2593 The Importance of Endoscopy in Diagnosis of Lupus Enteritis

Abstract

INTRODUCTION: Lupus enteritis is defined as vasculitis or inflammation of the small bowel with supportive image and/or biopsy findings in patients with SLE. Symptoms such as abdominal pain (97% of cases) and vomiting (42%) are non-specific. These symptoms represent a wide differential, including vasculitis, medication reactions, and infection. This can cause diagnostic dilemmas in patients with multiple comorbidities. CASE DESCRIPTION/METHODS: A 28-year-old female with SLE, lupus nephritis, and ESRD after failed renal transplant presented with one day of abdominal pain and vomiting. Her medications included mycophenolate mofetil, prednisone, and hydroxychloroquine. Physical examination revealed periumbilical tenderness without rebound or guarding. CT abdomen showed small bowel wall thickening and hyperemia in the proximal jejunum with bowel dilatation and no transition point. Labs were remarkable for elevated CRP and decreased C3 complement. Given her symptoms and abdominal imaging, she underwent small bowel enteroscopy that showed severe inflammation in the proximal jejunum with purple discoloration (Figure 1). Initial jejunal biopsy was concerning for vasculitis. The patient was treated with methylprednisolone. Her symptoms improved within one day. A CTA abdomen two days later showed no vascular abnormalities with interval improvement of jejunal edema. Final pathology of the jejunal biopsy (Figures 2 and 3) showed mildly inflamed and injured small intestinal mucosa with fibrin thrombi in small vessels, lamina propria hemorrhage and patchy lymphangiectasia, consistent with lupus enteritis in this clinical setting. DISCUSSION: The clinical presentation of lupus enteritis is non-specific but often associated with abdominal pain and vomiting in SLE patients. The jejunum is involved in 80% of cases. The underlying cause is believed to be immune-complex deposition and complement activation that produce diffuse microvascular injury, thrombosis, and increased vascular permeability. This can result in intestinal necrosis and perforation. Timely diagnosis and treatment lead to excellent response within days. This patient achieved symptomatic improvement after one day of high-dose steroids. Due to her dialysis schedule, CT angiogram of her abdomen was delayed until after symptom resolution. The normal imaging reflected treatment response rather than lack of disease and led to initial non-diagnosis until final pathology resulted. Our case highlights the value of endoscopy in patients with a suspicion of lupus enteritis.