Intra-abdominal manifestations of Henoch-Schönlein purpura

High risk and low incidence diseases: Pediatric intussusception

INTRODUCTION

Pediatric intussusception is a serious condition that carries with it a high risk of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric intussusception, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Intussusception is one of the most common pediatric abdominal emergencies. This is associated with one part of the intestine telescoping into another, resulting in bowel edema. If the intussusception remains untreated, obstruction, ischemia, necrosis, and perforation may result. Most cases are idiopathic, with 10-25 % associated with a pathologic mass or lead point. The most common age group affected includes those between 3 months to 5 years. The triad of intermittent abdominal pain, currant jelly stool, and sausage-shaped mass is uncommon, though most patients will present with intermittent abdominal pain. Nonbilious emesis and bloody stools (gross blood or guaiac positive) are also common. Younger patients can present atypically, including altered mental status or lethargy. Thus, intussusception should be considered in pediatric patients with abdominal pain, emesis, and a sausage-shaped mass, as well as those with atypical presentations such as altered mental status or lethargy if there is no other etiology found on testing. The diagnostic modality of choice is ultrasound. Plain radiography may assist in evaluating for obstruction and perforation. Treatment includes prompt reduction of the intussusception. In patients who are stable and have no evidence of perforation, non-operative reduction with hydrostatic or pneumatic reduction should be attempted. Operative intervention is necessary in those who are unstable, peritonitic, or have a focal lead point. Discharge may be appropriate for patients following successful non-operative reduction if the patient is able to tolerate clear fluids, is asymptomatic, and can return for any recurrence of symptoms.

CONCLUSION

An understanding of pediatric intussusception and its many potential mimics can assist emergency clinicians in diagnosing and managing this high risk disease.

Alteration of gut microbiota in Henoch-Schönlein purpura children with gastrointestinal involvement

BACKGROUND

The compositional and structural changes of gut microbiota were closely related to the status of Henoch-Schönlein purpura (HSP).

AIMS

To investigate if clinical indicators and gut microbiota differ between HSP patients with or without gastrointestinal (GI) involvement and to explore the alterations of fecal microbiota in HSP children with and without GI symptoms.

METHODS

A total of 22 children with HSP were enrolled in the study. Fecal microbiota composition was analyzed by 16S rRNA sequencing. Clinical indicators, fecal microbial diversity, and compositions were compared between the two groups.

RESULTS

Respectively, 9 patients with GI involvement (HSP-A) and 13 patients without GI involvement (HSP-N) were enrolled. Prealbumin (PA) and the ratio of immunoglobulin A (IgA) / complement (C)3 were significantly decreased in the HSP-A group and an elevated D-dimer was found in the HSP-N group. The relative abundances of Blautia, Lachnospira, and Haemophilus were significantly higher in the HSP-A group compared to HSP-N. Lower levels of unidentified Prevotellaceae, Parabacteroides, and Romboutsia were found in HSP-A patients. The linear discriminant analysis effect size (LEfSe) showed that the biomarkers for the HSP-A group included Blautia, Anaerostipes, Veillonella, Lachnospira, and Haemophilus. For the HSP-N group, unidentified Prevotellaceae, Intestinibacter, Romboutsia, and Akkermansia were the prominent biomarkers at the genus level. Additionally, the ratio of IgA/C3 exhibited a negative correlation with the genus Blautia. Meanwhile, PA showed negatively correlation with Veillonella.

CONCLUSIONS

These results provide a broader understanding for future microbial-based therapies to decrease the development of GI involvement and improve the clinical outcome of HSP in children.

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.

Ang-1, Ang-2, and Tie2 are diagnostic biomarkers for Henoch-Schönlein purpura and pediatric-onset systemic lupus erythematous

Henoch-Schönlein purpura (HSP) and pediatric-onset systemic lupus erythematosus (pSLE) are closely associated with vasculitis and vascular diseases. This study aimed to investigate the clinical diagnostic values of Ang-1, Ang-2, and Tie2 for HSP and pSLE. We surveyed 82 HSP patients, 34 pSLE patients, and 10 healthy children. The expression levels of Ang-1, Ang-2, and Tie2 in the serum and urine were assessed using enzyme-linked immunosorbent assay. The diagnostic values of Ang-1, Ang-2, and Tie2 for HSP and pSLE were evaluated using receiver operating characteristic curve analysis. The results revealed that the serum and urine expression levels of Ang-2 and Tie2 were significantly elevated in HSP and pSLE patients, whereas the Ang-1/Ang-2 values were reduced. Additionally, Ang-1 was highly expressed in the serum and urine of HSP patients and in the serum of pSLE patients. Ang-1, Ang-2, and Tie2 showed differential expression in various types of HSP and pSLE compared with their expression in healthy controls. In summary, Ang-1, Ang-2, and Tie2 can serve as biomarkers for HSP and pSLE. Moreover, Ang-1/Ang-2 values are reduced in HSP and pSLE patients. Ang-1, Ang-2, and Tie2 can be used as biomarkers for HSP and pSLE.

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.

Successful treatment of Henoch-Schönlein purpura-associated hematochezia in a child with hemophilia A: a case report

BACKGROUND

Henoch-Schönlein purpura (HSP) is a common form of immunological vasculitis in children. Hemophilia A is a genetic disorder and characterized by spontaneous hemorrhage or prolonged bleeding due to factor VIII deficiency. Both diseases increase the risk of bleeding, but they have different mechanisms. How should we treat patients with both diseases?

CASE PRESENTATION

An 8-year-old male with hemophilia A was diagnosed with HSP while receiving coagulation factor VIII replacement therapy in our hospital. Hematochezia occurred 6 days after the diagnosis of HSP. And he treated with coagulation FVIII, methylprednisolone and hemostatic drugs.

CONCLUSIONS

There is no causal relationship between hemophilia A and HSP, but both diseases can cause bleeding. This child's hematochezia was caused by HSP, but hemophilia could not be ignored during the treatment. Our case report adds to the present body of knowledge about the treatment of HSP associated hematochezia in a child with hemophilia A.

Blood routine examination: a simple way for differential diagnosis of immunoglobulin A vasculitis with abdominal involvement and appendicitis in children

To explore the value of blood routine examination indexes in the differential diagnosis of immunoglobulin A vasculitis (IgAV) with abdominal involvement and appendicitis in children. Forty-seven patients with IgAV and abdominal involvement, 95 cases with appendicitis, and 48 healthy children were enrolled in this study. Demographic and laboratory data were retrospectively recorded from medical files. The levels of serum percentage of lymphocytes (LYM%), percentage of eosinophils (E%), red cell volume distribution width (RDW) and platelet (PLT) count were higher, while blood cells (WBC) count, percentage of neutrophils (N%), percentage of monocytes (M%), mean platelet volume (MPV), platelet distribution width and C-reactive protein were lower in the group of IgAV with abdominal involvement compared to appendicitis group (P < 0.05). Multivariate logistic regression analysis showed LYM% (odds ratio (OR) = 1.34, P = 0.001) and RDW (OR = 2.96, P = 0.045) were independent risk factors for IgAV with abdominal involvement. N% (OR = 1.270, P = 0.006) and MPV (OR = 51.15, P = 0.042) were independently associated with appendicitis. Using receiver operating characteristic analysis, the optimal cut-off values (sensitivity and specificity) respectively were 42.17% (95.7%, 100.0%) for LYM%, 12.65% (83.0%, 83.2%) for RDW, 61.5% (91.6%, 97.9%) for NE% and 10.1fL (78.9%, 75.4%) for MPV, with the AUC values of 0.989, 0.881, 0.985, 0.810, respectively. Blood routine examination indices, especially the N%, LYM%, RDW, and MPV, can be used for simple differential diagnosis of IgAV with abdominal involvement and appendicitis.

Massive gastrointestinal hemorrhage caused by Henoch-Schoenlein purpura: A case report

RATIONALE

Henoch-Schoenlein purpura (HSP) is a systemic small-vessel vasculitis that commonly occurs in children. Gastrointestinal HSP can rarely progress to gastrointestinal perforation, followed by massive gastrointestinal bleeding.

PATIENT CONCERNS

An 8-year-old Chinese boy was transferred to the pediatric intensive care unit of our hospital with an emergency occurrence of purpura, severe hematemesis, large bloody stools, and sharp abdominal pain, and complained of abdominal pain and rash 2 weeks prior.

DIAGNOSIS

The patient had purpura with lower limb predominance, abdominal pain, and gastrointestinal bleeding. Immunofluorescence microscopy of histological sections showed granular and lumpy IgA focal deposition in the blood vessel walls. He was diagnosed with HSP.

INTERVENTIONS

Initially, he was treated with methylprednisolone, posterior pituitary injection, somatostatin, and hemocoagulase, together with the infusion of large blood products. Postoperatively, he was administered nasal continuous positive airway pressure -assisted ventilation, anti-infection treatment, albumin transfusion, platelet transfusion, abdominal drainage, methylprednisolone, fluconazole anti-fungal treatment, and wound dressing.

OUTCOMES

There was no evidence of rebleeding, abdominal pain, or purpura at the 2-month follow-up assessment.

LESSONS

Abdominal HSP should be alert to gastrointestinal perforation when using hormone therapy.

Clinical characteristics and associating risk factors of gastrointestinal perforation in children with IgA vasculitis

BACKGROUND

IgA vasculitis (IgAV) is a common small vessel vasculitis in children. Gastrointestinal perforation (GP) rarely presents as a complication of IgAV and is not well characterized. This study is aimed to investigate the clinical features, diagnosis, and risk factors of GP in children with IgAV.

METHODS

We retrospectively reviewed the clinical data of children with IgAV who attended our hospital between January 2014 and June 2018. The clinical risk factors and the corresponding treatments were analyzed for the children with IgAV complication with GP.

RESULTS

In total, 10,791 children with IgAV were reviewed in this study. GP was observed in 11 children with IgAV, accounted for 0.10% of the total cases. Among those GP patients, 1 case was gastric perforation, 10 cases were intestinal perforation. Five GP cases were identified by abdominal CT. Ultrasonography was failed to detect the occurrence of GP in five cases. The average duration of abdominal pain in the GP cases was 9.3 days, and 9 cases (81.8%) presented with abdominal pain for over 7 days. Gastric/intestinal perforation repair were performed for 3 IgAV GP cases under open surgery. The other eight cases were treated through enterectomy. In comparison with the patients without GP, the GP patients had significant higher rates in the aspect of the abdominal or mixed type of IgAV, abdominal pain duration more than 7 days, hematochezia, renal damage, and methylprednisolone treatment with the daily dosage more than 2 mg/kg.

CONCLUSION

GP children accounted for 0.10% of the total IgAV cases. The risk of GP is elevated in IgAV patients who has gastrointestinal symptoms and/or other symptoms such as hematochezia, renal damage, a prolonged abdominal pain (>7 days), administration of methylprednisolone (>2 mg/kg). Abdominal CT is highly recommended for the early detection of GP in IgAV patients.Key messagesGastrointestinal perforation (GP) rarely presents as a complication of IgAV and is not well characterized.11 out of 10,791 children with IgAV developed GP, accounting for 0.10% of the total number of cases.Abdominal CT is highly recommended for the early detection of GP in IgAV patients.

Penile involvement of immunoglobulin a vasculitis/Henoch-Schönlein purpura

BACKGROUND

Immunoglobulin A vasculitis/Henoch-Schönlein purpura (IgAV/HSP) is a leukocytoclasia vasculitis of childhood, predominantly affecting the skin, joints, gastrointestinal tract, and kidneys. The involvement of the penis is rare.

OBJECTIVE

We aimed to describe this rare manifestation of IgAV/HSP and to review the previous studies, including similar cases.

METHODS

Clinical data were reviewed for two children of penile involvement of IgAV/HSP in our hospital. More clinical cases were retrieved from the databases of PubMed/MEDLINE and Scopus from database inception to February 1, 2020.

RESULTS

We presented two boys aged three and five years both of whom had penile lesions after presenting with the typical rash of IgAV/HSP on lower extremities. The penile lesions improved entirely in a few days without treatment in one and with corticosteroid treatment in the other. The literature review revealed 12 articles describing 20 patients with penile involvement of IgAV/HSP. The penile findings were edema, erythema, ecchymosis, purpuric rash, edema, color change, stiffness of the shaft or prepuce, and tenderness. Penile lesions appeared before the purpuric rash of IgAV/HSP in three of 22 patients. The penile involvement could make the diagnosis challenging especially if the penile lesions appear before the typical rash of the disease. The lesions improved entirely in the short term in all patients; in five without treatment in fifteen after corticosteroid or immunosuppressive drug treatment.

CONCLUSIONS

It is important to raise awareness about this rare manifestation among health care providers. It is not clear whether corticosteroid treatment should be initiated for treatment since it seems as a self-limited feature. Treatment with corticosteroids could be considered in the treatment of selected cases especially with systemic involvement.

Proteomic analysis of urine reveals biomarkers for the diagnosis and phenotyping of abdominal-type Henoch-Schonlein purpura

BACKGROUND

Abdominal-type Henoch-Schonlein purpura (HSP) is a common refractory disease in children. Currently, no specific diagnostic biomarker is available for HSP.

METHODS

Children with abdominal type HSP were first diagnosed with three syndromes using Chinese traditional medicine. The urinary proteomes among the three syndromes of patients with abdominal type HSP and healthy controls were compared using two label-free proteomics quantifications, including data-dependent acquisition and data-independent acquisition.

RESULTS

For the comparison between patients with abdominal type HSP and healthy children, a total of 75 differential urinary proteins were identified by determining the overlap of the two experiments. The ingenuity pathway analysis (IPA) analysis showed that these differential proteins were correlated with the pathogenesis of abdominal type HSP. Of these, 37 proteins were distributed in 13 solid tissues as tissue-enriched proteins. Monitoring changes in these proteins might help us detect uncommon clinical manifestations of HSP. Patients with abdominal type HSP can be further distinguished into three syndromes based on the urine proteome. Finally, a panel of six urinary proteins (P25774, P09417, Q7Z5L0, P60900, P14550 and P09668) was constructed for both the diagnosis and phenotyping of abdominal type HSP.

CONCLUSIONS

Urinary protein biomarkers for the diagnosis and phenotyping of abdominal type HSP were identified, which will contribute to the personalized treatment of patients with abdominal type HSP.

Bowel ultrasonography in acute abdomen: beyond acute appendicitis

Acute abdomen is a common reason for consultation in the emergency department. A broad spectrum of entities, including diverse diseases of the gastrointestinal tract, can cause acute abdomen. Although computed tomography is the technique most widely used to evaluate acute abdomen in the emergency department, abdominal ultrasound is often performed first and allows bowel disease to be suspected. This article describes the ultrasound features of diverse bowel diseases that can cause acute abdomen, such as acute diverticulitis, bowel obstruction, gastrointestinal perforation, bowel ischemia, intraabdominal fat necrosis, and miscellaneous processes such as endometriosis, foreign bodies, or vasculitis. Radiologists must be familiar with the different features of abnormal bowel that can be detected incidentally in patients without clinical suspicion of bowel disease. This article focuses on ultrasonographic signs of bowel disease; other articles in this series cover the ultrasonographic signs of acute appendicitis, inflammatory bowel disease, and infectious diseases.

Life-threatening complications of Henoch-Schönlein purpura: diffuse alveolar haemorrhage, venous thrombosis and bowel ischaemia

Henoch-Schönlein purpura (HSP) is a common systemic vasculitis occurring in children. Making a diagnosis of HSP is often straightforward, managing its complications can be difficult. Diffuse alveolar haemorrhage (DAH), bowel ischaemia and venous thrombosis are rare complications of this disorder. We present a case of a 15-year-old teenage girl presenting with typical purpuric rash of HSP, developed DAH, bowel ischaemia and venous thrombosis. She was successfully treated with pulse methylprednisolone, intravenous Ig and intravenous cyclophosphamide.

Henoch-Schönlein purpura in Saudi Arabia: characteristics and rare vital organ involvement

Henoch-Schönlein purpura (HSP) is the most common small vessel vasculitis in children with an annual incidence of between 10 and 30 per 100,000. It is an inflammation that affects many organs primarily in the skin, gastrointestinal (GI) tract, musculoskeletal, also vital organs like kidneys and lungs which may lead to chronic kidney disease and pulmonary hemorrhage. In this review, we are showing the characteristics of Saudi patients with HSP and the relation with preceding infections, gender, and seasonal variations in addition to the common and most severe systemic involvements. We found cases that were challenging to diagnose and others with unfortunate fetal complications.

A good response to glucocorticoid for Henoch-Schönlein purpura with abdominal pain and gastrointestinal bleeding in an adult: A CARE case report

RATIONALE

Henoch-Schönlein purpura (HSP) is a small-vessel vasculitis that has been extensively studied in children, but little is known about its natural history in adults. There is no consensus regarding the treatment of glucocorticosteroids use for HSP. The efficacy of glucocorticoid for preventing from severe complications or relapse is also controversial in HSP.

PATIENT CONCERNS

A 21-year-old male was admitted to the hospital due to abdominal pain for more than 20 days, hematochezia for more than 10 days, and rash for 2 days.

DIAGNOSES

The diagnosis of HSP is based on the European League against Rheumatism and the Paediatric Rheumatology European Society in 2006.

INTERVENTIONS

The patient received glucocorticosteroids treatment for 17 days at the time of first hospitalization.

OUTCOMES

The abdominal pain and hematochezia completely disappeared on the 6th day after the use of glucocorticosteroids, and purpura completely disappeared on the 8th day.

LESSONS

Our patient has a good response to glucocorticoid. Glucocorticosteroids may be effective for the treatment of HSP.

Henoch-Schönlein purpura with intussusception and hematochezia in an adult: A case report

RATIONALE

Henoch-Schönlein purpura (HSP) is a common disease in children. However, HSP with intussusception and intestinal obstruction has a low morbidity in children and is occasionally seen in adults. Herein, a rare adult case of HSP complicated with intussusception and hemafecia that was successfully treated with surgery is described.

PATIENT CONCERNS

A 19-year-old Chinese man suffered from HSP combined with intussusception and intestinal obstruction and presented with vomiting, diarrhea, abdominal pain, and rash.

DIAGNOSIS

Henoch-Schönlein purpura with intussusception and intestinal obstruction.

INTERVENTIONS

The patient underwent an emergency laparotomy and manual reset.

OUTCOME

The patient was discharged 7 days after surgery in stable condition. We followed the patient to the sixth month after surgery. This patient has no long-term complications after surgery.

LESSONS

HSP with intussusception and intestinal obstruction is rarely seen in adults. Patients with HSP often present with abdominal pain as the first symptom, which is easily confused with other diseases. Once the HSP is diagnosed, surgery should be performed as soon as possible, provided there is no absolute contraindication.

Characteristics of intussusception among children in Korea: a nationwide epidemiological study

BACKGROUND

Intussusception is a gastrointestinal condition in which early treatment is critical. Although its epidemiology and comorbidities have been studied, few studies have included the entire pediatric population of a country. Therefore, we aimed to analyze the epidemiologic features of pediatric intussusception patients and identify comorbidities associated with intussusception in South Korea, using the public health database.

METHODS

We analyzed the data of children below 18 years of age, from the national database of South Korea, who were diagnosed with intussusception and managed such as air reduction or surgical methods from 2008 to 2016. Patients were categorized into six groups based on the comorbid diseases. Patients with structural lesion in gastrointestinal tract were divided diagnosis or diagnosis code.

RESULTS

The number of patients diagnosed with intussusception were 25,023 (16,024 males, 64.0%). Of them, the highest percentage was patients aged between 2 and 36 months (20,703; 82.7%). The incidence per 100,000 individuals aged up to 2 years was 196.7. The number of males were 16,024 (64.0%) and were almost twice the number of 8999 (36.0%) female patients. The maximum number of cases (n = 2517; 10.1%) were seen in September, followed by July (n = 2469; 9.9%). In February, the number of cases was lowest at 1448 (5.8%) patients (P < 0.001). The number of patients with structural lesions of the gastrointestinal tract that could lead to intussusception was 1207 (4.8%), while patients with acute gastrointestinal infectious disease were 4541 (18.1%). Among the structural lesions of the gastrointestinal tract that could be the leading cause of intussusception, lymphadenopathy was the most common, seen in 462 (56.6%) patients and an appendix-related condition was seen in 260 (31.9%) patients. Infectious diseases were more common in the younger children, while systemic diseases were more common in the older.

CONCLUSION

We confirmed that pediatric intussusception in South Korea shows a seasonal tendency, which is age-dependent and is associated with an exposure to infectious agents. Some infectious pathogens and underlying diseases might play an important role in the pathophysiology of intussusception.

Successful Treatment of IgA Vasculitis Complicated with Bowel Perforation and Crescentic Glomerulonephritis by Combination Therapy of Glucocorticoid, Cyclosporine and Factor XIII Replacement

We report the findings of an 18-year-old boy with immunoglobulin A vasculitis (IgAV) complicated with bowel perforation and nephritis. He presented with abdominal pain, arthralgia and palpable purpura. Massive proteinuria developed during his clinical course. The patient was treated successfully using combination therapy of glucocorticoid (GC), cyclosporine (CYA) and factor XIII (F XIII) replacement. A standard treatment strategy for severe IgAV patients has not been established due to its rarity. Combination therapy using GC, CYA and F XIII replacement should be considered for severe IgAV patients.

Neutrophil-to-lymphocyte ratio to predict gastrointestinal bleeding in Henoch: Schönlein purpura

BACKGROUND

Henoch-Schönlein purpura (HSP) is a common form of vasculitis in children. It typically involves small vessels of the skin, the gastrointestinal (GI) tract, joints, and kidneys. GI involvement is the most severe short-term complication and GI bleeding is a major complication of HSP, but there is no established predictive marker of GI bleeding. Blood neutrophil-to-lymphocyte ratio (NLR) has been proposed as a potentially useful marker of clinical outcome in diseases with an inflammatory component. The aim of this study was to clarify the association of NLR with HSP and investigate the usefulness of NLR as a marker to predict GI bleeding in children with HSP.

METHODS

All patients with newly diagnosed HSP were reviewed retrospectively. White blood cell count, hemoglobin, platelet counts, mean platelet volume, neutrophil and lymphocyte count were evaluated. NLR and platelet-to-lymphocyte ratio (PLR) were calculated using complete blood count data.

RESULTS

This study involved 141 HSP patients. GI involvement was found in 65 patients (46.1%), and, of these, 15 (10.6%) had GI bleeding. At the time of diagnosis, NLR was significantly higher (P = 0.001) and PLR significantly lower (P = 0.032) in patients with GI bleeding than in those without GI bleeding. On logistic regression analysis, NLR was the only independent predictor of GI bleeding (P = 0.004). The optimal cut-off of NLR for predicting GI bleeding was 2.86 (sensitivity, 73%; specificity, 68%).

CONCLUSIONS

NLR, a simple and easily obtainable parameter, is a potential predictive marker of GI bleeding in children with HSP.

Ultrasound assessment of the bowel: inflammatory bowel disease and conditions beyond

Ultrasound (US) is a versatile imaging study for the evaluation of the bowel in children. US imaging of the bowel can be used as the initial examination or in follow-up for many common pediatric diseases. In this article, we highlight our bowel US technique and describe how US can depict the features of a select group of bowel pathologies relevant to pediatric practice.

In vivo characterization of abnormalities in small-bowel diseases using probe-based confocal laser endomicroscopy

BACKGROUND AND STUDY AIMS

 Probe-based confocal laser endomicroscopy (pCLE) enables real-time optical biopsy. Little is known about pCLE imaging deep inside the small bowel, therefore the aim of this study was to determine its usefulness.

PATIENTS AND METHODS

 Between April 2014 and January 2016, we performed 38 pCLE examinations during double-balloon enteroscopy with intravenous fluorescein in 37 patients with: tumors (n = 10), vascular disorders (n = 6), inflammatory diseases and drug injuries (n = 13), other disorders (n = 4), and normal findings (n = 4). We measured the calibers of capillary and lymphatic vessels at 15 different sites and compared the calibers between pCLE images and histopathology. We also compared pCLE findings with pathologic diagnosis.

RESULTS

 The inner diameters of capillary vessels beneath the epithelium and in the middle of villi were 16.2 ± 3.0 µm and 14.5 ± 3.1 µm, respectively, in the pCLE images, but these were not consistent with formalin-fixed paraffin-embedded histology. In tumors, larger capillary vessels were observed in aggressive malignant lymphoma and metastasis, and a "soccer ball-like pattern" constituting homogenous dark cells packed with polygonal, narrower capillary vessels was characteristic in pCLE images of a malignant lymphoma follicle. Hereditary hemorrhagic telangiectasia and angiodysplasia contained anastomosis of capillary vessels of different calibers. In IgA vasculitis, segmental capillary strictures were observed. Intestinal lymphangiectasia with protein-losing enteropathy contained a reticular network of lymphatic vessels and dilated lymphatic ducts accompanied by numerous cell gaps. pCLE findings corresponded to pathologic diagnosis in 32 examinations (91 %).

CONCLUSIONS

 pCLE is useful for in vivo analysis of abnormalities of the capillary and lymphatic vessels and epithelium, and for diagnosis in various small-bowel diseases.

[Henoch-Schönlein Purpura Presenting as Intussusception]

Henoch-Schönlein purpura (HSP) is systemic vasculitis disease with various clinical manifestations. Gastrointestinal symptoms in patients with HSP are usually common, with an incidence rate of 62-90%. Most of these gastrointestinal symptoms occur after typical skin purpura, which is a very important clinical evidence for making a diagnosis of HSP. It is difficult to diagnose HSP without skin rash. About 25% of patients may experience gastrointestinal symptoms as their first symptoms. Herein, we report a case of ileo-colic intussusception associated with HSP in a 5-years-old girl presented with diffuse abdominal distension. Our patient did present any symptoms of HSP, such as purpura, arthralgia or arthritis, before surgery.

Gastrointestinal Bleeding and Management

There is a broad clinical spectrum of gastrointestinal bleeding in children, ranging from subtle laboratory findings to dramatic clinical presentations. This review provides a framework for the evaluation and management of gastrointestinal hemorrhage for pediatricians. It outlines strategies for obtaining a tailored patient history and conducting a thorough physical examination that can shed light on the location, severity, and likely etiology of bleeding. It appraises blood tests, radiologic tools, and endoscopic modalities frequently used to identify and control a source of bleeding.

A review of case and case series reports on Henöch-Schönlein syndrome-related pancreatitis

To summarize the experience of diagnosing and treating patients with Henoch–Schönlein purpura (HSP)-related pancreatitis, a systematic review of previously published cases was conducted. Among 13 reported cases, there were six males and seven females whose age from 3 to 70 years. The clinical features of these patients indicated that acute pancreatitis could be the initial manifestation of HSP, the radiological change was atypical, and most cases were alleviated with steroidal treatment. Good outcomes can be achieved in patients who are diagnosed early with HSP-related pancreatitis, and it is vital to begin timely treatment of HSP-related pancreatitis with corticosteroid.

Hospitalization rates for intussusception in children aged 0-59 months from 2009 to 2014 in Italy

The real cause of intussusception is not fully understood and a variety of conditions have been associated with it (Meckel diverticulum, polyps, duplication cysts, parasites, Henoch-Schönlein purpura, cystic fibrosis, hemolytic-uremic syndrome and infectious gastroenteritis). Furthermore few European countries, following WHO recommendation to monitor baseline incidence of intussusception before implementation of immunization program for rotavirus, used intussusception rate as a baseline value to compare the same figures in the period before and after introduction of vaccination. In this study, data of intussusception hospitalizations occurred among Italian children aged 0 through 59 months from 2009 to 2014 were analyzed. A total amount of 3,088 children were included, accounting for a hospitalization rate of 20.2 per 100,000. Overall, the hospitalization rate for intussusception had a slight increase in trend from 2009 to 2014 (18%). In particular children 0-11 months had a hospitalization rate higher than 12-59 months with an aggregate value of 36 Vs. 16 per 100,000 respectively. Among all children hospitalized for intussusception a total of 239 (7.7%) had also a previous or concomitant hospitalization for gastroenteritis. This study demonstrates that Italian hospitalizations for intussusception are increasing by time and the role played by different risk factors, including acute gastroenteritis, have to be investigated in the future. These data could be useful to monitor intussusception hospitalization in the perspective of anti-rotavirus vaccination introduction in Italy.

Systematic review shows that pathological lead points are important and frequent in intussusception and are not limited to infants

Intussusception is the most clinically relevant cause of bowel obstruction in infancy and can be idiopathic or occur as a result of pathological lead points. The incidence of these pathological lead points varies from 0.3 to 20%, and they can be mucosal, intramural or extrinsic structures. A systematic literature review was performed from 1998 to 2016 to evaluate the incidence and types of pathological lead points in paediatric intussusception, and this identified 31 epidemiological and retrospective case cohort studies, reviews and case reports.

CONCLUSION

Pathological lead points were frequent in intussusceptions and not limited to infants.

Henoch-Schönlein purpura from vasculitis to intestinal perforation: A case report and literature review

Henoch-Schönlein purpura (HSP) is generally a self-limited vasculitis disease and has a good prognosis. We report a 4-year-old Thai boy who presented with palpable purpura, abdominal colicky pain, seizure, and eventually developed intestinal ischemia and perforation despite adequate treatment, including corticosteroid and intravenous immunoglobulin therapy. Imaging modalities, including ultrasonography and contrast-enhanced computed tomography, could not detect intestinal ischemia prior to perforation. In this patient, we also postulated that vasculitis-induced mucosal ischemia was a cause of the ulcer, leading to intestinal perforation, and high-dose corticosteroid could have been a contributing factor since the histopathology revealed depletion of lymphoid follicles. Intestinal perforation in HSP is rare, but life-threatening. Close monitoring and thorough clinical evaluation are essential to detect bowel ischemia before perforation, particularly in HSP patients who have hematochezia, persistent localized abdominal tenderness and guarding. In highly suspicious cases, exploratory laparotomy may be needed for the definite diagnosis and prevention of further complications.

Henoch-Schönlein purpura complicated by acalculous cholecystitis and intussusception, and following recurrence with appendicitis

Henoch-Schönlein purpura (HSP) is the most common childhood systemic vasculitis. Gastro-intestinal involvement occurs in two-thirds of patients. The characteristic skin lesions generally precede abdominal symptoms or present concurrently. A 7-year-old boy presented with intussusception and acalculous cholecystitis and had a cholecystectomy. Two weeks later he was re-admitted with features typical of HSP which responded to corticosteroids. Eleven months later he presented with abdominal pain and recurrence of HSP and, at laparotomy, there was acute appendicitis. This is the first case of a child presenting with HSP complicated by acalculous cholecystitis.

Complicated Henoch-Schönlein purpura

We present a case of Henoch Schonlein pupura in a 6-year-old boy demonstrating some of the diagnostic pitfalls, complications and management challenges of this common paediatric condition.

High-dose methylprednisolone pulse therapy for treatment of refractory intestinal involvement caused by Henoch-Schönlein purpura: a case report

Introduction

Henoch–Schönlein purpura is an immunoglobulin A-mediated, small vascular inflammatory disease that can be associated with palpable purpura, arthralgia, abdominal pain, or nephritis. The presence of purpura facilitates the diagnosis of Henoch–Schönlein purpura at the onset of associated symptoms, whereas the absence of purpura makes the diagnosis challenging. It is important to diagnose Henoch–Schönlein purpura with delayed-onset skin purpura to avoid unnecessary surgery for acute abdomen. Most cases of Henoch–Schönlein purpura with severe abdominal pain are treated with low-dose steroids and intravenous immunoglobulin.

Case presentation

A 15-year-old Korean girl complained of severe abdominal pain and delayed-onset purpura on admission. Henoch–Schönlein purpura was diagnosed based on endoscopic findings of hemorrhagic duodenitis and duodenal vasculitis and abdominal computed tomography findings of edematous bowels. Two common initial treatments, a low-dose steroid and intravenous immunoglobulin, were administered, but there was no improvement for 1 month. Subsequently, we used high-dose intravenous methylprednisolone pulse therapy (30mg/kg/day, with a maximum of 1g/day), which dramatically alleviated her abdominal symptoms.

Conclusions

High-dose intravenous methylprednisolone pulse therapy can be used as the ultimate treatment for delayed-onset Henoch–Schönlein purpura with severe abdominal pain when symptoms do not improve after low-dose steroid and intravenous immunoglobulin treatments.

Pneumatosis intestinalis associated with Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is the most common vasculitis in children. It is a disorder of the inflammatory cascade leading to immunoglobulin A deposition and leukocytoclastic vasculitis of small vessels of skin, kidneys, joints, and gastrointestinal (GI) tract. A wide variety of GI manifestations are seen in ∼50% to 75% of patients with HSP. Diffuse colicky abdominal pain is the most common GI symptom. The small bowel is the most frequently involved GI site. Intussusception is rare but is the most common surgical complication. We report the case of a 2-year-old girl with a 5-day history of abdominal pain followed by a palpable purpuric rash. Her urinalysis, complete blood cell count, and tests of renal function were normal. An acute abdominal series was unremarkable initially, and abdominal ultrasound imaging showed ascites and thickened small bowel loops. She was diagnosed with HSP. The abdominal pain worsened, and an abdominal computed tomography scan demonstrated distal small bowel wall thickening and pneumatosis intestinalis in the descending colon. She was started on total parenteral nutrition and antibiotics and placed on bowel rest. She was given 2 mg/kg of intravenous immunoglobulin. Her abdominal pain gradually improved over the next week, and a repeat computed tomography scan showed significant improvement of the small bowel wall thickening and pneumatosis. The purpuric rash improved, and her abdominal pain resolved. We report a case of HSP and pneumatosis intestinalis, an association that has not been reported previously.

Common and uncommon applications of bowel ultrasound with pathologic correlation in children

OBJECTIVE

The purpose of this article is to describe the indications and techniques for bowel ultrasound for inflammatory bowel disease and other common and uncommon entities and describe and illustrate their imaging appearances, including endoscopic or surgical correlation.

CONCLUSION

Ultrasound is a useful tool for the evaluation of inflammatory bowel disease and many other bowel diseases. Radiologists must become familiar with the full potential of ultrasound in the evaluation of the bowel in children because the need for alternative radiation-free imaging techniques continues to grow.

Construction of a scoring system for predicting the risk of severe gastrointestinal involvement in Henoch-Schönlein Purpura

Objective

To evaluate the parameters associated with significant gastrointestinal (GI) involvement in Henoch-Schönlein Purpura (HSP), and construct a scoring system for the identification of patients at high risk of gross blood in stools.

Study design

Data for HSP patients hospitalized at each of seven institutes were retrospectively analyzed. Patients were divided into four groups according to the consequent severity of GI involvement. Identification of laboratory parameters at the time of admission were then used to differentiate the groups, and a scoring system to predict gross intestinal bleeding was constructed. Prognostic efficiency, correlation with the subsequent duration of abdominal pain, and association with manifestations excluding abdominal pain were also analyzed.

Results

An analysis of variance (ANOVA) test showed significant intergroup differences in white blood cell (WBC) count, neutrophil count, serum albumin, potassium, plasma D-dimer and coagulation factor XIII activity. A scoring system consisting of these parameters showed a good prognostic value for gross intestinal bleeding in a receiver operating characteristic (ROC) analysis, and a cut-off value of 4 points showed a sensitivity of 90.0% and specificity of 80.6%. The score was also correlated with the duration of abdominal pain after admission. A significantly higher score (s) was observed in patients presenting with nephritis, although the predictive value was poor.

Conclusion

A scoring system consisting of generally available parameters was of use in predicting severe GI involvement in HSP patients. Although further study is needed, initial therapy in accordance with disease activity may be taken into consideration using this scoring system.

Henoch-Schönlein disease localized in the appendix

A 16-y-old boy presented with complaints of acute abdomen. Ultrasonography showed an enlarged and tender appendix suggestive of acute appendicitis. The patient underwent surgery and during surgery the appendix was found with a red vasculitis-like distal end, not typical for acute appendicitis. Further per operative examination of the intestines revealed a circular, vasculitis-like red band in terminal ileum. Four days after surgery, the patient developed skin purpura and complained of joint pain classical of Henoch-Schönlein disease. Pathological evaluation of the appendix and a skin biopsy confirmed the diagnosis and the patient was managed accordingly.

Henoch-Schönlein purpura in children

Henoch-Schönlein purpura is the most common systemic vasculitis of childhood. In the majority of children, the outcome of Henoch-Schönlein purpura is excellent with spontaneous resolution of symptoms and signs. However, a small subset of patients will develop long-term sequelae in the form of chronic kidney disease. While the clinical presentation and diagnosis of Henoch-Schönlein purpura is straightforward, treatment of Henoch-Schönlein purpura nephritis and long-term renal outcomes of more severely affected children are less certain. This review article gives a general overview of Henoch-Schönlein purpura with emphasis on recently published information, including the new classification of childhood vasculitis, insights into pathogenesis of Henoch-Schönlein purpura and a summary of various treatments of established Henoch-Schönlein purpura nephritis.

Clinical manifestations and endoscopic characteristics of adult abdominal type allergic purpura: An analysis of 26 cases

AIM: To summarize the clinical and endoscopic features of abdominal type allergic purpura in adult patients.

METHODS: Clinical and endoscopic data for 26 adult patients with abdominal type allergic purpura were analyzed retrospectively.

RESULTS: All patients had abdominal pain, and 13 patients had digestive tract hemorrhage. Endoscopy revealed hyperaemia, edema, bleeding spots, erosion and ulcer in the gastrointestinal mucosa. Severe mucosal lesions were often found in the duodenum, ileum and caecum.

CONCLUSION: Gastrointestinal endoscopy is helpful for early diagnosis of adult abdominal type allergic purpura.

Henoch-Schonlein purpura with intestinal perforation and cerebral hemorrhage: A case report

Henoch-Schonlein purpura (HSP) with intestinal perforation and cerebral hemorrhage is a very rare clinical condition. There has been no report of HSP complicated with both intestinal perforation and cerebral hemorrhage until October 2012. Here we describe a case of HSP with intestinal perforation and cerebral hemorrhage in a 5-year-old girl. Plain abdominal radiograph in the erect position showed heavy gas in the right subphrenic space with an elevated diaphragm. Partial resection of the small intestine was performed, and pathological analysis suggested chronic suppurative inflammation in all layers of the ileal wall and mesentery. Seventeen days after surgery, cerebral hemorrhage developed and the patient died.

Acute appendicitis in two children with Henoch-Schönlein purpura

In Henoch-Schönlein purpura (HSP), involvement of the ileum and ascending colon with vasculitis can mimic appendicitis and cause unnecessary appendicectomy. A 13-year-old boy presented with signs of HSP and abdominal pain. He was treated with prednisolone (2 mg/kg/day) for 10 days, but there was no improvement. At laparotomy he had acute suppurative appendicitis. A 12-year-old girl presented with HSP associated with abdominal pain and bloody diarrhoea and at laparotomy was also found to have suppurative appendicitis. Both patients had vasculitic areas in the ileum. In HSP, although suppurative appendicitis is rare, it should always be considered and appropriate investigations, including ultrasonography, undertaken.