Endoscopic findings in Henoch-Schönlein purpura

Clinical characteristics and risk factors of IgA vasculitis with intussusception and intestinal perforation

AIM

Intussusception is the most common surgical complication of IgA vasculitis (IgAV), and intestinal perforation is usually associated with intussusception. If they are not recognised and treated in a timely manner, serious consequences may occur. The objective is to summarise the clinical features of IgAV complicated by intussusception and intestinal perforation and explore its risk factors.

METHODS

The clinical data of 32 patients with IgAV complicated by surgical complications (25 cases of intussusception and 7 cases of intestinal perforation) were retrospectively analysed. A total of 160 IgAV children with gastrointestinal (GI) involvement but without surgical complications were randomly selected as a control group. Binary logistic regression analysis was performed to explore the risk factors for IgAV with intussusception and intestinal perforation.

RESULTS

Compared with the intussusception group, the intestinal perforation group had a significantly higher number of patients with GI symptoms prior to skin purpura and GI bleeding, a significantly higher number of days of abdominal pain, a significantly higher Wong-Baker score, and a significantly higher white blood cell count. Multivariate logistic regression analysis indicated that age ≤7 years, GI symptoms prior to skin purpura, abdominal pain intensity (Wong-Baker scale) and timing of glucocorticoid treatment were independent risk factors of IgAV with intussusception and intestinal perforation.

CONCLUSION

Age less than 7 years, severe abdominal pain, and GI symptoms prior to skin purpura were risk factors for IgAV with intussusception and intestinal perforation. Early use of glucocorticoids may prevent intussusception and intestinal perforation.

Endoscopic and microscopic findings of gastrointestinal tract in Henoch-Schönlein purpura: Single institute experience with review of literature

Asia has the highest incidence of Henoch-Schönlein purpura (HSP). Although 50% to 75% of patients with HSP manifest gastrointestinal (GI) symptoms, endoscopic, and pathologic findings of HSP have been rarely reviewed in Asia.Patients diagnosed with HSP who had undergone endoscopic biopsy from GI tract (GIT) in Soonchunhyang University Seoul Hospital from 2000 to 2018 were evaluated and 25 cases with 44 biopsies from upper GI tract (U-GIT) or lower GI tract (L-GIT) were enrolled. Their clinical and endoscopic findings and histologic findings of endoscopic biopsy were reviewed.Of the 25 patients, 15 were males and 10 were females. There were 6 children and 19 adults. The most common GI symptom was abdominal pain (20/25), followed by loose stool or diarrhea (9/25). Biopsied sites included 19 from U-GIT (9 stomach and 10 duodenum) and 25 from L-GIT (7 terminal ileum, 1 cecum, 4 ascending, 1 transverse, 2 descending, 7 sigmoid, and 3 rectum). Erythema/petechia was the most common endoscopic finding in U-GIT, while erosion/ulceration was the most common one in L-GIT. In U-GIT, extravasted red blood cell (RBC) (14/19) was the most common histologic finding, while leukocytoclastic vasculitis (LCV)/capillarities were identified in 7 specimens, including 5 duodenum samples. In endoscopic investigations of L-GIT, erosion/ulceration (9/14) was predominantly identified. The most common histologic finding was also extravasted RBC (22/25), while LCV/capillarities were noted in 10 specimens, including 5 specimens from terminal ileum.The HSP commonly involves GIT. Histologic findings of our cases were not significantly different from results of previous studies in Western countries. However, endoscopic and pathologic characteristics of HSP have been rarely reviewed in Asia. Herein, we share experience of endoscopic biopsy of GIT in patients with HSP.

Adult-Onset Henoch-Schonlein Purpura Duodenitis

Henoch-Schonlein purpura (HSP) is an immune-mediated vasculitis. HSP presents with purple spots on the skin (purpura), arthralgia, digestive problems, and kidney injury. HSP is most commonly seen in children, and rarely presents in adults. The pathogenesis involves the deposition of immune complexes in small to medium size blood vessels which leads to necrosis and inflammation. Most patients recover after symptomatic treatment, while more severe cases are treated with steroids. We report a 28-year-old female patient who presented with two episodes of hematemesis, worsening abdominal pain, and bloody diarrhea. Physical examination showed erythematous, palpable, purpuric rashes on her thighs and lower legs. Contrast-enhanced computed tomography (CT) scan showed thickening of the duodenal wall, and upper endoscopy revealed mild gastric erythema and diffuse erythematous, hemorrhagic, friable mucosa with superficial, thick, adherent white exudate seen in the second portion of the duodenum, consistent with the diagnosis of HSP. We report on the clinical presentation of our patient, and review adult-onset HSP.

The Correlation of Endoscopic Findings and Clinical Features in Korean Patients with Scrub Typhus: A Cohort Study

Scrub typhus is an infectious disease caused by Orientia tsutsugamushi-induced systemic vasculitis, but the involvement of the gastrointestinal tract and the endoscopic findings associated with scrub typhus are not well understood. We performed a prospective study and recommend performing esophagogastroduodenoscopy (EGD) for all possible scrub typhus patients, regardless of gastrointestinal symptoms. Gastrointestinal symptoms, endoscopic findings and clinical severity based on organ involvement and ICU admission were analyzed. Gastrointestinal symptoms occurred in up to 76.4% of scrub typhus patients. The major endoscopic findings were ulcers (43/127, 33.9%). Interestingly, 7.1% (9/127) of the patients presented with esophageal candidiasis. There was no correlation between the presence or absence of gastrointestinal symptoms and the endoscopic grade (P = 0.995). However, there was a positive correlation between the clinical severity and the endoscopic findings (P = 0.001). Sixty-three percent of the patients presented with erosion or ulcers on prospectively performed endoscopic evaluations, irrespective of gastrointestinal symptoms. Gastrointestinal symptoms did not reflect the need for endoscopy. Scrub typhus patients could have significant endoscopic abnormalities even in the absence of gastrointestinal symptoms.

Henoch-Schönlein purpura complicated by acalculous cholecystitis and intussusception, and following recurrence with appendicitis

Henoch-Schönlein purpura (HSP) is the most common childhood systemic vasculitis. Gastro-intestinal involvement occurs in two-thirds of patients. The characteristic skin lesions generally precede abdominal symptoms or present concurrently. A 7-year-old boy presented with intussusception and acalculous cholecystitis and had a cholecystectomy. Two weeks later he was re-admitted with features typical of HSP which responded to corticosteroids. Eleven months later he presented with abdominal pain and recurrence of HSP and, at laparotomy, there was acute appendicitis. This is the first case of a child presenting with HSP complicated by acalculous cholecystitis.

Atypical tumour-like involvement of the colon in Henoch-Schonlein purpura successfully treated with the administration of factor XIII

Henoch-Schönlein purpura (HSP) is a type of systemic vasculitis of the small vessels, which frequently involves the skin, kidney and gastrointestinal tract. While the typical intestinal features of HSP include diffuse mucosal redness, small ring-like petechiae and haemorrhagic erosions, tumour-like lesions are rarely observed. The current study presents a rare case of HSP with an intestinal tumour-like lesion in the caecum. The intestinal lesion caused fresh melaena, and was completely resolved with the administration of factor XIII as described in previously reported cases. It is important to immediately undergo proper treatment for improving tumour-like lesions which may cause severe complications, such as excessive haemorrhage and stricture.

Gastrointestinal involvement in Henoch-Schönlein purpura

OBJECTIVE

To analyse the gastrointestinal manifestation of Henoch-Schonlein purpura (HSP) in adult patients, including clinical and endoscopic features.

MATERIAL AND METHODS

Patients with a final diagnosis of HSP admitted from January 1995 to January 2006 were included. Their medical records, including clinical presentation, laboratory data, endoscopy and pathology reports, were reviewed retrospectively.

RESULTS

One-hundred-and-fifteen patients were included. Gastrointestinal symptoms occurred in 90 patients (78.2%), with abdominal pain the most common symptom. Fifty-four patients underwent gastroscopy, while 24 underwent colonoscopy. The endoscopic lesions included mucosal erythema, oedema, multiple irregular ulcers and nodular changes. In the upper GI tract, the second portion of the duodenum was the most frequently involved area and is where the most severe lesions occur. In the lower GI tract, the rectum was the most frequently involved area, but the most severe lesions were found in the terminal ileum.

CONCLUSIONS

HSP may present with acute abdomen without typical skin manifestations, and gastroscopy and colonoscopy can be helpful in the early diagnosis of HSP in these patients. Typical endoscopic findings include diffuse mucosal oedema, erythema, petechia or multiple irregular ulcers, especially in the second portion of the duodenum or in the terminal ileum.

Isolated colonic leukocytoclastic vasculitis causing segmental megacolon: report of a rare case

We report the case of a 44-year-old white man who presented with progressively worsening crampy abdominal pain and distention. Deterioration of his clinical picture along with leukocytosis and radiographic evidence of severe colonic dilation rendered exploratory laparotomy necessary. Greatly distended and inflamed transverse and descending colon were evident and an extended left colectomy was performed. Characteristic changes of leukocytoclastic vasculitis in the serosal and muscular layers of the resected colon were demonstrated at histopathologic examination. Systemic leukocytoclastic vasculitis, usually coexisting with Henoch-Schonlein purpura, commonly affects the small bowel with clinical evidence of ischemia or bleeding. Colon involvement is infrequently reported in the context of systemic disease. Isolated colonic leukocytoclastic vasculitis without extraintestinal manifestations is rare. A previously unreported case of localized leukocytoclastic vasculitis of the left colon resulting in the impressive presentation of megacolon, without the presence of any precipitating factor or associated systemic disease is presented here, with an overview of the related literature.

Intestinal ischemia as the first manifestation of vasculitis

OBJECTIVE

To summarize current knowledge regarding the diagnosis and management of gastrointestinal vasculitis.

METHODS

Three cases of gastrointestinal vasculitis with acute abdominal ischemia as their first manifestation are presented. Underlying diseases were microscopic polyangiitis, systemic lupus erythematosus (SLE), and polyarteritis nodosa (PAN). Relevant English-language articles collected from the PubMed database were reviewed.

RESULTS

Among the angiitides, PAN, SLE, and Henoch-Schönlein are those most commonly accompanied by gastrointestinal complications. Intestinal vasculitis usually occurs when there is evidence of generalized disease activity. Abdominal computerized tomography is a valuable tool for diagnosing intestinal ischemia and suspected vasculitis.

CONCLUSIONS

In young patients presenting with intestinal ischemia, it is essential to assess the possibility of an underlying systemic disease. With prompt initiation of immunosuppressive treatment, surgery may be avoided. Prognosis is improved when there is minimal delay in surgical intervention.

Immunoglobulin A enteropathy: a possible variant of Henoch-Schönlein purpura

This study calls attention to a new syndrome presenting with gastrointestinal symptoms including abdominal pain, vomiting, and/or hematemesis and endoscopic multiple lesions predominantly in the descending duodenum, without the skin rash observed in Henoch-Schonlein purpura. We examined the gastrointestinal mucosa for IgA deposits in nine children and compared the results with those for three patients with Henoch-Schönlein purpura. In addition, gastroduodenal biopsy specimens of 11 patients with various diseases were studied as controls for IgA staining. Intestinal histology showed nonspecific mucosal inflammation without vasculitis. In six patients without rash (67%), IgA deposition was observed in the capillary wall with the same staining pattern as seen in two patients with Henoch-Schonlein purpura. Compared with the controls (9%), the positive rate of IgA deposition was significantly higher in nonrash patients (P < 0.01). Deposited IgA showed immunoreactivities of polymeric IgAl containing J chain. IgA deposits were ultrastructually seen along the plasma membranes of the endothelial cells. Overall, the data suggest that IgA deposition played a pathogenetic role in the gastrointestinal damage in this group of patients presenting primarily with gastrointestinal complaints. Further studies are needed to clarify whether this patient population has a variant of Henoch-Schönlein purpura or a distinct "IgA enteropathy."

GI involvement in Henoch-Schönlein purpura

BACKGROUND

The diagnosis of Henoch-Schönlein purpura is difficult, especially when abdominal symptoms precede cutaneous lesions. The aim of this study was to determine the distribution of GI involvement in Henoch-Schönlein purpura.

METHODS

Endoscopic or radiographic findings throughout the entire GI tract were retrospectively reviewed for 7 patients with Henoch-Schönlein purpura. Histopathologic findings were analyzed and correlated with findings at EGD and colonoscopy.

OBSERVATIONS

The duodenum and small intestine were most frequently involved (6 patients, each site). Contrast radiography of the small intestine demonstrated thickened mucosal folds or small barium flecks. Findings at EGD were multiple irregular ulcers, mucosal redness and petechiae in the duodenum. In 4 patients, the second part of the duodenum was predominantly affected. Ulcerating lesions accompanied by hematoma-like protrusions were detected in 4 patients in whom leukocytoclastic vasculitis was proven histopathologically.

CONCLUSIONS

EGD appears to have the greatest diagnostic utility in patients suspected to have Henoch-Schönlein purpura with GI involvement.

Duodenojejunitis: is it idiopathic or is it Henoch-Schönlein purpura without the purpura?

BACKGROUND

Henoch-Schönlein purpura is a small-vessel vasculitic disease that most often affects the skin. Gastrointestinal manifestations have been well described, including duodenojejunal inflammation (DJI).

METHODS

Four children with DJI and clinical features of HSP are described, in whom the rash was either not present or appeared atypically late in the illness.

RESULTS

The characteristic rash did not develop in three children, and it developed much later in one. The patients (three boys and one girl) were aged between 7 and 9 years (mean, 7.5 years). Growth characteristics were normal. In all patients, pain occurred acutely with colicky abdominal pain in the spring or fall of the year, and all stools were positive for occult blood. No infectious cause was identified. Upper gastrointestinal endoscopic examinations demonstrated significant visual and histologic duodenitis in a pattern consistent with previous reports in children with known HSP. Factor XIII activity was absent. Immunoglobulin A levels were increased in three of four children. All children made a prompt recovery with the administration of intravenous glucocorticoids. In one child, the characteristic rash of HSP developed 18 weeks after the initial examination.

CONCLUSION

Duodenojejunal inflammation may be the primary manifestation of HSP, even in the absence of the characteristic rash.

Henoch-Schönlein purpura: what does the "rash" look like in the gastrointestinal mucosa?

Two patients are reported with Henoch-Schönlein purpura, one with the typical presenting sign of purpuric skin lesions, the other whose diagnosis was made on the basis of endoscopic examination in the absence of an initial cutaneous eruption.

Diffuse hemorrhagic gastroenteropathy: report of a new entity

An apparently novel entity, diffuse hemorrhagic gastroenteropathy (DHG), in a 70-year-old female who had an unremitting course of chronic gastrointestinal blood loss for 3 years requiring transfusion of more than 200 units of packed red blood cells over this period is reported here. Endoscopy showed diffusely hemorrhagic mucosa in the stomach, duodenum, and small bowel. Full-thickness biopsy of the stomach and small intestine revealed luminal narrowing of capillaries and post-capillary venules within the lamina propria due to swelling and some proliferation of the endothelial cells with margination and emigration by neutrophils as well as partial occlusion of some vessels by fibrin thrombi. DHG may represent a new entity characterized by mucosal hemorrhage due to local mucosal ischemia of the gastrointestinal tract secondary to a small vessel "vasculopathy" apparently restricted to this site.