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| Journal of the New Zealand Medical Association,
20-June-2003, Vol 116 No 1176
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Recurrent bowel infarction in a patient with systemic lupus
erythematosus
Sarah White and Arend Merrie
Bowel infarction is an unusual but important surgical
complication of systemic lupus erythematosus (SLE). Almost half of SLE patients
experience abdominal pain,1 but only 5% develop
gastrointestinal vasculitis.2 Acute abdominal
pain in SLE is more often due to surgical than rheumatological pathology, and
mortality is high.3,4 We present a patient with
mesenteric vasculitis and recurrent bowel infarction, with past history
suggesting the same process in other organs. This case reiterates the importance
of considering vasculitis and supports the use of diagnostic
laparoscopy.
Case reportA 32-year-old woman with a five-year
history of SLE, on prednisone, presented with a one-week history of abdominal
and joint pain associated with loose bowel motions, nausea and vomiting.
Initially central and colicky, on presentation the pain was right-sided and
constant.
The patient had recently undergone acute laparoscopic
cholecystectomy for acalculus cholecystitis with gangrenous gall bladder.
Pre-operative CT had revealed an old splenic infarct. She had suffered a deep
vein thrombosis three years earlier, but continued to smoke.
On examination, the patient was febrile (38.2 °C) with
guarding in the right iliac fossa and percussion tenderness. PR exam confirmed
pain in the right adnexa. White count was
17x109, neutrophils
16x109. Abdominal X-ray showed a few central
air-fluid levels.
With a provisional diagnosis of acute appendicitis she
proceeded to theatre for diagnostic laparoscopy, where a necrotic caecum was
found. Laparotomy was performed with ileocolic resection and primary
anastomosis. Histology revealed multiple mesenteric thrombosis.
On Day 4 post-operation the patient had abdominal pain and
generalised peritonism. Repeat laparotomy revealed multiple ileal infarcts and
anastomotic breakdown. The diseased ileum was resected and the patient commenced
on heparin.
Echocardiography excluded an embolus of cardiac origin.
A planned re-look laparotomy on Day 5 found all remaining
bowel healthy. End ileostomy and mucus fistula were formed. Anti-nuclear
antibodies and anti-dsDNA were elevated. Histology showed vasculitis (Figure 1)
and the patient was commenced on warfarin.
Day 6 post-operation she had a recurrence of abdominal pain.
Mesenteric angiography revealed a 50% narrowing in the superior mesenteric
artery, with lesser narrowing in distal branches.
After three weeks of bowel rest with total parenteral
nutrition and high-dose immunosuppressives, the patient was discharged on Day
36. She remains well, awaiting the reversal of her ileostomy once medical
therapy is completed.
Figure 1. Vasculitis involving small mesenteric artery.
Fibrinoid necrosis of artery wall, with neutrophils and nuclear debris in wall,
surrounded by acute and chronic inflammation.
 DiscussionBeware the SLE patient with acute
abdominal pain. Most will have surgical pathology. Steroid therapy can cloud the
clinical picture, and anti-nuclear antibody titres are positive in only half of
presentations.1 Mortality from surgical
pathology in those with SLE ranges from 38% to
53%.3,4
Several studies have assessed and recommended CT images to
help diagnose mesenteric vasculitis and ischaemia in these
patients.6–8 Characteristic findings
include dilated lumen, thickened bowel wall, engorged mesenteric vessels,
mesenteric vessel thrombus, and intramural or venous gas. Increased attenuation
of mesenteric fat and the target sign of bowel-wall oedema are also indicative.
Three of these findings support the diagnosis of
ischaemia.7
Unstable patients for whom a delay for CT is inappropriate
would traditionally have proceeded to emergency laparotomy. This has been
associated with improved survival in several
studies.4,9,10 More recent evidence supports
consideration of diagnostic laparoscopy in such
patients.5 Laparoscopy allows minimally
invasive assessment of the acute abdomen with the opportunity to proceed to
laparotomy through the most appropriate incision. Avoiding a larger wound in
this manner gives a patient the best chance of a timely, uncomplicated
recovery.
In summary, patients with SLE and abdominal pain should be
assessed with a high suspicion of surgical pathology. The threshold for
operative intervention should be low. In the stable patient, CT scanning is
useful to confirm a diagnosis of mesenteric vasculitis with or without
ischaemia. Patients requiring urgent surgery should be considered for diagnostic
laparoscopy prior to laparotomy.
Author information:
Sarah J White, Surgical Registrar; Arend Merrie, Surgical Registrar, Department
of General Surgery, North Shore Hospital, Takapuna, Auckland
Correspondence: Dr
Sarah J White, Department of General Surgery, Hutt Hospital, Private Bag 31-907,
Lower Hutt. Fax: (04) 570 9273; email: sarahjwhite@hotmail.com
References:
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