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Wong NA. My approach to bowel ischaemia. J Clin Pathol 2023; 76:293-300. [PMID: 36813561 DOI: 10.1136/jcp-2023-208764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/27/2023] [Indexed: 02/24/2023]
Abstract
Resections of ischaemic bowel are one of the most common pathology specimens yet are often viewed as unappealing and diagnostically unrewarding. This article serves to dispel both misconceptions. It also provides guidance on how clinical information, macroscopic handling and microscopic assessment-and especially the interlinking of all three-can maximise the diagnostic yield of these specimens. This diagnostic process requires recognition of the wide range of causes of intestinal ischaemia, including several more recently described entities. Pathologists should also be aware of when and why such causes cannot be discerned from a resected specimen and of how certain artefacts or differential diagnoses can mimic ischaemia.
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Enterocolic Lymphocytic Phlebitis Treated Preoperatively with Biologics and Immunosuppressive Agents. Case Rep Pathol 2022; 2022:5120607. [PMID: 35295675 PMCID: PMC8920688 DOI: 10.1155/2022/5120607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/11/2022] [Indexed: 11/30/2022] Open
Abstract
Enterocolic lymphocytic phlebitis is phlebitis of unknown etiology in which lymphocytes affect veins without arteries and shows evidence of systemic vasculitis in the intestinal wall and mesentery, mainly in the small intestine and colon. Although patients present with a variety of gastrointestinal symptoms and findings like those of inflammatory bowel disease or ischemic bowel disease, there are no specific findings for enterocolic lymphocytic phlebitis. As a result, a diagnosis tends to be made after surgery. There are few case reports of enterocolic lymphocytic phlebitis, and the impact of chronic courses and immunosuppressive drugs on enterocolic lymphocytic phlebitis is not well known. A 47-year-old man was treated with infliximab and steroids for unexplained ulceration and narrowing of the ileocecal area, which was suspected to be inflammatory bowel disease with atypical findings. Lymphocytic phlebitis was noted in the surgical specimen, and enterocolic lymphocytic phlebitis was diagnosed. No recurrence of enterocolic lymphocytic phlebitis was observed postoperatively. This disease should also be considered among patients with inflammatory bowel disease-like lesions that do not respond to infliximab or steroids.
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Pancreatitis as the Leading Manifestation of Granulomatosis With Polyangiitis: Case Report and Review of the Literature. Pancreas 2021; 50:e85-e88. [PMID: 35041351 DOI: 10.1097/mpa.0000000000001944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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4
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Mengus C, Ozkurt S, Oztas E, Yasar Bilge NS, Isiksoy S, Yalcin AU. De novo isolated gastrointestinal tract vasculitis without associated systemic disease in renal transplant recipients successfully treated with rituximab. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:281-284. [PMID: 32129226 DOI: 10.4103/1319-2442.279954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Systemic vasculitic diseases can show recurrence after kidney transplantation, but de novo systemic vasculitis is rarely seen after kidney transplantation, and in literature, there are only a few cases. In general population, the incidence of isolated organ vasculitis is unknown, and according to the best of our knowledge, there is no information about de novo isolated organ vasculitis after renal transplantation. We report, most probably, the first case of a 40-year-old woman who was restarted on dialysis treatment after renal transplantation and developed isolated gastrointestinal vasculitis and intestinal hemorrhage under immunosuppressive treatment. She was treated successfully with rituximab.
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Affiliation(s)
- Cigdem Mengus
- Department of Nephrology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Sultan Ozkurt
- Department of Nephrology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Erkin Oztas
- Department of Gastroenterology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Nazife Sule Yasar Bilge
- Department of Rheumatology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Serap Isiksoy
- Department of Pathology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Ahmet Ugur Yalcin
- Department of Nephrology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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Zhang X, Furth EE, Tondon R. Vasculitis Involving the Gastrointestinal System Is Often Incidental but Critically Important. Am J Clin Pathol 2020; 154:536-552. [PMID: 32789454 DOI: 10.1093/ajcp/aqaa083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Xiaoming Zhang
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Emma Elizabeth Furth
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Rashmi Tondon
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
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Adult-Onset Immunoglobulin A Vasculitis. ACG Case Rep J 2020; 7:e00306. [PMID: 32337300 PMCID: PMC7162119 DOI: 10.14309/crj.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/07/2019] [Indexed: 11/26/2022] Open
Abstract
Immunoglobulin A vasculitis (IgAV), formerly Henoch–Schönlein purpura vasculitis, is a vasculitis commonly seen in children and only rarely described in adult patients. IgAV can present as arthralgia, rash, discolored urine, acute kidney injury, and gastrointestinal symptoms. We present a case of a 56-year-old man who presented with 1 month of worsening abdominal pain followed by a bilateral lower extremity rash. Laboratory evaluation indicated an acute kidney injury. Computed tomography and colonoscopy revealed terminal ileitis while kidney biopsy confirmed a diagnosis of IgAV.
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Pouli S, Kozana A, Papakitsou I, Daskalogiannaki M, Raissaki M. Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology. Insights Imaging 2020; 11:31. [PMID: 32086627 PMCID: PMC7035412 DOI: 10.1186/s13244-019-0823-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/29/2019] [Indexed: 12/11/2022] Open
Abstract
Gastrointestinal tract (GIT) perforation is a common medical emergency associated with considerable mortality, ranging from 30 to 50%. Clinical presentation varies: oesophageal perforations can present with acute chest pain, odynophagia and vomiting, gastroduodenal perforations with acute severe abdominal pain, while colonic perforations tend to follow a slower progression course with secondary bacterial peritonitis or localised abscesses. A subset of patients may present with delayed symptoms, abscess mimicking an abdominal mass, or with sepsis. Direct multidetector computed tomography (MDCT) findings support the diagnosis and localise the perforation site while ancillary findings may suggest underlying conditions that need further investigation following primary repair of ruptured bowel. MDCT findings include extraluminal gas, visible bowel wall discontinuity, extraluminal contrast, bowel wall thickening, abnormal mural enhancement, localised fat stranding and/or free fluid, as well as localised phlegmon or abscess in contained perforations. The purpose of this article is to review the spectrum of MDCT findings encountered in GIT perforation and emphasise the MDCT and clinical clues suggestive of the underlying aetiology and localisation of perforation site.
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Affiliation(s)
- Styliani Pouli
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Androniki Kozana
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Ioanna Papakitsou
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - Maria Daskalogiannaki
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece.
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Abstract
Rheumatological diseases (RDs) represent a diverse group of diseases that are inherited or related to environmental factors. RDs frequently affect the gastrointestinal (GI) tract, and gastroenterologists are often asked to evaluate patients with symptoms thought to represent an underlying or coexisting RD. GI manifestations of RDs vary based on the organ involved as well as the extent and duration of involvement. Although most manifestations of RD are nonspecific and not life-threatening, the chronicity and severity of symptoms can be debilitating and may lead to serious injury. This narrative review discusses the most common RD encountered by gastroenterologists: systemic lupus erythematosus, systemic sclerosis (scleroderma), dermatomyositis/polymyositis, rheumatoid arthritis, Sjögren syndrome, overlap syndromes, mixed connective tissue disease, Ehlers-Danlos syndromes, and other vasculitides. Each section begins with a brief overview of the condition, followed by a discussion of the etiopathophysiology, physical examination findings, GI manifestations, diagnostic tools (i.e., serologic, imaging, endoscopic, and functional), and treatment options.
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Gastrointestinal Tract Vasculopathy: Clinicopathology and Description of a Possible "New Entity" With Protean Features. Am J Surg Pathol 2019; 42:866-876. [PMID: 29624512 DOI: 10.1097/pas.0000000000001060] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Noninfectious gastrointestinal (GI) vasculopathic disorders are rare and are often overlooked in histopathologic examination or when forming differential diagnoses due to their rarity. However, involvement of the GI tract may lead to serious complications, including ischemia and perforation. Since awareness of the types of vasculopathy that may involve the GI tract is central to arriving at a correct diagnosis, we reviewed our institutional experience with GI tract vasculopathy in order to enhance diagnostic accuracy of these rare lesions. We report the clinical and histologic features of 16 cases (excluding 16 cases of immunoglobulin A vasculitis) diagnosed over a 20-year period. Of the 16 patients, 14 presented with symptoms related to the GI vasculopathy (including 2 presenting with a mass on endoscopic examination). The remaining 2 patients presented with incarcerated hernia and invasive adenocarcinoma. The vasculopathy was not associated with systemic disease and appeared limited to the GI tract in 8 patients. Eight had associated systemic disease, but only 6 had a prior diagnosis. The underlying diagnoses in these 6 patients included systemic lupus erythematosus (1), dermatomyositis (2), rheumatoid arthritis (1), eosinophilic granulomatosis with polyangiitis (1), and Crohn disease (1). One patient with granulomatous polyangiitis and 1 patient with systemic lupus erythematosus initially presented with GI symptoms. The 8 cases of isolated GI tract vasculopathy consisted of enterocolic lymphocytic phlebitis (4), idiopathic myointimal hyperplasia of the sigmoid colon (1), idiopathic myointimal hyperplasia of the ileum (1), granulomatous vasculitis (1), and polyarteritis nodosa-like arteritis (1). Isolated GI tract vasculopathy is rare, but appears to be almost as common as that associated with systemic disease. The chief primary vasculopathies are enterocolic lymphocytic colitis and idiopathic myointimal hyperplasia. Although the latter occurs predominantly in the left colon, rare examples occur in the small bowel and likely represent a complex, more protean disorder.
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Liang Y, Di Re A, El Khoury T. A rare case of lupus-related gastrointestinal vasculitis presenting as rectal gangrene. J Surg Case Rep 2019; 2019:rjz128. [PMID: 31044066 PMCID: PMC6486653 DOI: 10.1093/jscr/rjz128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/09/2019] [Indexed: 11/14/2022] Open
Abstract
Systemic lupus erythematosus (SLE) related gastrointestinal vasculitis is a rare condition limited to case studies within the literature however, no cases of rectal gangrene and perforation have been previously described. A 32-year-old male presented with abdominal pain, vomiting and fevers. CT demonstrated free gas and free fluid around the rectum indicative of a perforation. He proceeded to urgent laparotomy, confirming a diagnosis of rectal infarction and perforation. Uniquely, the involved segment of gangrene extended from the rectosigmoid to the anorectal junction. A Hartmanns procedure was performed. Histopathology confirmed underlying stenosis of the rectal arteries secondary to chronic vasculitis related to the affected areas. The current case is a unique presentation of SLE-related vasculitis. It highlights the need to judiciously investigate SLE patients presenting with surgical acute abdomen.
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Affiliation(s)
- Yi Liang
- Westemead Hospital, Cnr Hawkesbury and Darcy Road, Westmead NSW, Australia
| | - Angelina Di Re
- Westemead Hospital, Cnr Hawkesbury and Darcy Road, Westmead NSW, Australia
| | - Toufic El Khoury
- Westemead Hospital, Cnr Hawkesbury and Darcy Road, Westmead NSW, Australia.,University of Notre Dame Medical School, 160 Oxford Street, Darlinghurst NSW, Australia
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Bhatt DB, Seetharam A. Enteritis and Rapid-Onset Renal Dysfunction in a Previously Healthy Adult. Gastroenterology 2018; 154:e1-e3. [PMID: 29391142 DOI: 10.1053/j.gastro.2017.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 04/27/2017] [Accepted: 05/01/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Divya B Bhatt
- University of Arizona College of Medicine, Phoenix, Arizona
| | - Anil Seetharam
- University of Arizona College of Medicine, Phoenix, Arizona; Banner University Medical Center Transplant and Advanced Liver Disease Clinic, Phoenix, Arizona
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12
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Gong EJ, Kim DH, Chun JH, Ahn JY, Choi KS, Jung KW, Lee JH, Choi KD, Song HJ, Lee GH, Jung HY, Kim JH, Song IH, Kim YG. Endoscopic Findings of Upper Gastrointestinal Involvement in Primary Vasculitis. Gut Liver 2017; 10:542-8. [PMID: 27226428 PMCID: PMC4933413 DOI: 10.5009/gnl15198] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/05/2015] [Accepted: 10/20/2015] [Indexed: 12/19/2022] Open
Abstract
Background/Aims Gastrointestinal involvement in vasculitis may result in life-threatening complications. However, its variable clinical presentations and endoscopic features, and the rarity of the disease, often result in delayed diagnosis. Methods Clinical characteristics, endoscopic features, and histopathological findings were reviewed from medical records. Results Of 6,477 patients with vasculitis, 148 were diagnosed as primary vasculitis with upper gastrointestinal involvement. Of these, 21 cases (14.2%) were classified as large-vessel vasculitis, 17 cases (11.5%) as medium-vessel vasculitis, and 110 cases (74.3%) as small-vessel vasculitis. According to the specific diagnosis, IgA vasculitis (Henoch-Schönlein purpura) was the most common diagnosis (56.8%), followed by Takayasu arteritis (14.1%), microscopic polyangiitis (10.1%), and polyarteritis nodosa (6.8%). Gastrointestinal symptoms were present in 113 subjects (76.4%), with abdominal pain (78.8%) the most common symptom. Erosion and ulcers were striking endoscopic features, and the second portion of the duodenum was the most frequently involved site. Biopsy specimens were obtained from 124 patients, and only eight (5.4%) presented histopathological signs of vasculitis. Conclusions Diagnosis of vasculitis involving the upper gastrointestinal tract is difficult. Because of the widespread use of endoscopy, combining clinical features with endoscopic findings may facilitate making appropriate diagnoses; however, the diagnostic yield of endoscopic biopsy is low.
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Affiliation(s)
- Eun Jeong Gong
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Hyun Chun
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwi-Sook Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Ho Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Hye Song
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Koster MJ, Warrington KJ. Vasculitis of the mesenteric circulation. Best Pract Res Clin Gastroenterol 2017; 31:85-96. [PMID: 28395792 DOI: 10.1016/j.bpg.2016.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 12/09/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Vasculitis of the mesenteric circulation is an uncommon but life-threatening manifestation of systemic vasculitis. Initial symptoms are frequently non-specific and therefore patients often present to primary care physicians and gastroenterologists with abdominal pain or gastrointestinal bleeding. Given the severity of the conditions associated with mesenteric vasculitis, it is imperative to appropriately diagnose and initiate treatment of suspected cases. This review will focus on diseases commonly associated with vasculitis of the mesenteric vessels. Imaging characteristics and clinical features assisting in diagnosis as well as initial approaches to treatment are emphasized.
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Affiliation(s)
- Matthew J Koster
- Division of Rheumatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
| | - Kenneth J Warrington
- Division of Rheumatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Chetty R, Serra S. A pragmatic approach to vasculitis in the gastrointestinal tract. J Clin Pathol 2017; 70:470-475. [PMID: 28119348 DOI: 10.1136/jclinpath-2016-204308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/02/2017] [Indexed: 11/03/2022]
Abstract
Although vasculitis involving the gastrointestinal tract (GIT) is an uncommon occurrence, occasionally vasculitis can present as haemorrhagic infarction or ischaemia for which a length of bowel is removed. Invariably, the appropriate clinical history is not forthcoming, or vasculitis is not clinically suspected. The purpose of this overview is to provide the practising gastrointestinal (GI) pathologist with a framework to recognise and diagnose vasculitides within the GIT. The classification may be approached by aetiological agent or size of vessel involved; an international consensus group now favours the latter approach. The symptoms that systemic and/or localised vasculitis may cause in the GIT are protean and non-specific. As a result, pathologists examining resection specimens for unexplained haemorrhagic infarction or ischaemia should be aware that vasculitis may be a potential cause. Several well-known systemic vasculitides such as polyarteritis nodosa, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis or Churg-Strauss syndrome and granulomatosis with polyangiitis or Wegener's granulomatosis can occur in the GIT. The latter three constitute the antineutrophil cytoplasmic antibody-positive vasculitides. In addition, the so-called solitary organ vasculitis (SOV) can occur in the GIT as the harbinger of later onset systemic vasculitis, and be the cause of the GIT symptoms. In addition, SOV can occur incidentally and coexist with GIT disease such as gallstones or polyps, and there may be no manifestations of systemic vasculitis for years, or not at all.
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Affiliation(s)
- Runjan Chetty
- Department of Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Stefano Serra
- Department of Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
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Ruiz N, Rivera-Rosales R, Cedillo J, Luna-Rivero C, Flores-Suárez LF. Unusual cause of intestinal perforation in granulomatosis with polyangiitis (Wegener's). Int J Rheum Dis 2015; 20:280-281. [PMID: 26578158 DOI: 10.1111/1756-185x.12788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Natllely Ruiz
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Rosa Rivera-Rosales
- Department of Pathology, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Jesús Cedillo
- Respiratory Intensive Care Unit, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - César Luna-Rivero
- Department of Pathology, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
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16
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Gu Y, Zhu T, Wang Y, Xu H. Systemic lupus erythematosus with intestinal perforation: A case report. Exp Ther Med 2015; 10:1234-1238. [PMID: 26622471 DOI: 10.3892/etm.2015.2639] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 07/07/2015] [Indexed: 12/13/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune inflammatory disease, which can affect almost all systems and organs. Gastrointestinal disorder is one of the most noteworthy complications of patients with SLE. However, gastrointestinal disorder with intestinal perforation is rare, but potentially life-threatening if not treated promptly. The present study reported a case of SLE with intestinal perforation, where surgical intervention was performed and a crevasse (~3 cm in diameter) was detected in the ileum, ~60 cm from the ileocecal valve. Following surgery, the patient suffered from difficult ventilator weaning, septic shock and intestinal obstruction. The patient was successfully treated and discharged from the hospital after ~4 months of treatment. Intestinal perforation in SLE patients is potentially life-threatening; early diagnosis and prompt treatment are crucial to the management of this rare complication of SLE.
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Affiliation(s)
- Yuqing Gu
- Department of General Surgery, Taicang Hospital Affiliated to Soochow University, Taicang, Jiangsu 215400, P.R. China
| | - Tao Zhu
- Department of Intensive Care Unit, Taicang Hospital Affiliated to Soochow University, Taicang, Jiangsu 215400, P.R. China
| | - Yiqing Wang
- Department of General Surgery, Taicang Hospital Affiliated to Soochow University, Taicang, Jiangsu 215400, P.R. China
| | - Hongxing Xu
- Department of General Surgery, Taicang Hospital Affiliated to Soochow University, Taicang, Jiangsu 215400, P.R. China
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Seo MR, Kim TE, Ryu HJ, Baek HJ, Choi HJ. A Case of Enterocolic Lymphocytic Phlebitis Mimicking Surgical Abdomen. JOURNAL OF RHEUMATIC DISEASES 2014. [DOI: 10.4078/jrd.2014.21.2.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Mi Ryoung Seo
- Division of Rheumatology, Department of Internal Medicine, Gachon University School of Medicine, Gil Medical Center, Incheon, Korea
| | - Tae Eun Kim
- Department of Pathology, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Jung Ryu
- Division of Rheumatology, Department of Internal Medicine, Gachon University School of Medicine, Gil Medical Center, Incheon, Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gachon University School of Medicine, Gil Medical Center, Incheon, Korea
| | - Hyo Jin Choi
- Division of Rheumatology, Department of Internal Medicine, Gachon University School of Medicine, Gil Medical Center, Incheon, Korea
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Abstract
The noninfectious, inflammatory vasculitides include giant cell arteritis, Takayasu disease, Churg-Strauss angiitis, Wegener disease, polyarteritis nodosa, microscopic polyangiitis, Buerger disease, amyloid-β-related angiitis, and isolated vasculitis of the central nervous system. While these disorders are relatively uncommon, they produce a variety of neurologic diseases including muscle disease, mononeuropathy multiplex, polyneuropathy, cranial nerve palsies, visual loss, seizures, an encephalopathy, venous thrombosis, ischemic stroke, and intracranial hemorrhage. The multisystem vasculitides often have stereotypical clinical findings that reflect disease of the kidney, sinuses, lungs, skin, joints, or cardiovascular system. These disorders also usually have abnormalities found on serologic testing. Isolated vasculitis of the central nervous system is more difficult to diagnose because the clinical and brain imaging findings are relatively nonspecific. Examination of the cerebrospinal fluid will demonstrate changes consistent with an inflammatory process. Arteriography often shows areas of segmental narrowing affecting multiple intracranial vessels and brain/meningeal biopsy may be required to establish the diagnosis. Management of patients with a multisystem vasculitis or isolated vasculitis of the central nervous system is centered on the administration of immunosuppressive agents. In many cases, corticosteroids remain the mainstay of medical treatment.
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Affiliation(s)
- Harold P Adams
- Division of Cerebrovascular Diseases, Department of Neurology, Carver College of Medicine, University of Iowa Health Care Stroke Center, University of Iowa, Iowa City, IA, USA.
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Lupus mesenteric vasculitis: clinical features and associated factors for the recurrence and prognosis of disease. Semin Arthritis Rheum 2013; 43:759-66. [PMID: 24332116 DOI: 10.1016/j.semarthrit.2013.11.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 11/06/2013] [Accepted: 11/07/2013] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the clinical characteristics of lupus mesenteric vasculitis (LMV) and identify the potential factors and appropriate treatments that are associated with disease relapse and prognosis in LMV. METHODS A retrospective cohort study was performed among patients admitted to the First Affiliated Hospital of Sun Yet-sen University between 2002 and 2011. Demographic information, clinical symptoms, laboratory findings, imaging characteristics like abdominal CT scan, ultrasonography, medications including corticosteroid, cyclophosphamide, and other immunosuppressive agents, and outcomes were documented. The endpoints of the study were defined as occurrence of severe complications that needed surgical intervention, disease recurrence, or death. RESULTS Out of 3823 systemic lupus erythematosus (SLE) patients, 97 were diagnosed with mesenteric vasculitis with the overall prevalence of 2.5%. Among these 97 LMV patients, 13 died because of serious complications (13/97, 13.4%) and 2 presented intestinal perforation during the induction therapy stage. The logistic regression multivariate analysis indicated that leukopenia [peripheral WBC, odds ratio (OR) = 0.640, 95% confidence interval (CI): 0.456-0.896, P = 0.009], hypoalbuminemia (serum albumin, OR = 0.891, 95% CI: 0.798-0.994, P = 0.039) and elevated serum amylase (OR = 7.719, 95% CI: 1.795-33.185, P = 0.006) were positively associated with the occurrence of serious complications, while intravenous cyclophosphamide (CYC) therapy inhibited the occurrence of serious complications (OR = 0.220, 95% CI: 0.053-0.903, P = 0.036). A total of 79 patients who achieved remission were followed-up for 2-96 months and 18 cases experienced disease relapse (18/79, 22.8%). The statistical analysis adjusted by Cox proportional hazards models indicated that high-dose CYC therapy (≥ 1.0 g/m(2)/month) was a protective factor for disease relapse and led to better outcomes [hazard ratio (HR) = 0.209, 95% CI: 0.049-0.887, P = 0.034], while the severe thickness of the bowel wall (>8mm) was a risk factor (HR = 7.308, 95% CI: 1.740-30.696, P = 0.007). LMV and lupus cystitis occurred concurrently in 22 (22/97, 22.7%) patients, and the symptoms of urinary tract resolved after treatment with corticosteroid and immunosupressants. CONCLUSION LMV is one of the serious complications of SLE with high mortality. The current study demonstrated that leukopenia, hypoalbuminemia, and elevated serum amylase were associated with severe adverse events, while CYC therapy led to better outcomes during remission-induction stage. Severe thickness of the bowel was a risk factor while high-dose CYC therapy was a protective factor for disease relapse in intensification therapy stage. It is necessary to evaluate the urinary tract involvement once LMV is diagnosed due to the frequent coexistence of these 2 diseases.
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Takayasu V, Felipe-Silva A. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) syndrome and pulmonary thromboembolism: an overlooked concomitance. AUTOPSY AND CASE REPORTS 2013; 3:11-19. [PMID: 31528603 PMCID: PMC6673679 DOI: 10.4322/acr.2013.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 06/06/2013] [Indexed: 11/23/2022] Open
Abstract
The Eosinophilic Granulomatosis with Polyangiitis (formerly Churg- Strauss Syndrome) (EGPA) is a systemic inflammatory disease characterized by the presence of rhinitis, asthma, peripheral eosinophilia, and vasculitis-the latter being characteristic of the late stage of the disease. After several years from the onset of the disease, small- and medium-sized vessel vasculitis ensues, undertaking various organs and systems. Upper and lower airways, skin, nervous system, gastrointestinal tract, heart, and kidneys are the most commonly involved organs. It is believed that tissue injury is the result of processes mediated by antineutrophil cytoplasmic antibody (ANCA), or toxic mediators released by eosinophils. Although it is classified as ANCA-associated vasculitis, these autoantibodies are present in only 40% of cases. The authors report the case of a patient with EGPA, who had a history of asthma, peripheral and central neuropathy, palpable purpura, gastrointestinal micro perforation, peripheral eosinophilia, and the presence of myeloperoxidase-antineutrophil cytoplasmic antibody. Inflammatory parameters improved after the initiation of treatment, but 1 month after hospital discharge the patient developed symptoms compatible with pulmonary embolism and died. Thrombophilia that occurs in EGPA is due to the interaction between the inflammatory response and eosinophilia with the clotting system resulting in a pro-thrombotic state. Although not yet well-determined, the authors call attention to the possibility of the impact of thromboembolic events on the prognosis of patients with EGPA. In addition to the adequate immunosuppressive treatment, prophylaxis and treatment for thrombosis should never be overlooked.
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Affiliation(s)
- Vilma Takayasu
- Department of Internal Medicine - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Aloísio Felipe-Silva
- Anatomic Pathology Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
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Suzuki T, Matsushima M, Arase Y, Fujisawa M, Okita I, Igarashi M, Koike J, Mine T. Double-balloon endoscopy-diagnosed multiple small intestinal ulcers in a Churg-Strauss syndrome patient. World J Gastrointest Endosc 2012; 4:194-6. [PMID: 22624072 PMCID: PMC3355243 DOI: 10.4253/wjge.v4.i5.194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 09/12/2011] [Accepted: 03/30/2012] [Indexed: 02/05/2023] Open
Abstract
Churg-Strauss syndrome (CSS) is a systemic vascular disorder characterized by severe bronchial asthma, hypereosinophilia, and allergic rhinitis. Small intestinal ulcers associated with CSS are a relatively rare manifestation that causes gastrointestinal bleeding. Multiple deep ulcers with an irregular shape are characteristic of small intestinal involvement of CSS. Video-capsule-endoscopy (VCE), double-balloon endoscopy (DBE) and Spirus assisted enteroscopy have been developed recently and enabled observation of the small intestine. In this case report, we have described a patient with CSS who had multiple deep ulcers in the jejunum detected by oral DBE. Since severe gastrointestinal (GI) involvement has been identified as an independent factor associated with poor outcome, the careful investigation of GI tract must be needed for CSS patients with GI symptoms. We describe the usefulness of DBE for diagnosis of small intestinal ulcers in patient with CSS.
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Affiliation(s)
- Takayoshi Suzuki
- Takayoshi Suzuki, Masashi Matsushima, Yoshitaka Arase, Mia Fujisawa, Ichiro Okita, Muneki Igarashi, Jun Koike, Tetsuya Mine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa 259-1193, Japan
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:207-27. [DOI: 10.1097/spc.0b013e32833e8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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