Ab0856 chronic Intestinal Pseudo-Obstruction With Hydronephrosis: A Case Report on Such Disabling and Rare Complication of Lupus

Abstract

Background:Chronic intestinal pseudo-obstruction can be a rare complication of systemic lupus erythematosus. It is often late to be identified in contrast to other commoner organs involvement in systemic lupus erythematosus such as nervous system, joint and kidney.Objectives:To report a case of uncommon gastrointestinal complication of lupus, with associated hydronephrosis at the ureter, with treatment delay.Methods:We report a case of chronic intestinal pseudo-obstruction.Results:A 34 year old, with ten-year history of lupus nephritis, presented with recurrent abdominal pain and diarrhoea past nine months. The patient had just been diagnosed as end-stage renal failure a year ago, on regular haemodialysis. For the past ten years, the patient was not able to tolerate immunosuppressant due to the multiple episodes of infections, including shin carbuncle, herpes zoster, breast abscess and catheter-related candida/bacterial infections. However, the patient did not have any other major organs manifestations of lupus for the past ten years. The patient was apyretic. Multiple stool cultures were negative including Clostridium difficile. The abdominal radiography showed dilated small bowel with diffuse thickening of large and small bowels on computed tomography. Bilateral uretero-hydronephrosis was also noted without any evidence of obstructive uropathy on imaging. Ileocolic resection was done for presumed intestinal obstruction and the ileocolic biopsy did not reveal any granuloma, malignancy or vasculitis except for non-specific inflammation of cecum. Cytomegalovirus inclusion body was absent as well. Tuberculosis culture was negative. Oesophagoduodenoscopy and colonoscopy were offered in view of persistent unexplained loose stool and abdominal pain. But unremarkable findings were noted from multiple biopsy specimens of the small and large bowels. Second relook of the initial hemicolectomy specimen with special actin immunostain on the smooth muscle revealed degenerative changes of the muscularis propria. These were evidenced by cytoplasmic vacuolation, atrophy and pyknotic nucleus of the smooth muscle cells with surrounding oedema. Smooth muscle dysmotility could be the underlying pathology of this patient presentation. The patient responded well to intravenous immunoglobulin followed by azathioprine in addition to prednisolone and prokinetic agent.Conclusion:Prompt recognition is pivotal in this case could have prevented the unnecessary surgical intervention earlier. It is potentially reversible. Long term prognosis of this rare entity is, however, varying.Disclosure of Interests:None declared