Clinical analysis of 99 children with Henoch-Schönlein purpura complicated with overt gastrointestinal bleeding

Can the affected intestinal segment visualized on abdominal ultrasound predict gastrointestinal tract bleeding in immunoglobulin A vasculitis?

OBJECTIVES

The study aimed to evaluate immunoglobulin A vasculitis (IgAV) patients with gastrointestinal (GI) tract involvement and to reveal the relationship between the location and extent of the affected intestinal segment detected on the initial abdominal ultrasound and GI tract bleeding.

METHODS

This medical record review study was conducted on 117 IgAV patients with GI tract involvement between January 2016 and June 2023. Patients were divided into two groups: those with (n = 28) and without (n = 89) GI tract bleeding. Predictors of GI tract bleeding were investigated by comparing demographic, clinical characteristics, and laboratory findings.

RESULTS

Gender, age at diagnosis, symptoms at admission, rash distribution, GI tract complaints, and the elapsed time until the development of GI tract symptoms were similar in both groups. There was no difference between small intestinal, large intestinal, or small + large intestinal involvement (P = .89). The ileum was the most commonly affected intestinal segment in patients with and without GI tract bleeding (P = .37). Jejunal wall thickening (P = .04) and the number of affected intestinal segments (P = .008) were higher in patients with GI tract bleeding.

CONCLUSIONS

In IgAV patients, jejunum involvement and affected multiple intestinal segments shown by abdominal ultrasound are associated with GI tract bleeding.

Predictive Laboratory Markers for Gastrointestinal Complications in Children with Henoch-Schönlein Purpura

Background

Henoch-Schönlein Purpura (HSP) is a common systemic vasculitis in children that often involves the gastrointestinal system (GIS). Identifying reliable predictive markers for GIS complications is crucial for early intervention and improved patient outcomes.

Objective

This study aims to identify laboratory markers predictive of GIS complications in children with HSP using a machine learning approach.

Methods

This retrospective study included children diagnosed with HSP and a control group from May 2020 to January 2024. Detailed demographic and laboratory data, including WBC count, lymphocyte count, neutrophil count, platelet count, hemoglobin, NLR, PLR, MPV, MPR, C-reactive protein, ESR, albumin, BUN, creatinine, sodium, potassium, calcium, IgA, PT, aPTT, and INR, were collected. GIS complications was classified based on clinical symptoms and diagnostic findings. Patients were categorized into groups without GIS complications, with mild GIS complications, and with severe GIS complications. We compared laboratory parameters across these groups to identify significant differences associated with GIS complications. Furthermore, a predictive model was developed by a Random Forest classifier to identify key markers and assess their ability to distinguish between patients with and without GIS complications.

Results

Significant differences were observed in several laboratory parameters between HSP patients and the control group, and between patients with and without GIS complications. Key predictive markers identified included neutrophil count, NLR, WBC count, PLR, and platelet count. The RandomForest model achieved an accuracy of 91% and an AUC of 0.90.

Conclusion

Our findings highlight the importance of specific laboratory markers in predicting GIS complications in HSP. The use of machine learning models can enhance the early identification and management of high-risk patients, potentially improving clinical outcomes.

Abdominal imaging and endoscopic characteristics of adult abdominal IgA vasculitis: a multicenter retrospective study

BACKGROUND

IgA vasculitis (IgAV), previously known as Henoch-Schönlein purpura, is an IgA-mediated systemic small vessel vasculitis that tends to be more severe in adults than in children. Early diagnosis of IgAV involving the gastrointestinal tract remains difficult, especially in patients who present with gastrointestinal symptoms before purpura. This study aims to systematically analyze the abdominal imaging and endoscopic features of adult patients with abdominal IgAV, providing assistance to clinicians in the early recognition of this condition.

PATIENTS AND METHODS

This multicenter retrospective study was conducted in three large tertiary hospitals in China from January 2017 to January 2024. A total of 108 adult patients with abdominal IgAV, who had complete abdominal imaging and/or endoscopy results, were enrolled. The clinical manifestations, abdominal imaging findings, endoscopic characteristics, and serological indicators of the patients were analyzed.

RESULTS

The median age of the patients was 40 years (IQR: 26-55), with a male-to-female ratio of 2:1. Acute abdominal pain was the most common presenting symptom (100 patients, 92.59%). Bowel wall thickening was the most frequent finding on abdominal imaging (50/86 patients, 58.14%). Gastrointestinal endoscopy showed findings of congestion and erosion (32/67 patients, 47.76%), and erosion with ulcers (21/67 patients, 31.34%). Among patients with both imaging and endoscopic results, the duodenum (28/51 patients, 54.90%) and ileum (28/51 patients, 54.90%) were the most commonly affected sites. Laboratory findings revealed elevated white blood cell count (WBC), neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), D-dimer and fibrinogen levels, along with decreased albumin level. Comparing patients with gastrointestinal symptoms versus purpura as the initial symptom, those with gastrointestinal symptoms had higher levels of WBC (p < 0.05) and NLR (p < 0.01).

CONCLUSIONS

The most common symptom in adult abdominal IgAV patients is acute abdominal pain. In the early stage of the disease, most patients exhibit elevated levels of WBC, NLR, CRP, D-dimer, and fibrinogen, along with decreased albumin level. The duodenum and ileum are the most commonly affected sites. By integrating these findings, clinicians can identify abdominal IgAV patients earlier and more accurately.

Gastrointestinal bleeding in children with Henoch-Schönlein purpura combined with prognostic nutrition index may predict endoscopic duodenal ulcers during hospitalization: A single-center retrospective case-control study

Duodenal ulcer (DU) is the most common gastroscopic manifestation of abdominal Henoch-Schönlein purpura (HSP), which may cause severe bleeding and often requires esophagogastroduodenoscopy (EGD) to confirm the diagnosis. However, the condition of children with HSP changes rapidly; not all children are able to undergo EGD on time, and some hospitals do not have a pediatric EGD unit. Therefore, assessing the risk factors for developing DU in HSP using simple and readily available indicators is essential. Children with HSP at Wuhan Children Hospital from June 2020 to June 2022 were included in the training set and completed EGD. The patients were divided into 2 groups: those with (DU group) and without DU (non-DU group). Data were collected from the 2 groups, and univariate and multivariate logistic regression analyses were used to compare the 2 groups. Children with HSP admitted between July 2022 and June 2023 were included in the validation set. Four indicators, prognostic nutrition index, albumin (ALB), gastrointestinal (GI) bleeding, and duration of onset before EGD, were found in the DU and non-DU groups. GI bleeding and prognostic nutritional index (PNI) ≤ 53.0 have strong predictability for patients with HSP and DU. GI bleeding and PNI ≤ 53.0 may provide new reference evidence for condition assessment and treatment.

Multidrug-resistant IgA Vasculitis with Gastrointestinal Symptoms Successfully Treated with Intravenous Cyclophosphamide and Maintained with Mycophenolate Mofetil

We present the case of a 17-year-old woman with IgA vasculitis (IgAV) who presented with relapsing gastrointestinal (GI) symptoms that were refractory to glucocorticoid and combination therapy with cyclosporine A, azathioprine or mycophenolate mofetil (MMF). The patient responded well to remission induction with intravenous cyclophosphamide (IVCY) and was successfully maintained with MMF. Remission induction with IVCY followed by maintenance therapy with MMF was effective in a patient with multidrug-resistant IgAV with GI lesions.

Immunological Features of Children with Gastrointestinal Bleeding Due to Henoch-Schönlein Purpura

Background

This study aims to evaluate the immunological features of gastrointestinal (GI) bleeding in children with Henoch-Schönlein purpura (HSP).

Study Design

This retrospective study was conducted on children with HSP. Demographic and clinical data were collected, including serum immunoglobulin (Ig) levels, complement C3 and C4 levels, and lymphocyte subtype percentage.

Results

A total of 446 hospitalized children had HSP. Eighty-six children with HSP had GI bleeding, 114 had proteinuria, and 107 had hematuria. Lower arthralgia, prolonged glucocorticoid use, increased white blood cell counts, elevated neutrophils and neutrophil-to-lymphocyte ratio, reduced IgG and C3 levels, elevated CD19+ cell percentage, and reduced CD3+ cell and natural killer cell percentages were associated with GI bleeding risk in patients with HSP. Multivariate regression analysis revealed that arthralgia, glucocorticoid use, increased neutrophil percentage, reduced IgG and C3 levels, and increased CD19+ cell percentage were independent predictors of GI bleeding. Further analysis indicated that the combination of C3 and CD19+ cell percentages had a high predictive ability for GI bleeding in children with HSP.

Conclusion

This study indicated that reduced C3 and increased CD19+ cell percentages contributed to the development of GI bleeding in children with HSP. Specific immunologic profiles may be strongly correlated with GI bleeding risk in children with HSP.

Clinical characteristics and risk factors of IgA vasculitis with intussusception and intestinal perforation

AIM

Intussusception is the most common surgical complication of IgA vasculitis (IgAV), and intestinal perforation is usually associated with intussusception. If they are not recognised and treated in a timely manner, serious consequences may occur. The objective is to summarise the clinical features of IgAV complicated by intussusception and intestinal perforation and explore its risk factors.

METHODS

The clinical data of 32 patients with IgAV complicated by surgical complications (25 cases of intussusception and 7 cases of intestinal perforation) were retrospectively analysed. A total of 160 IgAV children with gastrointestinal (GI) involvement but without surgical complications were randomly selected as a control group. Binary logistic regression analysis was performed to explore the risk factors for IgAV with intussusception and intestinal perforation.

RESULTS

Compared with the intussusception group, the intestinal perforation group had a significantly higher number of patients with GI symptoms prior to skin purpura and GI bleeding, a significantly higher number of days of abdominal pain, a significantly higher Wong-Baker score, and a significantly higher white blood cell count. Multivariate logistic regression analysis indicated that age ≤7 years, GI symptoms prior to skin purpura, abdominal pain intensity (Wong-Baker scale) and timing of glucocorticoid treatment were independent risk factors of IgAV with intussusception and intestinal perforation.

CONCLUSION

Age less than 7 years, severe abdominal pain, and GI symptoms prior to skin purpura were risk factors for IgAV with intussusception and intestinal perforation. Early use of glucocorticoids may prevent intussusception and intestinal perforation.

Age-specific causes of upper gastrointestinal bleeding in children

The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.

Serum total bile acid levels assist in the prediction of acute intussusception with abdominal type Henoch-Schonlein purpura in children

Background

The severe acute abdomen associated with Henoch-Schonlein purpura (HSP) is an acute intussusception (AI). There is no reliable specific marker for AI with abdominal-type HSP. The serum total bile acid (TBA) level is a new prognostic marker associated with the severity of intestinal inflammation. The purpose of this study was to identify the prognostic value of serum TBA levels for the diagnosis of AI in children with abdominal-type HSP.

Methods

A retrospective study of 708 patients with abdominal-type HSP was conducted, with demographic data, clinical symptoms, hepatic function index, immune function markers, and clinical outcomes assessed. Patients were divided into two groups: HSP (613 patients) and HSP with AI (95 patients). The data were analysed using SPSS 22.0.

Results

Of the 708 patients, the serum TBA levels were higher in the HSP with AI group than in the HSP group (P < 0.05). Logistic regression analysis showed that vomiting (OR = 396.492, 95% CI = 14.93-10,529.67, P < 0.001), haematochezia (OR = 87.436, 95% CI = 5.944-1,286.214, P = 0.001), TBA (OR = 16.287, 95% CI = 4.83-54.922, P < 0.001), and D-dimer (OR = 5.987, 95% CI = 1.892-15.834, P = 0.003) were independent risk factors for abdominal-type HSP with AI. Receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off serum TBA value (sensitivity = 91.58%, specificity = 84.67%, AUC = 93.6524%) was >3 μmol/L for predicting AI in children with abdominal-type HSP. In this group of HSP patients with AI, a serum TBA level ≥6.98 μmol/L was significantly associated with an increased incidence of operative treatment (51.85% vs. 75.61%, P = 0.0181), intestinal necrosis (9.26% vs. 29.27%, P = 0.0117), and length of hospital stay [15.76 ± 5.31 vs. 10.98 ± 2.83 (days), P < 0.0001].

Conclusion

In children with HSP and AI, the serum TBA level was significantly higher. A novel but promising haematological indicator, the serum TBA level, helps identify HSP with and without AI and predicts intestinal necrosis in HSP with AI.

Immunoglobulin a vasculitis with testicular/epididymal involvement in children: A retrospective study of a ten-year period

The clinical characteristics and risk factors for testicular/epididymal involvement in 73 children with immunoglobulin A vasculitis (IgAV) who were admitted to our hospital between January 2012 and November 2022 were reviewed. The demographic data, laboratory parameters, and follow-up data of the patients were compared to those of 146 males without testicular/epididymal involvement. A logistic regression analysis was performed to determine the variables associated with testicular/epididymal involvement. The prevalence of testicular/epididymal involvement among male patients with IgAV was 1.3% (73/5,556). Increased blood flow in the testes and/or epididymis on ultrasound was found in 71 patients. The remaining two patients underwent surgical exploration for loss or reduction of testicular blood flow. One patient underwent orchiectomy for intraoperative confirmation of complete right testicular infarction. Pathological findings revealed IgA immune complex deposition in the testis. Patient age (odds ratio [OR] = 0.792; 95% confidence interval [CI]: 0.682-0.919, p = 0.002), platelet count (OR = 1.011; 95% CI: 1.002-1.020, p = 0.013), and immunoglobulin M (IgM) levels (OR = 0.236; 95% CI: 0.091-0.608, p = 0.003) were strongly associated with the occurrence of testicular/epididymal involvement in IgAV. Therefore, young age, increased platelet count, and low IgM levels in patients with IgAV are potential risk factors for testicular/epididymal involvement. Doppler ultrasound can help differentiate IgAV from acute scrotum. Most patients with testicular/epididymal involvement have good prognoses, although serious complications such as testicular infarction may occur.