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October 1995, Volume 45, Issue 10

Case Reports

A Case of Severe Ischemic Colitis Caused by Systemic Lupus Erythematosus

Mustafa Korkut  ( Department of Colorectal Surgery and Pathology, Aegean University Medical School, Izmir, Turkey. )
Yamac Erhan  ( Department of Colorectal Surgery and Pathology, Aegean University Medical School, Izmir, Turkey. )
Halit Osmanoglu  ( Department of Colorectal Surgery and Pathology, Aegean University Medical School, Izmir, Turkey. )
Murat Alkanat  ( Department of Gastroenterology, Aegean University Medical School, Izmir, Turkey. )
Muge Tuncyurek  ( Department of Gastroenterology, Aegean University Medical School, Izmir, Turkey. )
Necla Osmanoglu  ( Department of Colorectal Surgery and Pathology, Aegean University Medical School, Izmir, Turkey. )

Introduction

Systemic lupus erythematosus (SLE)is characterized by a wide range of clinical manifestations. Nearly in half of patients, gastrointestinal (01) symptoms such as abdominal pain, nausea, vomiting, diarrhea are encountered and one can rarely meet acute abdominal signs requiring laparotomy caused by GI vasculitis of SLE1-3 We report here a case who presented with acute abdomen with known history of SLE.

Case report

A diagnosis of SLE was made ma 30 year old woman in 1992 when she presented with polyarthralgia and skin eruptions especially significant on her face. She complained of occasional cramp-like abdominal pain, nausea, vomiting and mucorrhea. Investigations revealed an ESR of 62 mm, a haemoglobin of 10 g/dl and positive antinuclear antibody in a dilution of ito 640 granular. Semm complement levels of C3 and C4 were 72 and 10.3 u/i, respectively (Normal level of C3:50-90 u/l C4: 10-40 u/I). Serum IgA was 340 mg/dl and serum IgG was 152 mg/dl. A barium enema showed no abnormality except spasticity in caecum. Although SLE was considered to be the first diagnosis in this case, colonoscopy was planned inorderto rule out any other inflammatory bowel disease. During the period of bowel preparation for colonoscopic evaluation, She developed acute abdomen and was operated. At laparatomy, multiple small areas of ischemia especially at sites of terminal ileum and splenic flexum of colon were observed, but there was no evidence of 01 tract perforation (Figure I).

The ischemic areas of terminal ileum and colon appeared non-viable after initial exploration of thirty minutes and subtotal colectomy with ileostomy and sigmoid mucous fistula were performed. In early postopera­live period, the patient was treated with a course of cyclophos­phamide and methyiprednisolone. Then, resochin was added to this regimen. Seven months later sigmoidectomy with ileorecial anastomosis was performed. After the second operation she was given immuran. The patient is on medical treatment and close clinical follow-up. Histopathologic ex­anunation of the presected specimen revealed leucocytoclas­tic vasculitis showing vasculitis in sub mucosal vessels caus­ing severe colonic ischemia (Figure 2).

Discussion

In SLE, acumulation of circulating immune complexes cause vasculitis of small arteries and veins leading to focal ischemia, necrosis and perforation4. Because of relatively poor blood flow, ischemic lesions are more frequent in left colon5. The most common abdominal symptom of SLE is pain6. Additionally, anorexia, nausea, vomiting, diarrhea and malena can be encountered7. The diagnosis of an acute surgical abdomen due to SLE could be made with confidence only when the patient had concomitant disease activity mother organs8. Management of the acute abdominal manifestations of SLE is a difficult therapeutic and surgical challenge. In a patient with proven SLE and acute abdominal symptoms, there may be a role for high dosage steroid therapy as the lesions are produced by an immune complex induced vasculi­tis9. Depending upon the surgeon’s judgement for viability, resection or conservative management should be preferred. Our case, presented with acute abdomen which necessitated laparotomy. Therefore, it should always be considered that SLE can cause acute abdomen leading to an urgent emergency surgery.

References

1. Schur, P. H. Clinical features of SLE. Textbook ofrheumatology. In: Kelley W. N., Harris; E. D., Ruddy, S., Sledge, C. B. eds. Textbook of rheumatology. Philadelphia, W. B. Saunders Company, 1989, pp. 1116.
2. Weisman, M. H. and ZvalfIer, N. J. Vasculitis in connective tissue diseases. Clin. Rheuxn. Dis., 1980;6:359-69.
3. Zizic, T. M., Classen, J. N. and Stevens, M. B. Acute abdominal complications of systemic lupus erythematosus and polyarteritis nodosa. Am. J. Med., 1982;73:525-31
4. Stoddard, C. J., Kay, P H., Simms, J. M. et al. Acute abdominal complications ofsystemiclupuserythematosus. Br. J. Surg.. 1978;65:625-28.
5. Marston, A., Pheils, M. T., Thomas, M. L. et al. Ischemic colitis. Gut., 1966;7:1-15.
6. Hoffman, B. L., Katz, W. A. The gastrointestinal manifestations of systemic lupus eiythematosus: A review of the literature. Semin. Arthritis Rheum., 1980;9:237-47.
7. Harvey, A. M., Shulman, L. E., Tumulty, P. A. Systemic lupus erythematosus. Review of the literature and clinical analysis of 138 cases. J. Medicine, 1954;33:291-437.
8. Zizic, T. M., Shulman, L. E. and Stevens, M. B. Colonic perforations in systemic lupuserythematosus. Medicine, 1975;54:411-26.
9. Pollak, V. E., Grove, W. J., Kark, R. M. et al. Systemic lupus erythematosus simulating acute surgical condition of the abdomen. N. Engl. J. Med., 1958;259:258-266.

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