[Collagen diseases with gastrointestinal manifestations]

Ileal perforation as an initial manifestation of systemic lupus erythematosus: A case report

Introduction and importance

Lupus enteritis is uncommon in patients with SLE and usually presents with anorexia, vomiting, and abdominal pain. Intestinal perforation as an initial manifestation of SLE is rare and can have a grave prognosis if not timely diagnosed.

Case history

We report an unusual case of a 22-year-old regularly menstruating female who presented with features of perforation peritonitis as an initial manifestation of lupus enteritis. Intraoperatively, a gangrenous ileal segment with multiple perforations was present. Thus, with an intraoperative diagnosis of perforation peritonitis, a gangrenous segment of the small bowel was resected and a double-barrel jejuno-ileostomy was created.

Discussion

Lupus enteritis manifesting initially as bowel perforation can be an uncommon cause of acute abdomen. A plain chest X-ray can show gas under the diaphragm suggesting bowel perforation. A contrast-enhanced CT scan of the abdomen is the gold standard in diagnosing lupus enteritis with a good prognosis on steroids.

Conclusion

Primary closure, resection, and anastomosis of small gut or diverting stoma are required for management of perforation. A high degree of clinical suspicion is required for early diagnosis thus preventing the grave prognosis of such an entity.

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Bowel perforation in patients with SLE is rare.

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Diagnosis of this lupus enteritis is challenging owing to its rarity and non-specific presenting features.

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High degree of suspicion and timely diagnosis can prevent fatal complications.

A woman with adult-onset Still's disease and acute intestinal pseudo-obstruction

Adult-onset Still's disease may cause intestinal pseudo-obstruction via a cytokine storm. Early diagnosis and treatment are the key for patient survival before the development of serious complications such as macrophage activation syndrome.

Recurrent Stenosis of the Ileum Caused by Rheumatoid Vasculitis

A 65-year-old man with a 20-year history of rheumatoid arthritis was transferred to our hospital due to a second episode of intestinal obstruction, a fever, and joint pain within the previous 6 months. He had an extremely high rheumatoid factor level and decreased complement levels. Abdominal computed tomography, a small bowel series, and small intestinal endoscopy revealed severe ileal stenosis. Resection of the stenotic lesion was performed, and a histopathological examination revealed vasculitis. Rheumatoid vasculitis was diagnosed, and the patient began treatment with prednisolone and methotrexate, which improved his condition. Rheumatoid vasculitis is a rare, but possible cause of recurrent bowel obstruction.

[A case of lupus erythematosus profundus followed by systemic lupus erythematosus presenting with severe intestinal involvement]

A 52-year-old female visited the outpatient department of Sapporo Medical University hospital in 1984 due to a refractory rash on the skin of the trunk. Histological findings of a skin biopsy specimen indicated a diagnosis of lupus erythematosus profundus (LEP). The eruption remained quiescent with moderate doses of prednisolone. In October 2003, she was suddenly admitted to our hospital with abdominal pain, fever and bloody stool. Lupus enteritis was diagnosed based on an elevated level of anti-DNA antibody, low complementemia and diffuse edematous change of the intestinal walls on CT scans. Although high doses of corticosteroids resulted in transient improvement, melena developed again on the 24th hospital day. Colonoscopy revealed deep ulceration at the rectum and a gastrografin enema indicated perforation. Accordingly, the involved rectum was resected and an artificial anus was constructed on the 50th hospital day. Examination of the resected specimen by microscopy showed that the ulceration approached at the depth of the subserosal layer with intense infiltration of inflammatory cells around the vessels. The pathogenesis of the rectal lesion might have been due to vasculitis associated with systemic lupus erythematosus (SLE). The disease did not recur under the administration of 10 mg of prednisolone daily until November 2004. Colonic function made a remarkably untroubled recovery after the artificial anus was closed in February 2005. The LEP was generally accompanied by a mild form of SLE. This case seemed to be rare in that SLE was associated with severe lupus enteritis and a refractory rectal ulcer developed from LEP. Patients with SLE and intestinal involvement should be carefully monitored in cooperation with a surgeon.