved within 12 hours. Rechallenge with ibuprofen alone failed to produce a recurrence of symptoms. Enhanced synthesis of intestinal eicosanoids has been demonstrated in Crohn's disease. Misoprostol, a synthetic analog of one of the eicosanoids, could induce a flare-up of Crohn's disease as suggested in this patient. CONCLUSIONS: Misoprostol should be used with caution in patients with known inflammatory bowel disease.