Clinical characteristics of lupus enteritis in Japanese patients: the large intestine-dominant type has features of intestinal pseudo-obstruction

Lupus enteritis: a narrative review

Lupus enteritis (LE) is a rare manifestation of systemic lupus erythematosus. The pathophysiology of LE has not been fully elucidated, although inflammatory and thrombotic processes are likely important factors. The underlying pathophysiological mechanisms may depend on which portion of the intestine is affected. Over half of the patients with LE also present with renal or haematological complications. The diagnosis of LE is based on clinical, histopathological and imaging findings; abdominal computed tomography (CT) is the gold standard in diagnosis. Abdominal CT can also identify factors that predict complications and could potentially guide pharmacological and nutritional management. Timely identification and prompt treatment initiation are paramount to avoid life and organ threatening complications. Glucocorticoids are often the first-line treatment. Additional therapy including immunosuppressive therapy is utilised on a case-by-case basis as there are no clinical trials to define the optimal therapeutic approach. Surgical intervention may be needed especially if there is bowel perforation or peritonitis. In general, the prognosis of LE is good.

An Atypical Initial Manifestation of Systemic Lupus Erythematosus: Lupus Enteritis Accompanied by Intestinal Pseudo-Obstruction and Bilateral Hydronephroureter

Systemic lupus erythematosus (SLE) is a systemic, autoimmune, multisystem disease. Lupus enteritis accompanied by intestinal pseudo-obstruction (IPO) is a serious and rare initial manifestation that can lead to high mortality and morbidity in case of delay in diagnosis and treatment. Here, we present a very complicated case of a 36-year-old female Pakistani patient with lupus enteritis accompanied by IPO and bilateral hydronephroureter. The patient had a three-month history of fever, weight loss, recurrent diarrhea, vomiting, alopecia, and photosensitivity. She had a malar and discoid rash, with signs and symptoms of IPO and neuropsychiatric lupus. Her labs revealed positive anti-nucleosome antibodies (8 U/mL), anti-Ro antibodies (100 U/mL), and anti-La antibodies (53 U/mL); equivocal anti-dsDNA antibodies (7 U/mL) and anti-Sm antibodies (7 U/mL); direct Coomb's positive hemolytic anemia; raised C-reactive protein and erythrocyte sedimentation rate levels; low complement (C3 and C4) levels; and pyuria. IPO was evident on abdominal X-ray and CT scan. Her Systemic Lupus Erythematosus Disease Activity Index was 24, indicating severe disease flare. She was treated with intravenous methylprednisolone, hydroxychloroquine, and intravenous 500 mg cyclophosphamide. Her lab parameters and clinical mini-mental score improved, from 0/30 to 18/30. She was discharged on oral prednisolone 0.5 mg/kg/day, hydroxychloroquine, trimethoprim-sulfamethoxazole (prophylaxis for Pneumocystis jirovecii pneumonia), and mineral and vitamin supplements. She was followed up on the 15th day of discharge for the next dose of cyclophosphamide, and her clinical and lab parameters were normal at that time with gradual improvement in cognition. Lupus enteritis with coexisting IPO and bilateral hydronephroureter poses a diagnostic and therapeutic challenge because of atypical and uncommon manifestations of lupus and overlapping features with intestinal tuberculosis and other inflammatory bowel conditions.

Lupus enteritis: A 10-year experience in a single Latin American center

OBJECTIVE

The objective is to compare the clinical and laboratory characteristics of systemic lupus erythematosus (SLE) patients with and without lupus enteritis (LE) and to identify the factors associated with the occurrence of LE.

METHODS

We performed a retrospective, case-control study in hospitalized patients with SLE who were admitted to our tertiary hospital between January 2012 and December 2021. Sixteen LE patients (cases) were matched (1:3 ratio) for sex and birth year with 48 non-LE patients (controls). Univariable and multivariable logistic regression analyses were used to identify the variables associated with LE.

RESULTS

Of 2,479 SLE patients who were admitted to our hospital as inpatients, 16 (0.65%) were diagnosed as having LE. All patients, cases and controls, were of Mestizo ethnicity. SLE was diagnosed simultaneously with the first episode of LE in 10 (62.5%) patients. The median time from SLE diagnosis to the first episode of LE was 7 (IQR 0-78) months. LE patients had a shorter median disease duration [7 (0-78) vs 34 (9.5-79) months], and a significantly longer hospital stay (28.3 ± 15.8 vs 6.5 ± 7.9 days, p < 0.001) than non-LE patients. Most LE patients (93.8%) had concomitant lupus nephritis. LE patients had higher SLEDAI-2K scores than those without LE (20.5 ± 9.4 vs 9.8 ± 10.4, p < 0.001). By multivariable analysis, a higher SLEDAI-2K score (OR 1.10, 95% CI 1.02-1.18; p = 0.015) was independently associated with LE occurrence after adjusting for cutaneous involvement, lymphocyte count, serum creatinine, and serum complement C4. Recurrence was observed in two patients (12.5%), both with a bowel wall thickening > 8 mm. The two patients with large intestine-dominant LE developed intestinal pseudo-obstruction. No patient had life-threatening complications (intestinal hemorrhage, infarction, or perforation), and there were no deaths induced directly by LE itself.

CONCLUSION

In patients of Mestizo ethnicity, LE occurs during the early course of SLE, frequently is one of the presenting manifestations of SLE, and in most cases, it presents with concomitant lupus nephritis. Higher levels of disease activity at diagnosis were independently associated with LE occurrence and when recurrences occur, they do so in the context of severe wall thickness.

Dietary patterns and life-styles of patients with gastrointestinal involvement of systemic lupus erythematosus: Questionnaire survey from a tertiary center of China

OBJECTIVE

To investigate the dietary patterns and lifestyles of patients with lupus gastrointestinal (GI) involvement and to reveal the possible role of organ-specific involvement of systemic lupus erythematosus (SLE) on daily diet.

METHODS

Patients with SLE complicated with gastrointestinal involvement (SLE-GI) admitted to Peking Union Medical College Hospital (PUMCH) from January 2010 to September 2021 were enrolled. Age- and sex-matched SLE patients with lupus nephritis (SLE-LN) but free of other internal organs involvement who were admitted during the same period were enrolled as disease controls at the ratio of 1:1. In addition, a group of age- and sex-matched healthy people were also included as healthy controls (HCs). Questionnaires were distributed to these patients and HC to collect their dietary patterns and lifestyle information. Clinical features, dietary and lifestyle habits were compared between the two groups of patients and HC.

RESULTS

The questionnaire survey showed that compared with HC, the SLE-GI group had higher proportions of vegetarians (p = 0.014) and a lower proportion of omnivores (p = 0.058). A higher percentage of SLE-GI patients reported a traditional Chinese medicine (p = 0.018) taken history and surgical history (p = 0.014). They also less likely to take fried/pickled food (p = 0.042) and dietary supplements (p = 0.024) than HC. Higher percentages of SLE-GI patients and SLE-LN patients preferred self-catering (87.5% and 94.3%) over take-out food than HC (70.8%) (p = 0.127 and p = 0.016). No significant difference on drinking preference among the three groups, but it seemed more SLE-GI patients consumed yogurt than HC (p = 0.097). The SLE-LN patients were also found to have lower frequencies of staying up late (p = 0.005). The SLE-GI group also presented higher positivity rates for anti-SSA (69.6% vs. 45.7%, p = 0.020) and anti-SSB antibodies (32.6% vs. 10.9%, p = 0.011) but lower positivity rates for anti-dsDNA antibodies (30.4% vs. 82.6%, p < 0.001) compared with the SLE-LN group.

CONCLUSION

The dietary patterns, life-styles and autoantibody spectrum of SLE-GI patients differed greatly from those of SLE-LN patients and healthy people. These factors may reflect the influence of disease and organ involvement modes on patients' daily life and may contribute partly to the systemic involvement in SLE.

Predictive model of risk and severity of enteritis in systemic lupus erythematosus

INTRODUCTION

To describe the clinical and laboratory features of systemic lupus erythematosus (SLE) enteritis and to establish a predictive model of risk and severity of lupus enteritis (LE).

METHODS

Records of patients with SLE complaining about acute digestive symptoms were reviewed. The predictive nomogram for the diagnosis of LE was constructed by using R. The accuracy of the model was tested with correction curves. The receiver operating characteristic curve (ROC curve) program and a Decision curve analysis (DCA) were used for the verification of LE model. Receiver operating characteristic curve was also employed for evaluation of factors in the prediction of severity of LE.

RESULTS

During the eight year period, 46 patients were in the LE group, while 32 were in the non-LE group. Abdominal pain, emesis, D-dimer >5 μg/mL, hypo-C3, and anti-SSA positive remained statistically significant and were included into the prediction model. Area under the curve (AUC) of ROC curve in this model was 0.909. Correction curve indicated consistency between the predicted rate and actual diagnostic rates. The DCA showed that the LE model was of benefit. Forty-four patients were included in developing the prediction model of LE severity. Infection, SLE disease activity index (SLEDAI), CT score, and new CT score were validated as risk factors for LE severity. The AUC of the combined SLEDAI, infection and new CT score were 0.870.

CONCLUSION

The LE model exhibits good predictive ability to assess LE risk in SLE patients with acute digestive symptoms. The combination of SLEDAI, infection, and new CT score could improve the assessment of LE severity.

Lupus Vasculitis: An Overview

Lupus vasculitis (LV) is one of the secondary vasculitides occurring in the setting of systemic lupus erythematosus (SLE) in approximately 50% of patients. It is most commonly associated with small vessels, but medium-sized vessels can also be affected, whereas large vessel involvement is very rare. LV may involve different organ systems and present in a wide variety of clinical manifestations according to the size and site of the vessels involved. LV usually portends a poor prognosis, and a prompt diagnosis is fundamental for a good outcome. The spectrum of involvement ranges from a relatively mild disease affecting small vessels or a single organ to a multiorgan system disease with life-threatening manifestations, such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex. Treatment depends upon the organs involved and the severity of the vasculitis process. In this review, we provide an overview of the different forms of LV, describing their clinical impact and focusing on the available treatment strategies.

Lupus Enteritis: An Uncommon Presentation of Lupus Flare

Gastrointestinal (GI) symptoms are common in systemic lupus erythematosus (SLE) but are usually attributable to medication side effects, infections, or other underlying conditions. In rare cases, they are caused by the autoimmune process itself. In this report, we present two cases of lupus enteritis as the sole manifestation of lupus flare. We also provide a comprehensive review of available literature on this topic with a specific focus on clinical symptoms, complications, laboratory findings, histology, imaging findings, and therapies. Lupus enteritis is an uncommon manifestation of SLE. CT scan of the abdomen is the diagnostic modality of choice. The three major CT findings are target sign, comb sign, and increased mesenteric fat attenuation. Ascites is also commonly present. Corticosteroids and second-line immunosuppressants have been successfully employed in the treatment of lupus enteritis. Our cases highlight this unusual manifestation as the only symptom of active SLE. A high index of suspicion should be maintained when evaluating SLE patients presenting with GI symptoms to prevent diagnosis and treatment delays that could lead to serious complications such as bowel necrosis, perforation, and even death.

Clinical features of lupus enteritis: a single-center retrospective study

BACKGROUND

Lupus enteritis (LEn) is a rare complication of systemic lupus erythematosus (SLE). Timely diagnosis and treatment of LEn are necessary to prevent the most serious consequences - intestinal perforation, gastrointestinal bleeding, and death. We compared the clinical features of SLE patients with and without LEn.

METHODS

The clinical data of LEn inpatients at Suining Central Hospital from July 2012 to June 2020 were examined. These LEn patients were matched (1:2 ratio) with concurrently hospitalized SLE patients who did not have LEn. The two groups were compared using multivariate logistic regression.

RESULTS

We compared SLE inpatients with LEn (n = 43) and SLE inpatients without LEn (n = 86) at our institution. Multivariate logistic regression showed that ascites (odds ratio [OR]: 9.961, 95%CI: 2.215-44.802, P = 0.003), hydronephrosis (OR: 28.060, 95%CI: 2.303-341.962, P = 0.009), leukopenia (OR: 5.890, 95%CI: 1.813-19.135, P = 0.003), reduced complement C3 level (OR: 4.791, 95%CI: 1.605-14.300, P = 0.005), and elevated immunoglobin (Ig)A level (OR: 4.040, 95%CI: 1.307-12.487, P = 0.015) were independently associated with LEn. Within the LEn group, abdominal pain was the most common abdominal symptom (88.4%), and increased mesenteric fat attenuation (74.4%) and bowel wall thickening (58.1%) were the most common computed tomography (CT) findings. Most LEn patients (88.4%) required high-dose glucocorticoid therapy (≥ 80 mg methylprednisolone/day), and cyclophosphamide was the most commonly used immunosuppressant (62.8%).

CONCLUSIONS

Abdominal pain was the most common clinical symptom of LEn. Abdominal CT provides important information for detection and diagnosis of LEn. Ascites, hydronephrosis, leukopenia, hypocomplementemia (C3), and increased IgA were independently associated with LEn.

Clinico-Laboratory Features and Associated Factors of Lupus Mesenteric Vasculitis

Introduction

Lupus mesenteric vasculitis (LMV) is a rare but potentially life-threatening clinical entity in systemic lupus erythematosus (SLE) patients.

Objective

The present study was initiated to explore the clinical features and associated factors of LMV in SLE patients.

Methods

We conducted a retrospective study on 50 cases of SLE patients with lupus mesenteric vasculitis (LMV) from January 2010 to December 2019 and 89 cases of non-LMV-SLE patients with similar demographic and comorbidities were included as control. All the data regarding clinical features, laboratory findings, and treatment were reviewed independently by two experts in the field. Both univariate and multivariate logistic regression analyses were employed to identify the associated factors of LMV.

Results

The incidence of LMV was 2.9% among hospitalized SLE patients in the current study. The most frequent symptom and physical sign of LMV were respectively abdominal pain (48, 96%) and abdominal tenderness (45, 90%). Through univariate and subsequent multivariate analysis, oral ulcer (OR, 4.25; P = 0.024), urinary tract involvement (OR, 5.23; P = 0.021), and elevated D-dimer (OR, 1.121; P = 0.008) were demonstrated to be positively associated with LMV, while percentage of lymphocytes (OR, 0.928; P = 0.004) and complement 3 (OR, 0.048; P = 0.008) were negatively correlated with LMV.

Conclusions

Oral ulcer, urinary tract involvement, reduced percentage of lymphocytes and complement 3, elevated D-dimer could be associated factors for LMV in SLE patients.

Intestinal Pseudo-Obstruction as the Initial Clinical Presentation in Systemic Lupus Erythematosus: A Rare and Severe Disorder

Intestinal pseudo-obstruction (IPO) is a rarely recognized complication of systemic lupus erythematosus (SLE). We present a 36-year-old African American female, with only known past medical history of anemia, admitted for frequent vomiting, abdominal distension, abdominal pain, diarrhea, and fever that had been ongoing for 5 days. Laboratory results revealed leukopenia and thrombocytopenia. Imaging revealed dilated small bowel loops, abdominal ascites, as well as mild bilateral hydroureteronephrosis without obstructing calculus. Serologic testing confirmed a diagnosis of SLE. The patient was placed on immunosuppressive therapy and responded well. IPO has previously been described as a rare finding in patients with SLE, with bilateral hydroureteronephrosis and lupus interstitial cystitis having been noted as common concomitant factors. One must have a high level of suspicion to recognize it as being one of the initial clinical presentations. Early recognition and appropriate management preclude unnecessary invasive procedures that do not take into account the pathophysiology of the condition and allow for appropriate management and return of peristaltic function.

Systemic lupus erythematosus gastrointestinal involvement: a computed tomography-based assessment

Systemic lupus erythematosus (SLE) gastrointestinal (GI) complication is characterized by multi-segment and multi-compartment involvement. The aim of this study is to develop a computed tomography (CT) image-based system for disease evaluation. SLE patients with GI involvement from two independent cohorts were retrospectively included. Baseline abdominal CT scan with intravenous and oral contrast was obtained from each individual. A CT scoring system incorporating the extent of GI tract involvement and intestinal wall thickness, along with extra-GI compartment involvement, was developed and validated. The outcome measurement was the time to GI functional recovery, defined as the time to tolerable per os (PO) intake ≥50% of ideal calories (PO50). A total of 54 and 37 patients with SLE GI involvement were enrolled in the derivation and validation cohorts, respectively. The CT scores for SLE GI involvement were positively correlated with patients' time to PO50 (r = 0.57, p < 0.0001, derivation cohort; r = 0.42, p = 0.0093, validation cohort). Patients with a CT score ≤ 3 had a shorter time to PO50 (median time of 0 day) in pooled cohort, whereas those with a CT score > 3 incurred a significantly prolonged recovery with a median time to PO50 of 13 days (p < 0.0001). The CT-based scoring system may facilitate more accurate assessment and individualized management of SLE patients with GI involvement.

Small bowel ulcers: when is it not inflammatory bowel disease ?

PURPOSE OF REVIEW

Increasing use of small bowel endoscopy unravels ulcers in a relevant number of patients. Although often attributed to inflammatory bowel disease (IBD), these ulcers may be unspecific or caused by a variety of other diseases. This review summarizes the recent literature related to differential diagnosis of small bowel ulcers.

RECENT FINDINGS

NSAID enteropathy is the major differential diagnosis to IBD in patients with small bowel ulcers. Intestinal tuberculosis must be considered in patients at risk. Rare causes for small bowel ulcers are autoinflammatory, neoplastic, vascular diseases, or nontuberculous infections. Morphology of small bowel ulcers cannot provide a reliable differentiation, and even histology is not specific in all cases. History with special focus on NSAID medication and clinical symptoms not typical for IBD, laboratory tests in the search of systemic disease, and microbiologic testing of biopsies can be helpful. Genetic testing allows identification of few rare entities like defects in prostaglandin metabolism.

SUMMARY

Due to a massive overlap in the endoscopic appearance of small bowel ulcers between possible causes, diagnosis should be based on broad information also including history, histology, imaging, and laboratory tests.

The Contribution of Drugs and Helicobacter pylori to Gastric Mucosa Changes in Patients with Systemic Lupus Erythematosus and Antiphospholipid Syndrome

BACKGROUND

The nature and rate of gastric mucosal (GM) damage in systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) remain to be among the unsolved problems.

OBJECTIVE

To define the role of H. pylori and drugs in the development of GM damages in SLE and APS.

METHODS

A study was conducted on 85 patients with SLE and APS. All the patients underwent esophagogastroduodenoscopy with targeted biopsy of the mucosa of the gastric body and antrum. The presence of H. pylori in the gastric biopsy specimens was determined using polymerase chain reaction.

RESULTS

Endoscopic examination revealed that the patients with SLE and APS on admission had the following GM changes: antral gastritis (82.4%), erosions (24.7%), hemorrhages (8.2%), and pangastritis (8.2%). SLE and APS patients showed no direct correlation between the found GM damages and the presence of H. pylori. The use of glucocorticoid, low-dose acetylsalicylic acid, nonsteroidal anti-inflammatory drug, and anticoagulant in SLE and APS patients is accompanied by GM damage.

CONCLUSION

There was no evidence of the role of H. pylori in GM damage in the SLE and APS patients. More frequent detection of H. pylori was observed in anticoagulants or low-dose acetylsalicylic acid users than in glucocorticoids and nonsteroidal anti-inflammatory drugs ones.