Duodenal findings on ultrasound in children with Schonlein-Henoch purpura and gastrointestinal symptoms

Superior mesenteric artery syndrome: risk factor for duodenal involvement in Henoch-Schönlein purpura

BACKGROUND

The anatomical location of the third portion of the duodenum is between the superior mesenteric artery (SMA) and the abdominal aorta (AA). When the aorto-mesenteric angle (AMA) is small and the aorto-mesenteric distance (AMD) is short, the duodenum becomes tightly compressed between these two blood vessels. Severe compression can obstruct the duodenum, resulting in vomiting and abdominal pain. This clinical condition is termed superior mesenteric artery syndrome (SMA syndrome). The duodenum is frequently affected in Henoch-Schönlein purpura (HSP). The aim of the present study was to verify that duodenal anatomy mimicking SMA syndrome is a risk factor for duodenal involvement and abdominal pain in HSP.

METHODS

A prospective case-control study involving 12 HSP patients compared with 48 age- and sex-matched children (controls) was conducted. Bowel abnormalities were defined as thickened wall >3 mm and paralytic ileus detected on ultrasound. AMA, AMD and obesity index (OI) were compared between the two groups on Mann-Whitney testing. The correlation between duodenal bowel abnormalities and SMA syndrome was examined using Fisher's exact test.

RESULTS

AMA, AMD and OI were significantly smaller in the HSP patients (P < 0.001, 0.003 and 0.026, respectively). All HSP patients, but only 10 controls, met the ultrasound diagnostic criteria for SMA syndrome (100% vs 20.8%, P < 0.001).

CONCLUSIONS

Duodenal compression by SMA against the AA, which mimics SMA syndrome, may lead to duodenal bowel abnormalities with abdominal pain in thin children with HSP.

Significance of bowel wall abnormalities at ultrasound in Henoch-Schönlein purpura

OBJECTIVES

To describe the polymorphism of intestinal ultrasound findings in children with gastrointestinal symptoms of Henoch Schönlein purpura (HSP) and to investigate the clinical relevance of these findings in terms of symptoms and length of hospitalization.

PATIENTS AND METHODS

Clinical and ultrasound data from 43 consecutive children with HSP (36 with and 7 without abdominal symptoms) were reviewed. Patients with abdominal symptoms of HSP were divided into 4 groups (0-III) representing at ultrasound normal appearance and differentiated, pseudodifferentiated, and dedifferentiated bowel wall thickening, respectively. The diagnostic value of ultrasound in diagnosing gastrointestinal involvement of HSP (grades I-III) was calculated using as the standard of reference the absence or presence of clinical symptoms. Average duration of symptoms and hospitalization in the 4 groups was compared.

RESULTS

The respective sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound for the diagnosis of gastrointestinal involvement of HSP was 83.3%, 100%, 100%, and 53.8%. Groups 0 to III contained, respectively, 5/36 (13.9%), 6/36 (16.7%), 22/36 (61.1%), and 3/36 (8.3%) patients. The groups' average duration of symptoms, respectively, was 2.20 +/- 2.06, 5.67 +/- 1.88, 6.29 +/- .94, and 17.67 +/- 2.66 days, whereas the length of hospitalization, respectively, was 4.80 +/- 2.96, 9.17 +/- 2.70, 11.46 +/- 1.35, and 24.67 +/- 3.82 days. The duration of both symptoms and hospitalization was significantly higher in group III than in the other groups (P < 0.05).

CONCLUSIONS

In children with gastrointestinal involvement of HSP, dedifferentiated wall thickening as shown by ultrasound is associated with a poor clinical prognosis.

Adult T-cell lymphoma mimicking Henoch-Schönlein purpura

We report a male patient with adult T-cell lymphoma, who was initially diagnosed clinically as having Henoch-Schönlein purpura (HSP) with abdominal pain and specific purpura. Adult T-cell lymphoma-like cells were minimal and abdominal lymph nodes were transiently swollen, and the symptoms were improved by supportive management. Although the clinical course was compatible with HSP, the histological examination revealed infiltration of lymphocytes rather than neutrophils. Later he developed lymphoma and was treated with chemotherapy. This rare case suggests the importance of skin biopsies to seek the underlying pathology in adult HSP.

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.