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Gastroenterology Research

Case Report

Volume 3, Number 2, April 2010, pages 91-92

Nicorandil Induced Colonic Ulcer: A Late Complication?

Nicorandil is used for the treatment of ischemic heart disease. Oral and anal ulcerations are rare but recognized side effects of the drug occurring within few months of commencement of the treatment [1, 2]. Colonic ulcers are even rarer [3, 4]. Exact pathogenesis of these ulcers is not known but it appears to be related to the dose of Nicarandil [5]. Relationship of ulcer with duration of treatment is not known.

We present a case of 82 years old lady who developed colonic ulcers 8 years after commencing on nicorandil for ischemic heart disease.

An 82-year-old lady was presented with abdominal pain and constipation. She had colonoscopy which revealed a 2 x 2 cm polyp at 22 cm. This was excised. Histology showed a tubulovillous adenoma with mild dysplasia. She had 2 further “follow-up” colonoscopies at 2 yearly intervals. These were normal. A further colonoscopy 3 years later showed circumferential ulcer at the junction of the proximal and middle third of transverse colon (Fig. 1). Histology showed non-specific inflammatory changes; there was no evidence of granulomata, dysplasia or neoplasia. Persistent ulceration was noted on 2 further colonoscopies at one year interval (Fig. 2). Biopsies were benign on both the occasions. The ulceration was thought to be secondary to mucosal prolapse.

Click for large image

Figure 1. Ulceration in transverse colon noted 8 years after commencing Nicorandil.

Nicorandil, a potassium activator is a third line drug in the treatment of severe ischaemic heart disease [4]. It acts by relaxing the smooth muscle of the blood vessels, causing both arterial and venous vasodilatation. Its use has been associated with oral and anal ulcerations [6, 7], but ulcers at other sites in gastrointestinal tract have also been described [8, 9].

Pathogenesis of these ulcers is not known, but they appear to be related to the dose of Nicorandil and resolve upon withdrawal of the drug with median healing time of 12 weeks. Other proposed mechanisms are vascular steal phenomenon and direct local effect of either Nicorandil itself or its metabolite [5].

Most of the oral ulcers develop within few months of commencing the Nicorandil [10]. Our patient though on a high dose of Nicorandil developed ulcers in the colon 8 years after commencingtreatment, suggesting that this may be a long term effect of the drug. Her 3 colonoscopies during these 8 years did not show any evidence of ulceration. Healing of ulcer on discontinuing the medication confirmed the etiological role of Nicorndil.

Nicorandil should be considered in the differential diagnosis of idiopathic gastrointestinal ulceration to avoid unnecessary surgical intervention. Physicians prescribing the drug should be aware of this side effect. This drug is used for ischemic heart disease and patients using this are also more likely to be on anticoagulants which increase the risk of bleeding from ulcers. Surgeons treating the patients with per rectal bleeding should consider discontinuing Nicorandil along with anticoagulation in appropriate circumstances.

Most of the ulcers develop within few months of commencing the Nicorandil [10]. Our patient developed ulcer in colon 8 years after commencing the treatment suggesting that this may be a long term effect of the drug.

Competing Interests

None to declare.

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Gastroenterology Research is published by Elmer Press Inc.