Lupus Enteritis: A Rare Manifestation of a Common Complaint of Abdominal Pain

Document Type

Article

Abstract

INTRODUCTION:

A rare manifestation of systemic lupus erythematosus (SLE) is enteritis. It is important to recognize this diagnosis, as complications of untreated disease include protein losing enteropathy, mesenteric vasculitis, and pseudo-obstruction. Lupus enteritis (LE) responds well to pulse dose steroids in 70%. We present a case of LE complicated by a protein losing enteropathy as the first clinical manifestation of lupus.

CASE DESCRIPTION/METHODS:

A 28-year-old woman with history of cholecystectomy one month prior presented to the emergency department for abdominal pain and severe diarrhea. On presentation she was afebrile and normotensive. On exam she was tender to palpation in the epigastric area. She had no jaundice or rash. Laboratory studies showed alkaline phosphatase 294 IU/L, albumin 3.0 gm/L, erythrocyte sedimentation rate 27mm/hr, and leukocytosis 11.9mcL. Stool cultures were negative. A CT scan with contrast showed edema of the small bowel with mucosal enhancement and large volume ascites. Differentials included inflammatory bowel disease, infectious diarrhea or post-operative bile peritonitis given the temporal relationship with recent surgery. A HIDA scan was negative for biliary leak. Analysis of the ascites revealed no bilirubin, negative cultures, and no malignant cells with a serum ascites albumin gradient (SAAG) of 0.7. Both EGD and colonoscopy were unremarkable with negative biopsies. She was treated empirically with cholestyramine, with little effect. Ruling out other etiologies, a malabsorption or protein losing enteropathy was considered. Further workup showed positive ANA (1:1280), positive double-stranded DNA, and low complement levels (C3 and C4). Rheumatology recommended initiating steroids for lupus enteritis. Her symptoms improved and she was discharged on a steroid taper.

Discussion:

Gastrointestinal involvement is common in SLE, however just 5.8% of patients have lupus enteritis. Furthermore, a protein losing enteropathy is even more rare, only described in small case series usually seen in young females. Presentation can be vague with abdominal pain, severe diarrhea, and anasarca. Diagnosis is aided by hypoalbuminemia and excluding other causes of decreased protein synthesis or loss. Characteristic findings of LE on CT are bowel wall edema, wall enhancement with dilatation of the bowel lumen “target sign,” and ascites. LE is usually steroid responsive. Timely treatment is important as complications like bowel perforation can result in a mortality of 2.7%.

First Page

S1471

Last Page

S1472

DOI

10.14309/01.ajg.0000713308.27528.17

Publication Date

10-1-2020

Link to Full Text

Share

COinS