Systemic lupus erythematosus with a giant rectal ulcer and perforation

Intestinal perforation with systemic lupus erythematosus: A systematic review

Intestinal perforation (IP) is a rare complication of systemic lupus erythematosus (SLE), and the timely diagnosis and treatment of IP are necessary to prevent death. In this study, the clinical features of IP in SLE were described in an attempt to enhance its understanding to reduce mortality. The clinical data of IP in SLE from 1984 to 2022 were retrospectively collected. A total of 18 patients were enrolled, and data on clinical symptoms, preoperative evaluation, surgical procedures, and postoperative outcomes were collected and retrospectively analyzed. The analysis included 15 females and 3 males, with a mean age of 49.2 years. Fifteen patients (83.3%) had a history of the disease for >5 years, and the SLE disease activity index score of 1 (5.6%) patient was <5 points and that of 17 (94.4%) patients was >10 points. A total of 9 (50%), 5 (27.7%), 3 (16.7%), and 1 (5.6%) patient had lesions in the rectum, colon, ileum, and both ileum and appendix, respectively. The cause of perforation in 12 (66.7%) patients was lupus mesenteric vasculitis and in 3 (16.7%) patients was chronic inflammation. Seven (38.9%) patients had other immune system diseases. All patients were treated with steroids and surgical treatment. However, 5 patients died after surgery. A disease duration of >5 years, SLE disease activity index score of >10, nonstandard use of steroids, and concomitant presence of other immune system diseases are the possible risk factors of IP in SLE. The most common site of perforation was the rectum, which was caused by lupus mesenteric vasculitis. The results suggest that the key to successfully manage such cases is early diagnosis, aggressive resuscitation, antibiotics, steroid therapy, and prompt surgical intervention.

Systemic lupus erythematosus complicated by Crohn's disease with rectovaginal fistula

Background

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, and few cases combine with Crohn’s disease. We present the first SLE patient concurrent with Crohn’s disease and rectovaginal fistula. She was successfully treated with vedolizumab and surgical intervention. Besides, she also had a rare opportunistic infection, cryptococcal pneumonia, in previous adalimumab treatment course.

Case

A 57 year-old female had SLE in disease remission for 27 years. She suffered from progressive rectal ulcers with anal pain and bloody stool, and Crohn’s disease was diagnosed. She received adalimumab, but the lesion still progressed to a rectovaginal fistula. Besides, she suffered from an episode of cryptococcal pneumonia under adalimumab treatment course. Therefore, we changed the biologics to vedolizumab, and arrange a transverse colostomy for stool diversion. She had clinical remission without active inflammation, but the fistula still persisted. Then, she received a restorative proctectomy with colo-anal anastomosis and vaginal repair. Follow-up endoscopy showed no more rectal ulcers or fistula tracts, and contrast enema also noted no residual rectovaginal fistula.

Conclusion

When a SLE patient had unusual rectal ulcers, Crohn’s disease should be considered. Biologics combined with surgical intervention is an optimal solution for Crohn’s disease with rectovaginal fistula. Although cryptococcal pneumonia is a rare opportunistic infection in the biological treatment, we should always keep it in mind.

Systemic Lupus Erythematosus Presenting with Ischemic Proctitis and Abdominal Compartment Syndrome

Ischemic colitis and proctitis is a rare manifestation of systemic lupus erythematosus (SLE) and results from mesenteric vasculitis. Owing to diverse blood supply and presence of multiple collaterals, rectum is the least effected site in SLE enteritis. Ischemic proctocolitis as the presenting feature of SLE is exceedingly rare, with only three cases reported in the published scientific literature. We present the first case of SLE presenting as ischemic proctitis, leading to intraperitoneal hemorrhage and abdominal compartment syndrome. A young lady presented with ischemic proctitis and a hematoma masquerading as a pelvic mass, with subsequent development of massive intraperitoneal hemorrhage, shock, and rectal perforation. The patient required urgent surgery and was initiated on high-dose steroids.

[Rectal Ulcer Developed in Systemic Lupus Erythematosus without Ischemic Colitis]

Rectal involvement by systemic lupus erythematosus (SLE) is quite rare. Approximately 14 cases have been reported worldwide, but only one with ischemic colitis has been reported in Korea. A 17-year-old female patient was hospitalized with abdominal pain and hematochezia. Sigmoidoscopy revealed only a simple rectal ulcer without ischemic colitis. cytomegalovirus and bacterial infections were excluded. A sigmoidoscopic rectal biopsy indicated a rectal invasion by SLE, but the patient showed an acute worsening conditions that did not respond to treatment. This paper reports a case of rectal ulcer that developed in SLE without ischemic colitis with a review of the relevant literature.

[Anorectal manifestations in systemic diseases]

Numerous systemic diseases (vasculitis, connective tissue disease or sarcoidosis) can display an involvement of the perianal skin, the rectum and/or the anus. Such knowledge is important in order to treat these complications specifically when possible. Lesions of the anorectum arising from systemic diseases can sometimes cause perforations in the peritoneal cavity (if concerning the higher portion of the rectum) and/or fistulization to the anal margin. Differential diagnosis, mostly infectious or inflammatory (Crohn's disease) must be ruled out in every case. Other systemic diseases can display specific manifestations as this is the case in scleroderma which can lead to anal incontinence. Despite the relative rarity of these manifestations, their ignorance would forbid global management of these complex diseases. It should thus be detected in each consultation and a regular follow-up must be provided with a proctologist and/or a gastroenterologist when needed.

Successful treatment of rectal ulcers in a patient with systemic lupus erythematosus using corticosteroids and tacrolimus

Systemic lupus erythematosus (SLE) is frequently accompanied by gastrointestinal symptoms. Although all parts of the gastrointestinal tract may be affected, colonic involvement is quite rare. Colonic ulceration, particularly in the rectum, is associated with a high mortality rate in patients with SLE, despite immunosuppressive therapy. While a standard regimen for treating rectal ulcers as a complication of SLE has not been established, combination therapy with steroids and immunosuppressive agents is necessary because of the associated high mortality rate. In this report, we describe a patient with SLE whose condition was complicated with ulcerative lesions in the rectum and sigmoid colon; the lesions were successfully treated with a combination of corticosteroids and tacrolimus therapy. Tacrolimus could be a useful additional or alternative modality for treating rectal involvement in SLE.

Rectal ulcers induced by systemic lupus erythematosus

A 28-year-old woman presented with diarrhoea, haematochezia, tenesmus and rectal pain for 2 months. She was diagnosed with systemic lupus erythematosus (SLE) 8 years ago and remained on prednisone, azathioprine and hydroxychloroquine. Blood work revealed a positive ANA (antinuclear antibody test), anti-dsDNA 749 IU/mL (0-300 IU/mL), C3 0.22 g/L (0.65-1.65 g/L) and C4 0.05 g/L (0.16-0.60 g/L). Stool studies were unremarkable. MRI of the pelvis showed a rectum with eccentric wall thickening. Flexible sigmoidoscopy showed severe proctitis with multiple deep ulcers and diffuse submucosal haemorrhage. Rectal biopsy revealed crypt architectural distortion and reactive fibrosis in the lamina propria. The patient was given mesalamine suppository for 2 weeks with minimal improvement. Repeat flexible sigmoidoscopy showed a coalesced 3×4 cm full-thickness rectal ulcer. Therefore, the patient was given intravenous methylprednisolone for 3 days, followed by intravenous cyclophosphamide for 2 weeks. Her symptoms resolved and repeat flexible sigmoidoscopy showed fibrotic healing of the rectal ulcers.

Colitis associated with active systemic lupus erythematosus successfully treated with rituximab

Intestinal vasculitis is a serious and often underrecognized complication of systemic lupus erythematosus (SLE) usually managed with high-dose corticosteroids. We report a case of corticosteroid refractory colitis (likely due to intestinal vasculitis) that achieved remission with a single cycle of high-dose rituximab. This has not previously been described to our knowledge. A 46-year-old woman with SLE presented with 1-week history of bloody diarrhea, abdominal pain, worsening joint pains, fatigue, and mouth ulcers. There was evidence of increased SLE activity with low C4, raised anti-double-stranded DNA antibody, leukopenia, and anemia. Colonoscopy showed active pancolitis (confirmed histologically). A diagnosis of acute colitis associated with active SLE was made, and she received intravenous methylprednisolone 1 g daily for 3 days followed by 60 mg oral prednisolone daily. She continued to have symptomatic colitis with worsening anemia requiring frequent blood transfusions. She then received 2 doses of rituximab 1 g (750 mg/m(2)) 2 weeks apart that led to improvement in colitis symptoms and SLE disease activity over the next 4 weeks. A repeat colonoscopy (and histology) confirmed good resolution of colitis. Six months later, she continued to be in remission with low-dose prednisolone. Intestinal vasculitis should be considered as a possible cause of acute abdominal pain in SLE as early recognition and treatment can improve long-term survival. Rituximab can be an effective alternative for patients refractory to conventional treatment.

Systemic lupus erythematosus presenting as ischaemic proctitis

Ischaemic colitis is relatively uncommon in systemic lupus erythematosus (SLE), with only very few case reports or case series in world literature. Ischaemic colitis occurs when SLE activity is high and is inarguably due to small vessel vasculitis affecting the large or small intestine. Ischaemic proctitis with rectal ulceration, as a presenting feature in SLE, is even rarer with only two case reports in the world to date. We present the case of a 38-year-old woman, who presented with haematochezia which subsequently proved to be due to ischaemic proctitis with a large rectal ulcer in a case that was subsequently diagnosed as SLE. The clinical course in this patient greatly improved with aggressive management with systemic steroids.

Systemic lupus erythematosus complicated with acute myocardial infarction and ischemic colitis

Acute myocardial infarction (AMI) is one of the most severe manifestations in patients with systemic lupus erythematosus (SLE). Ischemic colitis, mainly caused by intestinal vasculitis, is also one of the most serious, but uncommon, complications in SLE patients. "SLE vasculitis" simultaneously involving cardiac and gastrointestinal vessels has yet to be reported. This is the first report of SLE accompanying AMI, ischemic colitis and perforation of the digestive tract possibly due to SLE vasculitis, which was dramatically improved by treatment with high-dose glucocorticoid.

Abdominal Manifestations of Systemic Lupus Erythematosus: Spectrum of Imaging Findings

Systemic lupus erythematosus is an immune-mediated syndrome in which the immune response is to non–organ-specific antigens, and virtually every organ in the abdominal cavity may become involved. Only renal involvement forms part of the diagnostic criteria, however, a combination of typically nonspecific findings, including peritoneal surface, enteric, renal, renal tract, pancreatic, adrenal, hepatobiliary, and splenic manifestations, should be looked for in patients with known lupus or other connective tissue disease who are undergoing abdominal imaging and may suggest the diagnosis in patients presenting with an acute abdomen. Our work presents the spectrum of imaging findings of abdominal manifestations of systemic lupus erythematosus.

Ischemic colitis associated with intestinal vasculitis: Histological proof in systemic lupus erythematosus

Ischemic colitis is an uncommon complication in patients with systemic lupus erythematosus (SLE). In previously reported cases of colitis caused by SLE, intestinal vasculitis is implicated as the causative process, but is rarely confirmed histologically. We described a case of a 32-year-old man with increased activity of SLE, who presented with hematochezia and abdominal pain due to ischemic colitis with small vessel vasculitis which was proven by sigmoidoscopic biopsy. The clinical course of the patient was improved after steroid and conservative management.

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.

A Case of Amicrobial Pustulosis of the Folds Associated with Neutrophilic Gastrointestinal Involvement in Systemic Lupus Erythematosus

BACKGROUND

Amicrobial pustulosis of the folds is a recently described entity characterized by relapsing pustular lesions involving predominantly the cutaneous folds and the scalp. The disease typically occurs in the context of an autoimmune or systemic disease and should be included within the spectrum of neutrophilic dermatoses.

OBSERVATION

We describe a patient with a history of systemic lupus erythematosus, who developed amicrobial pustulosis of the folds. Strikingly, the patient also exhibited recurrent oral and gastrointestinal manifestations that paralleled the course of the cutaneous signs.

CONCLUSIONS

Our observation indicates that, in analogy to the other neutrophilic dermatoses, amicrobial pustulosis of the folds can also be complicated by the development of extracutaneous neutrophilic involvement, knowledge of which is critical for its diagnosis and proper management.

Two cases of systemic lupus erythematosus complicated with colonic ulcers

We report two cases of systemic lupus erythematosus (SLE) complicated with colonic ulcerations. One patient was successfully cured by steroid therapy, while the other did not respond to steroid but oral mesalazine was effective. Systemic lupus erythematosus is frequently accompanied by gastrointestinal symptoms, but colonic lesions are quite rare, and the regular treatment is not fixed yet. The high-dose steroidal regimen may be effective for microvasculitis, although it may increase the risk of perforated ulcer of the intestinal tract, which is a life-threatening complication. Further analysis of its outcomes, and establishment of the regular guideline for its treatment are expected.

[Collagen diseases with gastrointestinal manifestations]

Collagen vascular diseases are known to present with a diverse array of gastrointestinal manifestations. These can be classified as: 1) gastrointestinal damage due to the collagen vascular disease itself; 2) adverse events caused by pharmacotherapies; or 3) gastrointestinal infections following immunosuppression due to corticosteroid (CS) administration. The first group includes lupus enteritis and protein-losing gastroenteropathy in systemic lupus erythematosus (SLE), reflux esophagitis, chronic intestinal pseudo-obstruction, and pneumatosis cystoids intestinalis in systemic sclerosis, amyloidosis in rheumatoid arthritis, bowel ulcer and bleeding in rheumatoid vasculitis and microscopic polyangiitis, and ileocecal ulcer in Behcet disease. In particular, colonic ulcers associated with SLE represent refractory lesions resistant to CS. Analysis of reported cases showing colonic lesions with SLE (22 cases in Japan) revealed that mean duration of SLE was 9.9 years and 77% of colonic lesions were observed in the rectum and sigmoid colon. Half of the patients developed intestinal perforation or penetration, and 6 of the 11 patients with perforation died. The second group includes lesions in the small and large intestine due to nonsteroidal anti-inflammatory drugs (NSAIDs) and CSs, in addition to peptic ulcers. As perforation in CS-treated patients displays relatively high incidence with poor prognosis, careful attention to such complications is needed. The third group includes candidal esophagitis and cytomegalovirus (CMV) enteritis. Prompt diagnosis is required to prevent colonic bleeding and perforation due to CMV.

Systemic lupus erythematosus in the intensive care unit

SLE causes significant morbidity and mortality by multisystem organ involvement. Infections are the leading cause of morbidity and mortality in patients with SLE. Meticulous exclusion of infection is mandatory in patients with SLE, because infections may masquerade as exacerbation of underlying disease; and the immunosuppression used to treat severe forms of exacerbation of lupus can have catastrophic consequences in patients with infections. Corticosteroids are the first-line therapy for most noninfectious complications of SLE, with various adjuvant immunosuppressive agents such as cyclophosphamide being increasingly used in combination with plasmapheresis. Some recent series have shown an improved survival rate, but this improvement needs to be confirmed by further studies. Controlled trials comparing various therapeutic options are lacking, and optimal therapy has not been defined.

Gastrointestinal manifestations of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) can involve any part of the gastrointestinal tract. In this review, we list the gastrointestinal manifestations of SLE and analyze current approaches in investigating and treating these common conditions. Abdominal symptoms and signs may be due to SLE or due to medications used in the treatment of SLE. In patients with abdominal pain and active SLE, it is critical to diagnose vasculitis or thrombosis with appropriate scanning and institute early immunosuppressive or surgical treatment.