Life-Threatening Gastrointestinal Bleeding due to a Jejunal Lesion of Henoch-Schönlein Purpura

Abstract

The case of a 56-year-old patient with Henoch-Schönlein purpura (HSP) and fulminant gastrointestinal bleeding is reported. The patient was admitted to hospital because of palpable purpura on both legs, painful joints and diffuse abdominal pain. Suspected HSP was histologically proven and treated with prednisolone. Despite recovery, acute gastrointestinal bleeding, with melena and a drop in hemoglobin concentration from 11.2 to 4.2 g/dl, occurred 30 days after medication was started. Immediate endoscopic examination of the upper gastrointestinal tract showed no signs of bleeding whereas colonoscopy showed fresh blood and blood clots in the terminal ileum and the colon. Since the bleeding source could not be detected endoscopically, mesenteric angiography was performed, demonstrating active bleeding from a jejunal artery. Thereafter the bleeding source was located by intraoperative peroral enteroscopy and treated by resection of a short segment of jejunum.

Henoch–Schönlein purpura complicated with severe gastrointestinal bleeding

“…In this regard, the various gastrointestinal manifestations confirmed in our patient may not be surprising. Indeed, it has been reported that gastrointestinal bleeding may occasionally become severe enough to require transfusion or laparotomy in patients with HSP [3,[11][12][13]. However, the clinical impact of the current report should be emphasized in that this case illustrates the potential for lethal bowel bleeding, which has been mentioned in only a few previous literature [13,[17][18][19].…”

“…Otherwise, there may have been a potential discrepancy in the clinical benefit of the therapeutic regimens applied in the current patient with respect to the gastrointestinal and glomerular injuries associated with HSP. Similarly, the deterioration of gastrointestinal symptoms despite improvements in skin, joint and renal manifestations during treatment with prednisolone has been reported [12].…”

“…The potential benefits of immunomodulatory management, including corticosteroids, immunosuppressants and PEX, have demonstrated varied levels of success in numerous clinical experiences among the patients with severe or complicated cases of HSP [8][9][10]33], while the abdomen may be tender and distended or similar to an acute abdomen, resulting in unnecessary surgery in some HSP cases [34]. The main indications for surgery in patients with the disease are intussusception, infarction and perforation, while focal arterial bleeding may also be considered as an alternative determinant of the need for surgical management [3,12,13]. In the current case, we faced a therapeutic dilemma, as the endoscopic analysis and scintigraphic findings suggested that there were multifocal bleeding sites, including the duodenum, jejunum and terminal ileum, leading us to empirically pursue the use of corticosteroid treatment combined with PEX instead of surgery.…”

“…It has been considered that abdominal involvement, including pain, nausea, vomiting and/or gastrointestinal bleeding, occurs in more than half of patients affected with HSP [3,9]. The small intestine is the most frequently involved part in the gastrointestinal tract, presumably due to its predilection to ischemic injury [3], while the second portion of the duodenum, as well as the stomach, terminal ileum and colon, are often affected [3,[11][12][13][14]. Of note, abdominal symptoms precede purpuric lesions by several days in 12-19 % of patients with HSP [3,4,[9][10][11], posing diagnostic challenges to physicians.…”

A Case of IgA-related Enteropathy Complicated with Gastrointestinal Bleeding and Progressive IgA Nephropathy: A Possible Variant Henoch-Schönlein Purpura?

“…Serious bleeding, requiring transfusion or surgery or leading to death, was shown in 11% of the patients, in a retrospective review of 250 French adult patients (6). The small intestine is predominantly the most involved part of the gastrointestinal tract, and the second portion of the duodenum, stomach, terminal ileum and colon are also frequently affected (9)(10)(11)(12). The endoscopic findings in gastrointestinal lesions are expressed by redness, ulcers, edema and erosions.…”