Localized Vasculitis of the Gastrointestinal Tract

Mesenteric Artery Dissection and Wall-Thickening, Case Study and General Review

Mesenteric artery dissection (D) and wall-thickening (WT) are rare vasculopathies that can lead to serious complications. This is a single center analysis of all patients evaluated for mesenteric arterial (celiac, superior (SMA) and/or inferior mesenteric (IMA)) D and/or WT from January 1, 2000, to January 31, 2020 at our hospital. Among the 101 included patients, the average age was 55.6 ± 13.6 years, mostly affecting men (62%). There were 20 celiac artery D, 8 WT, 15 D with WT, 15 SMA D, 7 WT, 8 D with WT, one IMA D, two WT, and 25 with multiple arterial involvement. Primary etiologies included segmental arterial mediolysis (SAM) (n = 17), isolated D (n = 17), localized vasculitis of the gastrointestinal tract (LVGT) (n = 16), fibromuscular dysplasia (FMD) (n = 13), extension of thoracoabdominal aortic D (n = 12), and trauma (n = 12). Most (71%) patients presented with abdominal pain. Hypertension (55%), hyperlipidemia (33%) and tobacco use (31%) were prevalent. Management included conservative (22%), medical (47%), endovascular (19%), and/or open repair (12%) with high in-hospital survival (98%) and symptom relief (73%). Our paper complements the scarce literature addressing the diagnosis and management of rare mesenteric vasculopathies. Most patients improved with conservative management, reserving endovascular or surgical interventions for symptomatic patients with more complicated presentations.

Vasculitis Involving the Gastrointestinal System Is Often Incidental but Critically Important

OBJECTIVES

This study was aimed to investigate the significance of unexpected vasculitis identified in gastrointestinal (GI) specimens by determining its prevalence and correlation with clinical outcomes.

METHODS

GI specimens with histologic evidence of vasculitis were identified in our pathology database over a 10-year period (January 2008 to August 2018). Clinical history, treatment, and follow-up were reviewed.

RESULTS

Of the 131,367 GI pathology cases received over the 10-year study period, 29 (0.02%) cases showed histologic evidence of GI vasculitis. The majority (69%, 20/29) were not clinically suspected. Of these, 20% (4/20) of patients were subsequently diagnosed with systemic vasculitis. During the mean follow-up period of 34.0 months, 24% (4/17) of the patients with this unexpected diagnosis died as the result of direct complications of GI vasculitis. We also found that 95% of cases with unexpected vasculitis in their GI pathology specimens were communicated in a timely manner to the ordering physicians, which necessitated the immediate initiation of additional workups in 85% of these patients.

CONCLUSIONS

The GI involvement of vasculitis is rarely encountered by pathologists, but its diagnosis carries tremendous clinical significance with a high mortality rate. Therefore, timely communication is highly recommended for the early diagnosis and treatment of this disease.

Hepatic and Mesenteric Vasculitis as Presenting Manifestation of Mixed Cryoglobulinemia Related to Chronic Hepatitis C Virus Infection in a Female Patient

Approximately 80% of patients with hepatitis C virus infection develop chronic liver disease as cirrhosis, and 40% develop autoimmune complications as mixed cryoglobulinemia (MC). Gastrointestinal involvement in MC is rare, and even more so is hepatic involvement. We report a case of an 87-year-old woman with a 10-year history of blood transfusion-acquired hepatitis C virus infection, without treatment. She consulted the emergency department for diffuse abdominal pain, associated with vomiting. After 2 weeks of hospitalization in the intensive care unit, a diagnosis of MC was made; cirrhosis and secondary mesenteric and hepatic vasculitis were confirmed by a diagnostic laparoscopy. Unfortunately the condition of the patient worsened with sepsis and resulted in death in the fourth week from admission. This case highlights the importance of having in mind gastrointestinal tract vasculitis as a medical cause of abdominal pain in patients with chronic hepatitis C virus infection and using data laboratory tests, images, and histopathologic studies to aid with the diagnosis.

Gastrointestinal tract involvement in granulomatosis with polyangiitis

INTRODUCTION

Granulomatosis with polyangiitis (GPA) is a necrotising vasculitis of small arteries and veins. In its classical manifestation GPA affects the upper and lower respiratory tract and kidneys. However, other organs, including those of the gastrointestinal tract, may be affected as well.

AIM

To present the clinical manifestations of gastrointestinal tract involvement in patients with GPA.

MATERIAL AND METHODS

We analysed case records of 34 patients with GPA treated in the Department of Nephrology, Transplantology, and Internal Medicine of the Medical University of Gdansk from 1991 to 2009.

RESULTS

In 9 of 34 patients, 2 men and 7 women, aged 18 to 74 years, gastrointestinal complications were observed in the course of GPA. In two of them a localised and in seven a generalised type of GPA was diagnosed. The main symptoms relating to gastrointestinal tract were: oral mucosa ulcerations, gum mucosa hypertrophy, dyspepsia, vomiting, stomachache, gastrointestinal haemorrhage, diarrhoea, and symptoms of gastrointestinal tract perforation. Two patients required urgent surgical treatment. In 2 of the 5 patients who developed gastrointestinal bleeding, it was the direct cause of death. The histopathological confirmation of specificity of changes in gastrointestinal tract was established only in 2 cases. Tissue samples collected during endoscopy usually revealed only nonspecific inflammation or the presence of ulcers.

CONCLUSIONS

Therapeutic strategies accepted for GPA treatment are effective in treating patients with gastrointestinal involvement in the course of the disease. Some complications require surgical intervention.

Uncommon presentations of primary systemic necrotizing vasculitides: the Great Masquerades

INTRODUCTION

Systemic vasculitides are great masqueraders and at times their presenting manifestations can be very different from the usual recognized patterns. Such uncommon presentations of granulomatosis with polyangiitis (Wegener's granulomatosis), classical polyarteritis nodosa and unclassifiable vasculitides are described here with the relevant review of literature.

METHODS

All patients diagnosed as having systemic vasculitides and classified as having granulomatosis with polyangiitis (Wegener's granulomatosis), classic polyarteritis nodosa, microscopic polyangiitis and unclassifiable vasculitis according to EMEA consensus methodology and followed up prospectively from June 2007 to December, 2011 were included. Details of uncommon presentations of these disorders were identified.

RESULTS

Seventy-nine patients with systemic vasculitides were seen under our rheumatology services during this period. These included 45 patients with granulomatosis with polyangiitis (Wegener's granulomatosis), 18 with classic polyarteritis nodosa, five with microscopic polyangiitis, four with Churg-Strauss syndrome and seven with unclassifiable vasculitis. The uncommon presentations of granulomatosis with polyangiitis were a tumefactive subcutaneous mass in the thigh; prostatomegaly with obstructive uropathy and advanced renal failure; and predominant gastrointestinal (GI) vasculitis with thrombocytopenia and coagulopathy at presentation. The uncommon manifestations of classic polyarteritis nodosa were secondary antiphospholipid antibody syndrome and Budd-Chiari syndrome. One patient with massive lower GI bleeding required surgical resection of the large bowel which showed isolated necrotizing granulomatous GI vasculitis. Single organ vasculitis of the GI tract was diagnosed.

CONCLUSIONS

Systemic necrotizing vasculitides may present with uncommon manifestations and a high index of suspicion is required for early diagnosis and prompt treatment to prevent adverse outcomes.

[Fever of unknown origin in gastroenterology]

The gastrointestinal tract may be of major clinical or diagnostic importance in fever of unknown origin. To the classical diseases in this sense belong very different diseases as Whipple's disease, Familiar Mediterranean Fever, isolated mesenterial vasculitis, and manifestations of immune reconstitution inflammatory disease, but also unusual manifestations of otherwise easily recognized diseases like special forms of celiac disease, or inflammatory bowel disease. Endoscopical techniques to obtain biopsies for diagnostic procedures are frequently crucial to solve the diagnostic puzzle. In some cases the bioptic material may not be sufficient to reach a diagnosis and further surgical intervention is necessary (intestinal lymph-nodes or bowel resections) to acquire enough tissue for a definite diagnosis. Nevertheless using these different approaches in most cases of fever of unknown origin the underlying cause can be identified which for many patients means not more or less than significant improvement or even survival.

Vasculitis and the intensive care

Most frequent reasons for intensive care unit (ICU) admission in vasculitis patients are severe respiratory insufficiency due to diffuse alveolar haemorrhage, sepsis and/or pneumonia and an acute abdomen due to bowel infarction. Other reasons are massive gastrointestinal bleeding, thromboembolism and/or scissures. In a patient, not previously diagnosed as having vasculitis, diagnosis can be difficult and must be made as soon as possible, since immunosuppressive therapy should be instituted immediately. Immunosuppressive therapy in severe cases consists of high-dose corticosteroids and cyclophosphamide. In addition, in many cases plasma exchange has to be instituted as well. Prognosis is related to disease activity scores of vasculitis and of severity of illness as measured by the APACHE III scoring system and/or the SOFA score. Septic shock is still the leading cause of death in patients with vasculitis. Nowadays, death due to active untreated vasculitis is rare in experienced clinics.

Single-organ vasculitis

PURPOSE OF REVIEW

To provide a critical analysis of a rare disorder, single-organ vasculitis, emphasizing those organs in which the excision of the vasculitic lesion can be curative. To recommend a rational approach to diagnosis, longitudinal follow-up and treatment.

RECENT FINDINGS

Patients with focal single-organ vasculitis affecting abdominal and genitourinary organs, breast and aorta have been reported as individual cases and small series. Single-organ vasculitis differs from systemic forms of vasculitis in disease expression and prognosis. Occasionally, what appears to be a localized process evolves into a systemic disease. Depending on the organ affected, some clinical, serological and histopathologic features may be helpful in predicting the extent of the vasculitic process. With the exception of severe ischemic or hemorrhagic complications affecting the abdominal organs and dissection or rupture of the aortic arch, the prognosis of focal single-organ vasculitis tends to be excellent. Resection of the inflammatory lesion may be curative.

SUMMARY

The diagnosis of focal single-organ vasculitis is always presumptive and requires exclusion of systemic illness at the time of diagnosis as well as throughout the period of continued care. Clues from clinical symptoms, laboratory tests and histopathologic features at the time of diagnosis may assist in devising surveillance strategies.