Eosinophilic gastroenteritis associated with systemic lupus erythematosus

Eosinophilic Gastroenteritis with a Relapsing and Remitting Course with Presence of Autoimmune Antibodies

Background

Eosinophilic gastroenteritis (EGE) is an uncommon disease characterized by eosinophilic infiltration of the digestive tract, which occurs due to an uncertain aetiology. Although autoimmune diseases can later present as EGE, it is unusual for EGE to have positive autoimmune antibodies without the presence of an overt autoimmune disease. Case presentation. We report a 38-year-old previously healthy man who presented with abdominal discomfort and loose stools with pleural and peritoneal effusions progressing over several weeks. His investigations revealed severe eosinophilia in peripheral blood and ascitic fluid, and a laparoscopic full-thickness biopsy from the ileum demonstrated infiltration of eosinophils in all three layers of the intestine. There were no clinical features or investigations suggestive of parasitic disease, other diseases associated with eosinophilia, or autoimmune disease. Further investigations showed a highly positive ANA, positive p-ANCA, but did not meet the criteria to diagnose a specific autoimmune disease. The eosinophilia responded to an elimination diet with gradual resolution of eosinophilia and effusions, and once it reappeared after introduction of a normal diet.

Conclusion

EGE presenting as peripheral blood and ascitic fluid eosinophilia with the presence of pleural and/or peritoneal effusions is uncommon. Eosinophilic gastroenteritis can be associated with autoantibody positivity without any evidence of overt autoimmune disease manifestations. Elimination diet can be used as a potential option to prevent recurrences of EGE.

Causes of eosinophilic ascites – A systematic review

Background . In the last years an uprising interest for a relatively unknown entity, eosinophilic ascites (EA), has been recorded.

Our aim is to investigate the potential causes of EA development, as well as clinical, laboratory, endoscopic and radiologic features, management and outcome in these patients.

Methods . The following research was performed on PubMed (MEDLINE) database using the medical subject headings [Mesh] terms “Ascites” AND “Eosinophils”.

Results . A total of 284 results, dating from 1962 onwards, were found and abstracts were examined. 131 papers were excluded and the remaining 153 publications, consisting in case reports and series of cases, were analyzed.

From 171 patients with EA, 127 subjects (74%) had EGE, 17 (10%) parasitic and fungal infections, 11(7%) Hypereosinophilic syndrome and 16 patients (9%) less common diseases (eosinophilic pancreatitis, chronic eosinophilic leukemia, myelofibrosis, T-cell lymphoma, Churg Strauss Syndrome, Systemic lupus erythematosus, Familial paroxysmal polyserositis and Ménétrier’s disease). High eosinophil blood count and IgE levels as well as gastrointestinal symptoms are frequent. The diagnosis is based on ascitic fluid analysis, imaging and endoscopic biopsies. Therapy with corticosteroids results in resolution of eosinophilic ascites in almost all patients.

Conclusion . In most cases, in the absence of allergy, parasitic infections, malignancy, hematological disorders, peritoneal tuberculosis, inflammatory bowel disease or autoimmune disease, EA develops as a manifestation of eosinophilic gastroenteritis.

Noninvasive evaluation of gastric emptying and gastric wall thickness in SLE patients

OBJECTIVE

The objective of this study is to evaluate the gastric emptying in patients with systemic lupus erythematosus (SLE) with gastrointestinal involvement using three-dimensional (3D) ultrasonography.

METHODS

The gastric emptying times at 25% (T1), 50% (T2), and 75% (T3) of SLE patients with gastrointestinal involvement (n = 40) and healthy controls (n = 80) were evaluated and compared. In addition, the correlations among the gastric wall thickness, SLE disease activity index (SLEDAI), and upper gastrointestinal symptoms were calculated.

RESULTS

The gastric wall thickness was correlated with the SLEDAI (r = 0.928, p < 0.001) and the upper gastrointestinal symptom index (r = 0.848, p < 0.001). The emptying times T1, T2, and T3 of the SLE patients were 17.08 ± 2.65 min (mean ± standard deviation), 39.85 ± 6.54 min, and 83.58 ± 7.12 min, respectively. For healthy controls, they were 19.65 ± 5.39 min, 41.08 ± 7.51 min, and 70.34 ± 8.03 min. The T1 of the SLE patients was shorter (p < 0.01), while the T3 was longer (p < 0.001). Moreover, T3 in the SLE group had the best correlation with the upper gastrointestinal symptom index (r = 0.553, p < 0.001). T1 in the SLE group was anti-correlated with early satiety (r = -0.366, p < 0.05).

CONCLUSIONS

Combining the emptying times T1 and T3, as well as the gastric wall thickness, the SLEDAI and the upper gastrointestinal symptoms index can provide accurate clinical diagnosis of SLE with gastric involvement.

Eosinophilic gastrointestinal disorders associated with autoimmune connective tissue disease

OBJECTIVES

To determine the clinical and pathological characteristics of eosinophilic gastrointestinal disease (EGID) associated with autoimmune connective tissue disease (CTD).

METHODS

Systematic literature review.

RESULTS

Twenty cases of CTD associated with EGID were identified. Systemic lupus erythematosus was the main EGID-associated CTD (35%), followed by rheumatoid arthritis (20%), systemic sclerosis or inflammatory myopathies (15%, each), and Sjögren's syndrome, scleromyositis or other overlapping connective tissue disease (5%, each). No patient had a history of atopy. In contrast with classical EGID among which eosinophilic esophagitis is the most frequent type, eosinophilic gastritis and/or enteritis represented 95% of cases. Gastrointestinal symptoms were often unspecific. Peripheral eosinophilia was found in 67% of cases. Upper and lower gastrointestinal endoscopy showed abnormal findings in only 40% and 30% of cases, respectively. EGID was confirmed by evidence of digestive eosinophilic infiltration, mainly in mucosal or submucosal layer. In all but one patient, the CTD was diagnosed prior to the occurrence of the EGID. In total, 95% of EGID had a favorable outcome, with corticosteroids being used in almost all cases.

CONCLUSION

Clinicians should consider EGID as a possible diagnosis and perform gastrointestinal tract biopsies in patients with CTD presenting with gastrointestinal symptoms and unexplained eosinophilia. Conversely, more rarely extra-digestive features during follow-up in patients with EGID may lead to a diagnosis of an associated CTD. More research is needed to better understand the underlying pathophysiological processes leading to eosinophilic gastrointestinal infiltration in patients with CTD.

Eosinophilic Granulomatosis With Polyangiitis With Thrombotic Microangiopathy: Is Simultaneous Systemic Lupus Erythematosus Associated With Clinical Manifestations?: A Case Report and Review of the Literature

Eosinophilic granulomatosis with polyangiitis (EGPA) is one of the antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, which is characterized by vasculitis of the small to medium-sized vessels. On the contrary, thrombotic microangiopathy (TMA) is a life-threatening condition which can cause ischemic organ injury. Although several case reports have described patients with TMA associated with ANCA-associated vasculitis except for EGPA, there are no previous case reports of EGPA associated with TMA.A 71-year-old Japanese man was diagnosed with EGPA based on his asthma, eosinophilia, lung opacity, refractory sinusitis, and positive myeloperoxidase-ANCA. He was also diagnosed with TMA based on peripheral schizocytes and hemolytic anemia. We performed plasmapheresis and started high-dose corticosteroid therapy; thereafter, he improved promptly. His case also fulfilled the classification criteria of systemic lupus erythematosus (SLE) based on the pleural effusion, renal disorder, anemia, thrombocytopenia, positive antidouble-stranded DNA antibody, and low complement. Elements of SLE were thought to affect his clinical course.We reviewed 11 patients with EGPA or hypereosinophilic syndrome (HES) associated with SLE, including our case. Patients with EGPA or HES associated with SLE had more heart complications than patients with simple EGPA or simple HES did. Patients with EGPA or HES associated with SLE had more pleural effusion than patients with simple SLE did.Clinical manifestations of eosinophilia with SLE or SLE with eosinophilia may differ from simple SLE or simple eosinophilia.

Eosinophilic Esophagitis and Gastroenteritis

Eosinophilic gastrointestinal disease (EGID) can be classified as eosinophilic esophagitis (EoE) when the eosinophilia is limited to the esophagus or as eosinophilic gastritis (EG) if it is limited to the gastric tract, eosinophilic colitis (EC) if it is limited to the colon, and eosinophilic gastroenteritis (EGE) if the eosinophilia involves one or more parts of the gastrointestinal tract. EoE is by far the most common EGID. It is a well-defined chronic atopic disease due to a T helper type 2 (Th2) inflammation triggered often by food allergens. EoE diagnosis is done if an esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf). Globally accepted long-term therapies for EoE are the use of swallowed inhaled steroids or food antigen avoidance. The treatment of EoE is done not only to control symptoms but also to prevent complications such as esophageal stricture and food impaction. EGE cause non-specific gastrointestinal (GI) symptoms and are diagnosed if esophagogastroduodenoscopy (EGD)/colonoscopy show eosinophilia in one or more parts of the GI tract. They are rare diseases with an unclear pathogenesis, and they are poorly defined in terms of diagnostic criteria and treatment. Before initiating treatment of any EGE, it is imperative to conduct a differential diagnosis to exclude other causes of hypereosinophilia with GI localization. EGE are often poorly responsive to therapy and there is no commonly accepted long-term treatment. EG has many characteristics similar to EoE, including the fact that it is often due to a food allergen-driven Th2 inflammation; transcriptome analysis however shows that it is more a systemic disease and has a different gene signature than EoE. EC is a benign form of delayed food allergy in infant and is instead a difficult-to-treat severe inflammatory condition in older children and adults. EC in the latter groups can be a manifestation of drug allergy or autoimmune disease. Overall EGE, EC, and EG are rare and are a diagnosis of exclusion until more common causes of eosinophilia have been excluded.

Acute eosinophilic ascites: An unusual form of an unusual case

Eosinophilic gastroenteritis (EGE) is an uncommon disease characterised by eosinophilic infiltration in the gastrointestinal tract. EGE may involve more than one layer of the gastrointestinal tract. Clinical features depend on the layer and location which is involved. We report an unusual case of eosinophilic ascites associated with antinuclear antibody positivity, which is an unusual variety of serosal form of EGE.

Eosinophilic colitis is a sporadic self-limited disease of middle-aged people: a population-based study

AIM

Eosinophilic colitis (EC) is a rare manifestation of eosinophilic gastrointestinal disorders. Due to its rarity, little information is available on its natural history.

METHOD

From the single population-based pathology database of the Calgary Health Region (comprising a population of 1.28 million in 2008), cases of EC during the period 1996-2008 were identified. Medical records of all adults diagnosed with EC were identified and the pathology reviewed. The patients were then contacted for follow-up using a standardized questionnaire.

RESULTS

Seven cases of EC (four in women) were identified, with a median follow-up of 45 (23-79) months. The median age at diagnosis was 42 (22-70) years. Symptoms at diagnosis were abdominal pain (86%), nonbloody diarrhoea (57%), bloody diarrhoea (29%) and significant (>10%) weight loss (29%). Three patients gave a history of allergic reactions to drugs and four reported allergy to cows' milk. Endoscopic findings were nonspecific, ranging from oedema to small aphthous ulceration. An eosinophilic infiltrate was identified in the lamina propria in the initial colonic biopsy in all patients. Over the longer term, three patients experienced spontaneous resolution without treatment. Two continued to have mild diarrhoea and abdominal cramps but did not require medical therapy. Two patients required medical treatment by 5-aminosalicylic acid, with one requiring prednisone and azathioprine maintenance therapy.

CONCLUSION

Eosinophilic colitis is a rare mostly self-limiting disease affecting middle-aged adults. It usually has a mild clinical course and drug treatment is not usually necessary. When required, drug treatment follows the standard medication for other inflammatory bowel disease.

Eosinophilic gastroenteritis: An unusual type of gastroenteritis

Eosinophilic gastroenteritis (EGE) is a rare disorder characterized by eosinophilic infiltration of the bowel wall with various gastrointestinal manifestations. Till date only 280 cases have been described in the literature. A high index of suspicion, by excluding other causes of peripheral eosinophilia, is a pre requisite for accurate diagnosis. EGE is an uncommon gastrointestinal disease affecting both children and adults. It was first described by Kaijser in 1937. Presentation may vary depending on location as well as depth and extent of bowel wall involvement and usually runs a chronic relapsing course. This condition can respond to low dose steroid therapy, thereby preventing grave complications like ascites and intestinal obstruction that might need surgical intervention. The natural history of EGE has not been well documented. Eosinophilic gastroenteritis is a chronic, waxing and waning condition. Mild and sporadic symptoms can be managed with reassurance and observation, whereas disabling gastrointestinal (GI) symptom flare-ups can often be controlled with oral corticosteroids. When the disease manifests in infancy and specific food sensitization can be identified, the likelihood of disease remission by late childhood is high. GI obstruction is the most common complication. Fatal outcomes are rare.

Histopathologic diagnosis of eosinophilic conditions in the gastrointestinal tract

Eosinophils, a constitutive component of the columnar-lined gastrointestinal tract, play an essential role in allergic responses and parasitic infections. The tissue density of these cells also increases in a variety of conditions of uncertain etiology. With the exception of the esophageal squamous epithelium, in which no eosinophils are normally present, the population of normal eosinophils in the remainder of the luminal gut is poorly defined. Therefore, histopathologists must rely on their subjective judgment to determine when a diagnosis of eosinophilic gastritis, enteritis, or colitis should be rendered. Eosinophilic esophagitis is currently the best defined and most studied eosinophilic condition of the digestive tract; therefore, the confidence in accurate diagnosis is increasing. In contrast, the characteristic clinicopathologic features of eosinophilic conditions affecting other parts of the digestive tract remain somewhat elusive. This review was designed to present pathologists with simple and practical information for the biopsy-based histopathologic diagnosis of eosinophilic esophagitis, gastritis, enteritis, and colitis. It was prepared by critically reviewing more than 200 articles on the topic, along with incorporating evidence accumulated through our own collective experience. We anticipate that by increasing pathologists' confidence in reporting these abnormal but often nameless eosinophilic infiltrates, we can help better define and characterize their significance.

Eosinophilic colitis: university of Minnesota experience and literature review

Eosinophilic colitis is a rare form of primary eosinophilic gastrointestinal disease that is poorly understood. Neonates and young adults are more frequently affected. Clinical presentation is highly variable depending on the depth of inflammatory response (mucosal, transmural, or serosal). The pathophysiology of eosinophilic colitis is unclear but is suspected to be related to a hypersensitivity reaction given its correlation with other atopic disorders and clinical response to corticosteroid therapy. Diagnosis is that of exclusion and differential diagnoses are many because colonic tissue eosinophilia may occur with other colitides (parasitic, drug-induced, inflammatory bowel disease, and various connective tissue disorders). Similar to other eosinophilic gastrointestinal disorders, steroid-based therapy and diet modification achieve very good and durable responses. In this paper, we present our experience with this rare pathology. Five patients (3 pediatric and 2 adults) presented with diarrhea and hematochezia. Mean age at presentation was 26 years. Mean duration of symptoms before pathologic diagnosis was 8 months. Mean eosinophil count per patient was 31 per high-power field. The pediatric patients responded very well to dietary modifications, with no recurrences. The adult patients were treated with steroids and did not respond. Overall mean followup was 22 (range, 2-48) months.

Gastrointestinal eosinophils in health, disease and functional disorders

Eosinophils are potent innate immune cells that home to the gastrointestinal tract where they participate in host immunity to luminal pathogens, and help to maintain intestinal epithelial homeostasis. However, these cells are now recognized to have key functions in the pathogenesis of numerous other disorders of the gastrointestinal tract, including primary eosinophilic gastrointestinal disease, common functional conditions, such as dyspepsia, and also in gastrointestinal disorders in patients with allergic disease. We are just beginning to understand the potential pathological role of eosinophils in gastrointestinal disease, and it is increasingly likely that gastroenterologists and histopathologists will need to account for the presence of gastrointestinal eosinophils and relate their presence to gastrointestinal symptoms. This Review discusses the role of gastrointestinal eosinophils in health and disease, including their associations with functional and allergic disorders.

Eosinophilic colitis

Eosinophilic colitis (EC) is a rare form of primary eosinophilic gastrointestinal disease with a bimodal peak of prevalence in neonates and young adults. EC remains a little understood condition in contrast to the increasingly recognized eosinophilic esophagitis. Clinical presentation of EC is highly variable according to mucosal, transmural, or serosal predominance of inflammation. EC has a broad differential diagnosis because colon tissue eosinophilia often occurs in parasitic infection, drug-induced allergic reactions, inflammatory bowel disease, and various connective tissue disorders, which require thorough searching for secondary causes that may be specifically treated with antibiotics or dietary and drug elimination. Like eosinophilic gastrointestinal disease involving other segments of the gastrointestinal tract, EC responds very well to steroids that may be spared by using antihistamines, leukotriene inhibitors and biologics.

Eosinophilic enteritis in association with systemic lupus erythematosus

Eosinophilic gastroenteritis (EGE) is an uncommon disease and has rarely been reported in association with connective tissue diseases as systemic lupus erythematosus. We report a 36-year-old woman who developed recurrent episodes of abdominal pain, nausea, vomiting and melena. Complete blood counts showed elevated eosinophil counts. Ultrasound and CT-scan images studies were significant for bowel wall thickening and ascites. The patient underwent an exploratory laparotomy with a mesenteric biopsy and appendectomy that showed eosinophil infiltration in the muscularis propria, establishing the diagnosis of EGE. The patient developed pleural effusions, with laboratory studies showing haemolytic anaemia, thrombocytopenia, positive antinuclear antibody and anticardiolipin antibodies. The patient was treated with high-dose systemic corticosteroid therapy, with successful resolution of symptoms. Three months later, she developed a new episode of abdominal pain defined as intestinal pseudo-obstruction that was resolved without complications.

Evaluation of the patient with suspected eosinophilic gastrointestinal disease

This article focuses on the evaluation and management of eosinophilic gastrointestinal diseases other than eosinophilic esophagitis. Those diseases include eosinophilic gastritis, gastroenteritis, enteritis, and colitis. The diagnosis of eosinophilic gastrointestinal disease is primarily dependent on the clinical history and histopathology of multiple biopsy specimens after ruling out other causes of intestinal eosinophilia. The diagnosis of eosinophilic gastrointestinal diseases other than eosinophilic esophagitis is complicated by the lack of uniformly accepted diagnostic criteria. Treatment involves evaluation for food sensitivity, elimination diets, and the use of anti-allergy and anti-inflammatory medications with varying degrees of success. Little is known about the natural history of eosinophilic gastrointestinal diseases, underscoring the need for long-term follow-up studies of patients with these disorders.

Eosinophilic enteritis with ascites in a patient with overlap syndrome

Gastrointestinal involvement is frequent in patients with systemic lupus erythematosus (SLE). Eosinophilic gastroenteritis, however, has only rarely been described in rheumatological conditions, despite its reported connection to autoimmune diseases, such as hypereosinophilic syndrome, vasculitides, and systemic mastoidosis. It presents typically with abdominal pain and diarrhea and is only exceptionally associated with ascites. Diagnosis can be problematic, as several other clinical conditions (malignancies, infection/tuberculosis, and inflammatory bowel diseases) have to be ruled out. It is basically a nonsurgical disease, with excellent recovery on conservative treatment. We report the rare case of a young woman with overlap syndrome who presented with abdominal pain and ascites. The diagnosis of eosinophilic enteritis was made based on clinical, radiological, and laboratory criteria. The patient was treated with corticosteroids with excellent response.

Allergy and autoimmunity: parallels and dissimilarity: the yin and yang of immunopathology

The etiopathogenesis of allergy and autoimmune diseases is caused by genetic and acquired (environmental) factors, which might be common to both immunopathologies. Genetic factors play an important role in the development and process of immunopathological diseases. Several studies suggest a close relation between gene polymorphism of HLA and cytokines and development of autoimmunity and allergy. Certain gene polymorphisms act as risk or as protective factors. The infection also plays an important role in the induction of allergy and autoimmunity--as a trigger or as a protective factor. Moreover, similar clinical manifestations of both immunopathologies could result in diagnostic problems. This review summarizes the linkage of mechanisms of etiopathogenesis, clinical manifestations and therapeutic strategy between allergic and autoimmune diseases.

Eosinophilic gastroenteritis

Eosinophilic gastroenteritis is an infrequently diagnosed condition that is characterized by prominent eosinophilic infiltration of the stomach or small intestine, generally localized to one level of the intestinal wall; the variable organ locus and wall depth produce heterogeneous clinical presentations. A strong association with atopy is present in most cases, supported by circumstantial evidence and the demonstration of Th-2 proinflammatory cytokine profiles in animal studies. A high degree of suspicion is required to establish the diagnosis, which must be based on intense gastrointestinal eosinophilia. Management is directed toward removal of offending allergens and use of anti-inflammatory agents. Novel and emerging treatments on the horizon are biologic therapies and selective anti-eosinophil agents.

Gut eosinophilia in food allergy and systemic and autoimmune diseases

Eosinophilic gastroenteritis is a rare disease characterized by striking tissue eosinophilia in any layer of the gut wall; however, many diseases can cause increased gut eosinophilia. Allergic reactions to food are an important cause of gut eosinophilia. Not all adverse reactions to food are IgE mediated, and most cases of IgE-mediated food allergy do not have eosinophilic gastroenteritis. Parasitic, bacterial, and viral pathogens as well as certain systemic diseases such as vasculitis can cause gut eosinophilia. These heterogeneous conditions are reviewed in this article.

Diarrhoea, ascites and eosinophilia: an unusual triad

The onset of diarrhoea and cramp-like abdominal pain following consumption of an identified food type is not an uncommon presentation to many practitioners. However, when it fails to settle and is associated with unusual features both on examination and on initial work-up, then a more complex diagnostic and therapeutic conundrum needs to be considered. We report on such a case where the onset of diarrhoea was associated with ascites and peripheral eosinophilia. A variety of causes including parasitic and tuberculous infection were excluded. A diagnosis of eosinophilic enteritis was made based on definite criteria, and appropriate management was instituted. In this report we discuss the diagnostic criteria and some of the proposed pathophysiologic theories in order to explain this unusual disease process.

Eosinophilic gastroenteritis with ascites and hepatic dysfunction

Eosinophilic gastroenteritis is a rare gastrointestinal disorder with eosinophilic infiltration of the gastrointestinal wall and various gastrointestinal dysfunctions. Diagnosis requires a high index of suspicion and exclusion of various disorders that are associated with peripheral eosinophilia. We report a case of eosinophilic gastroenteritis, which had features of the predominant subserosal type presenting with ascites and hepatic dysfunction, and which responded to a course of low-dose steroid.

Gastroduodenal diseases of childhood

PURPOSE OF REVIEW

This paper will review new developments in the etiology and management of gastric and duodenal diseases affecting children.

RECENT FINDINGS

Despite dropping prevalence rates in developed nations, most new Helicobacter pylori infections are primarily acquired during childhood. Resistance to standard triple therapy and falling eradication rates are increasing problems for clinicians, necessitating the study of alternative treatment strategies. Eosinophilic diseases of the gastrointestinal tract are being increasingly recognized. Although population-based epidemiology and the natural history of eosinophilic diseases are not yet fully characterized, biologic therapies are in development for the treatment of these chronic, often refractory, conditions. A recent US National Institutes of Health celiac disease consensus conference suggested that infants' diet constituents and timing of solid food introduction are potential environmental influences in the development of celiac disease.

SUMMARY

New methods of diagnosis and treatment are greatly impacting care of pediatric patients with gastric and duodenal diseases. Less invasive but highly accurate tools for diagnosis are becoming better validated. Early diagnosis and effective intervention in most gastroduodenal disorders of childhood can alter natural history and improve overall quality of life.

Eosinophilic enteritis with systemic lupus erythematosus

Gastrointestinal manifestations are common in systemic lupus erythematosus (SLE). Eosinophilic enteritis is a rare disorder of uncertain cause that was recently reported for the first time in association with SLE. This report presents a second case of eosinophilic enteritis in a 47-year-old female patient with SLE. The patient presented with recurrent episodes of abdominal pain, nausea, vomiting, and diarrhea. Complete blood counts on occasion showed elevated eosinophil counts. The patient underwent a comprehensive workup over several weeks, culminating in a small bowel biopsy that showed eosinophil infiltration in the muscularis propria, establishing the diagnosis. The patient was treated with a prolonged taper of prednisone with successful resolution of symptoms.

Investigations and management of gastrointestinal and hepatic manifestations of systemic lupus erythematosus

Gastrointestinal (GI) manifestations of systemic lupus erythematosus (SLE) are protean. Any part of the GI tract and the hepatobiliary system can be involved. Up to two-third of SLE patients develop GI symptoms at some stage of their illnesses. Clinical presentations of GI lupus are non-specific and can be difficult to differentiate from infective, thrombotic, therapy-related and non-SLE etiologies. Clinical acumen and appropriate endoscopic, biopsy and imaging procedures are essential for establishing the correct diagnosis. Acute abdominal pain in SLE patients can herald an intra-abdominal catastrophe and should be evaluated promptly. Surgical intervention should be instituted without delay if conservative management fails or when there is clinical or radiological suspicion of visceral perforation or intra-abdominal collections.