DA94 - Non-Infectious Enteritis or Ulcer of the Small Intestine: Complete Coding Guide

1. Introduction

Enteritis or non-infectious ulcer of the small intestine represents a set of inflammatory and ulcerative conditions affecting the small intestine without infectious origin. This diagnostic category encompasses lesions caused by medications, adverse effects of oncologic treatments such as chemotherapy and radiotherapy, as well as allergic and systemic disorders that compromise the integrity of the intestinal mucosa.

The clinical importance of this condition lies in its increasing prevalence, especially in populations undergoing prolonged oncologic treatments and in chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs). Studies demonstrate that medication-induced enteritis represents a frequent cause of gastrointestinal morbidity, and can lead to serious complications such as bleeding, perforation, and intestinal obstruction.

From a public health perspective, the appropriate recognition of these conditions is fundamental for the proper management of patients undergoing oncologic treatment, elderly polymedicated individuals, and individuals with autoimmune diseases. The severity can range from mild and self-limited symptoms to potentially fatal conditions that require urgent surgical intervention.

Correct coding using ICD-11 is critical for several reasons: it enables appropriate epidemiologic tracking of these conditions, facilitates appropriate resource allocation in health systems, aids in clinical research on risk factors and outcomes, and ensures appropriate reimbursement for services provided. Furthermore, the precise distinction between infectious and non-infectious enteritis guides fundamentally different therapeutic decisions, avoiding unnecessary use of antimicrobials and directing treatment toward the underlying cause.

2. Correct ICD-11 Code

Code: DA94

Description: Non-infectious enteritis or ulcer of the small intestine

Parent category: Diseases of the small intestine

Official definition: Non-infectious enteritis and ulcer of the small intestine constitute inflammation or tissue injury in the small intestine of non-infectious origin, usually due to medications, including side effects of chemotherapy or radiotherapy; or allergic or systemic disorders. Its severity can range from mild and bothersome to severe and life-threatening.

This code was developed to specifically capture intestinal injuries of non-infectious nature, clearly differentiating them from enteritis caused by pathogenic agents. The classification recognizes the multifactorial nature of these conditions and the importance of identifying the underlying etiology to guide appropriate clinical management.

Code DA94 belongs to the chapter on diseases of the digestive system in ICD-11 and is positioned within the hierarchy that organizes conditions of the small intestine. This location facilitates navigation by healthcare professionals and coders, allowing for quick and accurate identification of the appropriate code during the clinical documentation process.

The explicit inclusion of medication-related causes, effects of oncologic treatments, and systemic disorders in the official definition reflects contemporary understanding of the main etiologies of this condition and guides professionals on when this code should be applied.

3. When to Use This Code

The DA94 code should be used in specific clinical situations where there is clear evidence of inflammation or ulceration of the small intestine without an infectious component. Below are the most common practical scenarios:

NSAID-induced enteritis: Patients on chronic use of nonsteroidal anti-inflammatory drugs who develop abdominal pain, diarrhea, iron deficiency anemia from chronic blood loss, and endoscopic or capsule endoscopy evidence of ulcers or erosions in the small intestine. This scenario is particularly common in elderly patients with rheumatic diseases who use these medications regularly. Diagnosis requires temporal correlation between medication use and symptom onset, in addition to exclusion of infectious causes.

Radiation enteritis (radiation-induced): Patients undergoing abdominal or pelvic radiotherapy for treatment of neoplasms (cancer of the colon, rectum, prostate, uterus, ovary, or bladder) who develop gastrointestinal symptoms during or after treatment. Radiation enteritis can manifest acutely during treatment or chronically months to years after completion of radiotherapy. Symptoms include diarrhea, abdominal pain, bleeding, and malabsorption. Diagnosis is based on history of prior radiotherapy, characteristic endoscopic findings, and exclusion of other causes.

Chemotherapy-induced enteritis: Oncology patients receiving chemotherapeutic agents such as 5-fluorouracil, methotrexate, irinotecan, or alkylating agents who develop intestinal mucositis. This condition manifests with severe diarrhea, abdominal pain, nausea, and vomiting during or shortly after chemotherapy cycles. Severity can range from mild to potentially fatal, with risk of sepsis secondary to bacterial translocation. The DA94 code is appropriate when the causal relationship with chemotherapy is established and infectious causes have been excluded.

Eosinophilic enteritis: Patients with eosinophilic infiltration of the small intestine wall, manifesting with abdominal pain, diarrhea, malabsorption, and weight loss. Diagnosis requires intestinal biopsy demonstrating significant eosinophilic infiltrate in the absence of parasitic infections or other causes of tissue eosinophilia. This condition may be associated with food allergies, atopic disorders, or be idiopathic.

Small intestine ulcers associated with immunosuppressive medications: Patients on mycophenolate mofetil, azathioprine, or other immunosuppressants who develop intestinal ulcers. These lesions may occur in transplant recipients or patients with autoimmune diseases undergoing immunosuppressive treatment. Clinical presentation includes abdominal pain, diarrhea, and potentially intestinal perforation.

Enteritis associated with systemic diseases: Patients with systemic vasculitides, refractory celiac disease, or other autoimmune conditions who develop small intestine inflammation as a manifestation of the underlying disease. The DA94 code is appropriate when enteritis is secondary to the systemic condition and there is no superimposed infectious component.

4. When NOT to Use This Code

It is fundamental to distinguish situations where code DA94 is not appropriate, avoiding coding errors that may compromise the quality of clinical data:

Crohn's disease of the small intestine (code 1221996518): When there is evidence of chronic inflammatory bowel disease characterized by transmural inflammation, segmental pattern, presence of non-caseating granulomas or typical complications such as fistulas and stenoses. Crohn's disease has distinct histopathological and clinical characteristics that differentiate it from non-infectious enteritis. The presence of perianal involvement, terminal ileal involvement with "cobblestone" pattern and family history of inflammatory bowel disease favor the diagnosis of Crohn's disease.

Functional diarrhea (code 1150846989): When the patient presents with chronic diarrhea without evidence of intestinal inflammation, structural alterations or identifiable organic causes. Functional diarrhea is a diagnosis of exclusion within functional gastrointestinal disorders, characterized by recurrent liquid or soft stools without significant abdominal pain and with normal complementary tests.

Non-infectious neonatal diarrhea (code 1478592418): When diarrhea occurs specifically in the neonatal period, requiring specific coding for this age group. The causes of neonatal diarrhea have pathophysiological and etiological particularities that justify a separate diagnostic category.

Infectious enteritis: When there is identification of an infectious agent (bacterial, viral, parasitic or fungal) through cultures, molecular tests or parasitological examinations. Even if the patient is using medications potentially causing enteritis, the confirmed presence of infection requires the use of specific codes for infectious enteritis.

Intestinal obstruction: When the clinical presentation is predominantly obstructive, even if there is an associated inflammatory component. Intestinal obstruction requires specific coding due to its distinct therapeutic implications.

It is essential to perform adequate diagnostic investigation, including imaging studies, endoscopy when indicated, and exclusion of infectious causes before assigning code DA94.

5. Step-by-Step Coding Process

Step 1: Assess diagnostic criteria

The first step in appropriate coding is to confirm that the patient presents with objective evidence of enteritis or small intestine ulcer. This requires:

Clinical evaluation: Documentation of compatible symptoms including abdominal pain, diarrhea, gastrointestinal bleeding (manifested by iron deficiency anemia or melena), nausea, vomiting, weight loss, and signs of malabsorption. The clinical history should detail the chronology of symptoms, medications in use, previous or ongoing oncologic treatments, and presence of systemic diseases.

Laboratory tests: Complete blood count to assess anemia and leukocytosis, inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), serum albumin, renal function and electrolytes. Liver function tests and malabsorption markers such as vitamin B12 and folate may be relevant.

Imaging studies: Computed tomography or magnetic resonance imaging of the abdomen can demonstrate bowel wall thickening, wall edema, ascites, or complications such as perforation. Computed tomography or magnetic resonance enterography offers better evaluation of the intestinal mucosa.

Endoscopic methods: Video capsule endoscopy is particularly useful for direct visualization of the small intestine mucosa, identifying ulcers, erosions, stenoses, and areas of bleeding. Balloon-assisted enteroscopy allows not only visualization but also biopsy of identified lesions.

Step 2: Verify specifiers

After confirming the diagnosis, it is necessary to adequately characterize the condition:

Severity: Classify as mild (minimal symptoms without significant functional impact), moderate (symptoms that interfere with daily activities, requiring therapeutic adjustments), or severe (incapacitating symptoms, complications such as significant bleeding, perforation, or need for hospitalization).

Specific etiology: Identify and clearly document the underlying cause: medication-induced (specifying the drug), radiation-induced (detailing previous radiotherapy), chemotherapy-related (identifying the protocol used), or associated with a specific systemic disorder.

Duration: Distinguish between acute presentation (recent symptoms related to recent exposure to the causal factor) and chronic (persistent or recurrent symptoms, as in chronic radiation enteritis).

Complications: Document presence of bleeding, anemia, malnutrition, electrolyte imbalances, perforation, or secondary obstruction.

Step 3: Differentiate from other codes

DA90 (Nonstructural anomalies of small intestine development): This code refers to congenital or developmental alterations, while DA94 is for acquired conditions. The key difference is the congenital versus acquired nature of the condition. If the patient has intestinal malrotation or another developmental anomaly, use DA90. If enteritis developed after exposure to medications or radiation, use DA94.

DA91 (Small intestine obstruction): Although noninfectious enteritis may occasionally cause secondary obstruction, code DA91 is used when obstruction is the primary and predominant manifestation. The key difference is the clinical presentation: obstruction presents with abdominal distension, absence of gas and stool passage, vomiting, and radiologic signs of obstruction. If obstruction is secondary to enteritis, code both conditions appropriately.

DA92 (Other acquired anatomical alterations of small intestine): This code is for acquired structural alterations that are not primarily inflammatory or ulcerative. The key difference is the nature of the lesion: DA92 for anatomical alterations such as fibrotic stenoses, adhesions, or acquired diverticula without active inflammation. DA94 for active inflammatory or ulcerative processes. In cases of chronic radiation enteritis with established fibrotic stenosis, it may be necessary to consider both codes.

Step 4: Required documentation

For appropriate coding and audit defense, documentation should include:

Mandatory checklist:

Detailed description of symptoms and their chronology
Current and previous medications, with doses and duration of use
History of radiotherapy or chemotherapy with dates, doses, and radiation fields
Results of relevant laboratory tests
Reports of imaging studies describing findings in the small intestine
Endoscopy or video capsule endoscopy reports with description of lesions
Biopsy results when available
Documented exclusion of infectious causes (negative cultures, negative tests)
Differential diagnosis considered
Assessment of severity and presence of complications
Established causal relationship between the etiologic factor and enteritis

6. Complete Practical Example

Clinical Case:

A 68-year-old female patient with a diagnosis of rectal cancer 18 months ago, who underwent low anterior resection followed by adjuvant chemoradiotherapy. She completed radiotherapy treatment 14 months ago, having received a total dose of 50.4 Gy in the pelvic field. She initially progressed well, but 4 months ago developed a progressive picture of liquid diarrhea (6-8 bowel movements daily), colicky abdominal pain, weight loss of 8 kg, and intense fatigue.

On physical examination, she appeared emaciated and pale, with a slightly distended abdomen and diffuse tenderness on palpation, without signs of peritoneal irritation. Laboratory tests revealed hemoglobin of 9.2 g/dL, serum albumin of 2.8 g/dL, elevated C-reactive protein. Stool cultures and Clostridium difficile toxin testing were negative.

Abdominal computed tomography demonstrated diffuse thickening of small bowel loops, mainly ileum, with mucosal enhancement and wall edema. Video capsule endoscopy revealed multiple shallow ulcers and areas of friable mucosa with telangiectasias in the ileum, compatible with radiation enteritis. Enteroscopy biopsy confirmed chronic inflammatory changes with submucosal fibrosis and vascular ectasia, without evidence of malignancy or infection.

Step-by-Step Coding:

Criteria Analysis:

Diagnostic confirmation: Patient presents clinical, laboratory, radiological, and endoscopic evidence of small bowel enteritis.
Non-infectious nature: Negative stool cultures and lack of response to antimicrobial treatment exclude infectious etiology.
Identified etiology: Clear history of prior pelvic radiotherapy with compatible chronology (symptoms started 10 months after completion of radiotherapy, within the temporal window for chronic radiation enteritis).
Exclusion of alternative diagnoses: Absence of Crohn's disease characteristics (no perianal involvement, no granulomas, different lesion pattern), not functional diarrhea (documented organic alterations present), not intestinal obstruction (absence of obstructive signs).

Code selected: DA94 - Noninfective enteritis or ulcer of small intestine

Complete justification:

This code is appropriate because the patient presents with small bowel enteritis of clearly non-infectious etiology, secondary to prior radiotherapy treatment. The official definition of code DA94 explicitly specifies "adverse effects of chemotherapy or radiotherapy" as one of the main causes of this condition.

The endoscopic findings of ulcers and telangiectasias are characteristic of radiation enteritis. The chronology (symptoms starting months after completion of radiotherapy) is typical of the chronic form of this condition. The exclusion of infectious causes through negative microbiological testing confirms the non-infectious nature of the enteritis.

Applicable complementary codes:

Code for secondary anemia (if coding of comorbidities is necessary)
Code for protein-calorie malnutrition (considering hypoalbuminemia and significant weight loss)
Code for history of malignant neoplasm of rectum (for complete clinical context)

7. Related Codes and Differentiation

Within the Same Category:

DA90: Non-structural anomalies of small intestine development

When to use DA90: Pediatric patient with history of gastrointestinal symptoms since birth, investigation reveals intestinal malrotation or other congenital anomaly of small intestine development.

When to use DA94: Adult patient who develops enteritis after initiation of anti-inflammatory treatment or after radiotherapy.

Main difference: DA90 is for congenital or developmental conditions present since birth or early childhood, while DA94 is for inflammatory conditions acquired throughout life, typically related to environmental, medication, or therapeutic exposures.

DA91: Obstruction of small intestine

When to use DA91: Patient presents with progressive abdominal distension, vomiting, absence of gas and stool passage, and imaging demonstrating air-fluid levels and dilated bowel loops with transition point.

When to use DA94: Patient with diarrhea, abdominal pain, and endoscopic evidence of inflammation or ulceration without signs of obstruction.

Main difference: DA91 refers to mechanical blockage of intestinal transit, while DA94 refers to inflammatory or ulcerative process of the mucosa. In cases where chronic enteritis (such as radiation-induced) has led to development of obstructive stenosis, both codes may be necessary, with the obstruction code as the primary diagnosis if this is the acute manifestation that prompted the visit.

DA92: Other acquired anatomical alterations of small intestine

When to use DA92: Patient with history of prior abdominal surgery develops intestinal adhesions, or patient with acquired diverticula of small intestine without active inflammation.

When to use DA94: Patient with evidence of active inflammation or ulceration of intestinal mucosa related to medications or radiation.

Main difference: DA92 is for structural or anatomical alterations without primary active inflammatory process, while DA94 is specifically for active inflammatory or ulcerative processes. The distinction can be challenging in cases of chronic radiation enteritis where there is both fibrosis (anatomical alteration) and residual inflammation; in these cases, the predominant component should guide primary coding.

Differential Diagnoses:

Celiac disease: Distinguished by presence of specific antibodies (anti-tissue transglutaminase, anti-endomysium), villous atrophy on histopathological examination, and response to gluten-free diet. Although it can cause enteritis, it has specific coding.

Intestinal lymphoma: Can present with similar symptoms, but biopsy reveals malignant lymphoid proliferation. Requires specific oncological coding.

Chronic mesenteric ischemia: Characterized by postprandial abdominal pain (intestinal angina), abdominal bruit, and evidence of mesenteric arterial stenosis on vascular studies.

8. Differences with ICD-10

In ICD-10, non-infectious enteritis was coded in a less specific manner, frequently using code K52.9 (Gastroenteritis and colitis, non-infectious, unspecified) or more specific codes such as K52.1 (Toxic gastroenteritis and colitis) when there was a relationship with medications.

The main change in ICD-11 with code DA94 is increased specificity for small intestine conditions, clearly separating them from colonic conditions. ICD-10 frequently grouped gastroenteritis and colitis under the same codes, making precise anatomical distinction difficult.

Another significant difference is the explicit inclusion in the ICD-11 definition of specific causes such as chemotherapy and radiotherapy, reflecting the growing importance of these etiologies in contemporary clinical practice. ICD-10 required additional external cause codes to specify these etiologies.

The practical impact of these changes includes greater epidemiological precision, allowing more accurate tracking of gastrointestinal complications from oncologic treatments, better resource allocation for management of these conditions, and facilitation of clinical research on prevention and treatment of therapy-induced enteritis.

For professionals and institutions transitioning from ICD-10 to ICD-11, it is important to review cases previously coded as K52.1 or K52.9 to determine whether DA94 would be more appropriate, especially when there is clear documentation of small intestine involvement and non-infectious etiology.

9. Frequently Asked Questions

How is the diagnosis of non-infectious enteritis made?

The diagnosis requires a multifaceted approach. It begins with a detailed clinical history identifying symptoms (diarrhea, abdominal pain, weight loss), medications in use, previous oncologic treatments, and systemic diseases. Laboratory tests evaluate anemia, inflammation, and malabsorption. Exclusion of infectious causes is fundamental through stool cultures and parasite tests. Imaging studies such as computed tomography or magnetic resonance enterography identify intestinal wall thickening and complications. Video capsule endoscopy is the gold standard for direct visualization of the small bowel mucosa, allowing identification of ulcers, erosions, and inflammatory patterns. Biopsy through enteroscopy confirms the diagnosis and excludes other conditions such as lymphoma or celiac disease.

Is treatment available in public health systems?

Treatment for non-infectious enteritis is generally available in public health systems, although the availability of specific diagnostic technologies such as video capsule endoscopy may vary among different regions and institutions. Management includes supportive measures such as hydration, nutritional correction, and symptomatic control that are widely accessible. Medications such as corticosteroids, somatostatin analogs for radiation enteritis, and mucosal protective agents are frequently provided. More specialized treatments such as hyperbaric therapy for severe radiation enteritis may have limited availability. Discontinuation or modification of causative medications is a low-cost and highly effective intervention.

How long does treatment last?

The duration of treatment varies significantly depending on the etiology and severity. NSAID-induced enteritis generally improves within weeks after medication discontinuation, although complete healing may take months. Chemotherapy-related enteritis typically resolves after completion of the treatment cycle, but may require support for weeks. Acute radiation enteritis generally improves gradually after completion of radiotherapy, but the chronic form may persist indefinitely, requiring long-term management. Eosinophilic enteritis may require prolonged treatment with corticosteroids or dietary elimination for months to years. Severe cases with complications may require prolonged hospitalization and surgical interventions.

Can this code be used in medical certificates?

Yes, the code DA94 can and should be used in medical certificates when appropriate, especially in contexts where non-infectious enteritis causes temporary or permanent work disability. Documentation should include a description of the condition, its severity, and the functional impact on the patient's work capacity. In cases of severe enteritis secondary to chemotherapy or radiotherapy, the certificate may justify leave during the treatment and recovery period. It is important that the certificate be accompanied by adequate supporting documentation, including complementary tests that confirm the diagnosis.

Can patients with non-infectious enteritis develop serious complications?

Yes, although many cases are mild to moderate, serious complications can occur. Significant gastrointestinal bleeding can lead to severe anemia requiring transfusions. Intestinal perforation is a potentially fatal complication that requires urgent surgical intervention, particularly in cases of deep drug-induced ulcers. Intestinal obstruction can develop secondary to fibrotic strictures, especially in chronic radiation enteritis. Severe malabsorption can result in severe malnutrition, vitamin deficiencies, and electrolyte imbalances. Sepsis can occur due to bacterial translocation through damaged mucosa, especially in immunosuppressed patients.

How to differentiate non-infectious enteritis from Crohn's disease?

Differentiation can be challenging but is fundamental. Crohn's disease typically presents in younger patients, has a relapsing-remitting course, frequently involves the terminal ileum with a segmental pattern, and may have extraintestinal manifestations (articular, cutaneous, ocular). Histologically, the presence of non-caseating granulomas is characteristic of Crohn's disease. Perianal involvement with fistulas or abscesses favors Crohn's disease. Non-infectious enteritis generally has a clear temporal relationship with a triggering factor (medication, radiation), distribution correlated with the radiation field or diffuse pattern in medication-induced cases, and absence of granulomas. Positive family history of inflammatory bowel disease favors Crohn's disease.

Can radiation enteritis be prevented?

Prevention strategies exist but do not completely eliminate the risk. Modern radiotherapy techniques such as IMRT (intensity-modulated radiotherapy) and image-guided radiotherapy allow better field delineation and reduced exposure of healthy intestine. Appropriate dose fractionation reduces toxicity. Use of spacers between rectum and prostate in prostate radiotherapy minimizes rectal and small bowel exposure. Some studies suggest benefit from probiotics, glutamine, or other supplements during radiotherapy, but evidence is limited. Identification of individual risk factors (vascular disease, diabetes, smoking, previous abdominal surgery) allows stratification and potentially adjustments to the treatment plan.

Is there specific treatment for NSAID-induced enteritis?

The fundamental treatment is discontinuation of the causative NSAID, with substitution by alternative analgesics when necessary. Proton pump inhibitors, although effective for gastric lesions, have limited benefit for enteritis. Misoprostol may offer some protection but is often poorly tolerated. Cases with bleeding may require endoscopic hemostatic therapy if the lesions are accessible. Iron supplementation for anemia and nutritional support are important. In severe refractory cases, surgery may be necessary for resection of severely affected or complicated segments due to perforation or obstruction. Prevention through judicious use of NSAIDs, especially in elderly and high-risk patients, is the best strategy.

Conclusion:

The code DA94 of ICD-11 represents an advance in diagnostic specificity for non-infectious enteritis and ulcers of the small intestine, allowing better characterization of these clinically important conditions. Appropriate coding requires clear understanding of definitions, diagnostic criteria, and differentiation of similar conditions. Healthcare professionals should be aware of the increasing prevalence of these conditions, especially in the context of oncologic treatments and chronic medication use, ensuring appropriate documentation and adequate clinical management to optimize patient outcomes.

External References

This article was prepared based on reliable scientific sources:

References verified on 2026-02-04

Noninfectious enteritis or ulcer of the small intestine

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