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*For reference only for medical professionals Seeing both trees and forests: From acute abdomen to rheumatic immune disease, we need to understand the manifestations of gastrointestinal lesions related to connective tissue diseases.
A 30-year-old woman with acute abdomen was admitted to the hospital.
The clues are rather secret, but there is only one truth.
Have you guessed it? The new issue of the wind bill is finalized, waiting for you to judge ~ the case after the first visit, the dangerous situation patient is a 30-year-old female, married, due to "abdominal pain with vomiting for 1 day, aggravated by 3 hours", the emergency department was admitted to the hospital.
The patient had epigastric pain without obvious precipitating cause, presenting paroxysmal tingling, accompanied by nausea and vomiting.
The vomit content was the content.
There was no history of repeated fever, rash, arthritis, oral ulcers and hair loss, chest tightness, and palpitation.
And other symptoms.
Three hours ago, the patient's abdominal pain area expanded compared with the previous one, and the patient began to experience total abdominal pain.
The nature of the pain was difficult to describe, and the symptoms gradually worsened, accompanied by tenesmus, and diarrhea twice.
Physical examination revealed a drop in oxygen partial pressure, extensive abdominal tenderness, and weakened bowel sounds.
Emergency abdominal CT scan: small bowel obstruction, bowel wall edema, abdominal and pelvic effusion, and increased density in the superior mesenteric artery, except for embolism (see Figure 1).
Figure 1.
Plain CT scan of the abdomen to further improve the abdominal enhanced CT + superior mesenteric artery CTA: small bowel obstruction changes, stomach and small bowel edema.
Abdominal and pelvic effusion, changes in abdominal dry density, atherosclerosis? There is no obvious embolism in the superior mesenteric artery, and some branches are slightly thinner.
(See Figure 2) Figure 2.
Patients with abdominal enhanced CT + superior mesenteric artery CTA temporarily admitted to the Department of Vascular Surgery with "abdominal pain waiting to be diagnosed".
If you don’t have a clear idea, it’s okay.
Continue to look down and enter the next stage~2 multi-disciplinary consultations.
After entering the department, you will be banned from eating and drinking, gastrointestinal decompression, and active anti-infection, anticoagulation, pain relief and other treatments.
. However, the patient's abdominal pain continued to worsen, showing severe tingling, unbearable, and began to experience irritability, decreased oxygen partial pressure, shortness of breath, increased blood pressure, and increased heart rate.
Gastrointestinal surgery, gastroenterology, nephrology, and rheumatology and immunology are invited to consult in multiple disciplines, considering that the possibility of rheumatism is high, and the basis for other specialized diseases is insufficient.
So, here comes the question.
In addition to the abdominal manifestations, does the patient have any other clues? Careful observation revealed that the patient had a dark red "chilblain-like" rash on both sides of the auricle.
Detailed medical history was asked: a history of miscarriage (fetal abortion in the first trimester) and a history of "chilblain" for more than 20 years.
The case has progressed here, and it seems that the diagnosis is a bit more eye-catching.
As expected, the patient's test results returned on the second day after admission (see Table 1), which confirmed our conjecture.
Table 1 The main test indicators are summarized as follows: In summary, consider the patient's acute abdomen as systemic lupus erythematosus (SLE) mesenteric vasculitis and small bowel obstruction, combined with lupus nephritis and multiple serous effusions.
After 3 mountains and rivers reappeared, Liu Anhuaming was transferred to the Department of Rheumatology and Immunology on the second day after admission.
For treatment, diet was banned, gastrointestinal decompression was given, methylprednisolone was injected intravenously 80mg/d, gamma immunoglobulin 20g×5d, and albumin supplementation, anticoagulation, fluid replacement, nutritional support, etc.
Explain the condition to the family: SLE patients may involve the digestive system, severe cases may have gastrointestinal bleeding, and even develop acute abdomen such as intestinal necrosis and intestinal perforation.
On the 4th day after admission, the patient’s chest CT showed pericardial effusion and pleural effusion (see Figure 3).
Abdominal color Doppler ultrasound showed: effusion in the abdominal cavity and mild hydrops in both kidneys.
Figure 3.
The current diagnosis of chest CT patients on the 4th day after admission: SLE, mesenteric vasculitis, small bowel obstruction, protein-losing enteropathy, lupus nephritis, multiple serous effusion, hydronephrosis, hypoproteinemia, anemia. 4 Following the past, after intensive treatment, the symptoms of abdominal pain began to alleviate.
On the 3rd day after admission, the symptoms basically subsided; on the 6th day, the gastrointestinal decompression was stopped and the liquid diet was changed; on the 8th day, the hemoglobin increased to 116g/L.
Lactate dehydrogenase (LDH), IgG4, C-reactive protein (CRP), erythrocyte sedimentation rate were normal, microalbumin/creatinine decreased from 424.
31 to 162.
3, anticardiolipin antibody was negative, and lupus anticoagulant was positive.
One week after admission, the patient began to eat and move normally, and the hormones were gradually reduced.
Before discharge, he was changed to oral hormones, plus hydroxychloroquine and mycophenolate mofetil.
No gastrointestinal symptoms reappeared.
The abdominal enhanced CT was repeated.
The patient's intestinal tract Edema, intestinal obstruction, and abdominal and pelvic effusion basically subsided (see Figure 4).
It is recommended that patients be rechecked in the rheumatology and immunology clinic for a long time and follow up regularly.
Figure 4.
Re-examination of abdominal enhanced CT case summary after treatment.
The patient was admitted to hospital with acute abdominal pain.
The abdominal pain became progressively worse, accompanied by nausea, vomiting, and low-grade fever.
Enhanced CT indicated thickening of the intestinal wall, abnormal enhancement, and mesenteric vascular filling.
In addition, the patient has a history of miscarriage, a dark red skin rash on the auricle, positive antinuclear antibodies, decreased complement C3, increased IgG, positive antibodies for nRNP/Sm, PM-Scl, and pANCA, positive for lupus anticoagulant, and obvious D-dimer Elevated, urinary protein is positive, LDH is slightly elevated, hypoalbuminemia and anemia, and multiple serous effusions.
In summary, considering the diagnosis of SLE, he was treated with hormones and gamma globules combined with immunosuppressive agents and significantly improved without recurrence.
In this case, the acute abdomen of the young women is outstanding and does not have specificity.
Moreover, gastrointestinal symptoms are not one of the diagnostic criteria for SLE.
SLE has no gastrointestinal specific antibodies, and early diagnosis is difficult.
In previous reports, patients with SLE had acute abdominal pain or diarrhea as the first symptoms, and went to general surgery, emergency department or gastroenterology department.
Misdiagnosis and treatment were often encountered.
Some patients even died due to missed diagnosis and treatment.
If not treated promptly and effectively, it can lead to intestinal ischemia with bleeding, gastrointestinal perforation, sepsis, and even diffuse intestinal necrosis.
The condition is dangerous.
The fatality rate of SLE combined with acute abdominal pain is up to 50%. The Department of Rheumatology and Immunology is a young subject with a late start.
The current understanding of rheumatic immune diseases is still limited, and the rate of missed diagnosis and misdiagnosis is high.
Seeing both trees and forest: From acute abdomen to rheumatic immune disease, we need to understand the manifestations of gastrointestinal lesions related to connective tissue diseases.
The pathological basis of SLE is vasculitis, which can lead to mild symptoms such as abdominal pain, diarrhea, nausea, vomiting, and loss of appetite, as well as mesenteric vasculitis, acute pancreatitis, pseudo-intestinal obstruction, serositis, ascites, and protein-losing bowel.
Sickness etc.
SLE with acute abdomen as the first manifestation is not common in clinical practice, and the prevalence is between 0.
2% and 9.
7%.
Early diagnosis and timely treatment are very important to improve the prognosis of patients with rheumatism.
In clinical work, attention should be paid to a comprehensive physical examination and detailed medical history.
SLE can affect multiple systems, and the initial manifestations are also diverse.
This patient was diagnosed early and received timely treatment, and the prognosis has been significantly improved.
It also suggests that multidisciplinary collaboration can help improve the survival rate of rheumatism patients.
References: [1]Paul T.
Kröner, Tolaymat OA, Bowman AW, et al.
Gastrointestinal Manifestations of Rheumatological Diseases[J].
American Journal of Gastroenterology, 2019:1.
[2] Lv Liangjing, Lin Yanwei.
Pay attention to systemic erythema Gastrointestinal involvement of lupus[J].
Chinese Journal of Digestion, 2020, 40(05):289-291.
A 30-year-old woman with acute abdomen was admitted to the hospital.
The clues are rather secret, but there is only one truth.
Have you guessed it? The new issue of the wind bill is finalized, waiting for you to judge ~ the case after the first visit, the dangerous situation patient is a 30-year-old female, married, due to "abdominal pain with vomiting for 1 day, aggravated by 3 hours", the emergency department was admitted to the hospital.
The patient had epigastric pain without obvious precipitating cause, presenting paroxysmal tingling, accompanied by nausea and vomiting.
The vomit content was the content.
There was no history of repeated fever, rash, arthritis, oral ulcers and hair loss, chest tightness, and palpitation.
And other symptoms.
Three hours ago, the patient's abdominal pain area expanded compared with the previous one, and the patient began to experience total abdominal pain.
The nature of the pain was difficult to describe, and the symptoms gradually worsened, accompanied by tenesmus, and diarrhea twice.
Physical examination revealed a drop in oxygen partial pressure, extensive abdominal tenderness, and weakened bowel sounds.
Emergency abdominal CT scan: small bowel obstruction, bowel wall edema, abdominal and pelvic effusion, and increased density in the superior mesenteric artery, except for embolism (see Figure 1).
Figure 1.
Plain CT scan of the abdomen to further improve the abdominal enhanced CT + superior mesenteric artery CTA: small bowel obstruction changes, stomach and small bowel edema.
Abdominal and pelvic effusion, changes in abdominal dry density, atherosclerosis? There is no obvious embolism in the superior mesenteric artery, and some branches are slightly thinner.
(See Figure 2) Figure 2.
Patients with abdominal enhanced CT + superior mesenteric artery CTA temporarily admitted to the Department of Vascular Surgery with "abdominal pain waiting to be diagnosed".
If you don’t have a clear idea, it’s okay.
Continue to look down and enter the next stage~2 multi-disciplinary consultations.
After entering the department, you will be banned from eating and drinking, gastrointestinal decompression, and active anti-infection, anticoagulation, pain relief and other treatments.
. However, the patient's abdominal pain continued to worsen, showing severe tingling, unbearable, and began to experience irritability, decreased oxygen partial pressure, shortness of breath, increased blood pressure, and increased heart rate.
Gastrointestinal surgery, gastroenterology, nephrology, and rheumatology and immunology are invited to consult in multiple disciplines, considering that the possibility of rheumatism is high, and the basis for other specialized diseases is insufficient.
So, here comes the question.
In addition to the abdominal manifestations, does the patient have any other clues? Careful observation revealed that the patient had a dark red "chilblain-like" rash on both sides of the auricle.
Detailed medical history was asked: a history of miscarriage (fetal abortion in the first trimester) and a history of "chilblain" for more than 20 years.
The case has progressed here, and it seems that the diagnosis is a bit more eye-catching.
As expected, the patient's test results returned on the second day after admission (see Table 1), which confirmed our conjecture.
Table 1 The main test indicators are summarized as follows: In summary, consider the patient's acute abdomen as systemic lupus erythematosus (SLE) mesenteric vasculitis and small bowel obstruction, combined with lupus nephritis and multiple serous effusions.
After 3 mountains and rivers reappeared, Liu Anhuaming was transferred to the Department of Rheumatology and Immunology on the second day after admission.
For treatment, diet was banned, gastrointestinal decompression was given, methylprednisolone was injected intravenously 80mg/d, gamma immunoglobulin 20g×5d, and albumin supplementation, anticoagulation, fluid replacement, nutritional support, etc.
Explain the condition to the family: SLE patients may involve the digestive system, severe cases may have gastrointestinal bleeding, and even develop acute abdomen such as intestinal necrosis and intestinal perforation.
On the 4th day after admission, the patient’s chest CT showed pericardial effusion and pleural effusion (see Figure 3).
Abdominal color Doppler ultrasound showed: effusion in the abdominal cavity and mild hydrops in both kidneys.
Figure 3.
The current diagnosis of chest CT patients on the 4th day after admission: SLE, mesenteric vasculitis, small bowel obstruction, protein-losing enteropathy, lupus nephritis, multiple serous effusion, hydronephrosis, hypoproteinemia, anemia. 4 Following the past, after intensive treatment, the symptoms of abdominal pain began to alleviate.
On the 3rd day after admission, the symptoms basically subsided; on the 6th day, the gastrointestinal decompression was stopped and the liquid diet was changed; on the 8th day, the hemoglobin increased to 116g/L.
Lactate dehydrogenase (LDH), IgG4, C-reactive protein (CRP), erythrocyte sedimentation rate were normal, microalbumin/creatinine decreased from 424.
31 to 162.
3, anticardiolipin antibody was negative, and lupus anticoagulant was positive.
One week after admission, the patient began to eat and move normally, and the hormones were gradually reduced.
Before discharge, he was changed to oral hormones, plus hydroxychloroquine and mycophenolate mofetil.
No gastrointestinal symptoms reappeared.
The abdominal enhanced CT was repeated.
The patient's intestinal tract Edema, intestinal obstruction, and abdominal and pelvic effusion basically subsided (see Figure 4).
It is recommended that patients be rechecked in the rheumatology and immunology clinic for a long time and follow up regularly.
Figure 4.
Re-examination of abdominal enhanced CT case summary after treatment.
The patient was admitted to hospital with acute abdominal pain.
The abdominal pain became progressively worse, accompanied by nausea, vomiting, and low-grade fever.
Enhanced CT indicated thickening of the intestinal wall, abnormal enhancement, and mesenteric vascular filling.
In addition, the patient has a history of miscarriage, a dark red skin rash on the auricle, positive antinuclear antibodies, decreased complement C3, increased IgG, positive antibodies for nRNP/Sm, PM-Scl, and pANCA, positive for lupus anticoagulant, and obvious D-dimer Elevated, urinary protein is positive, LDH is slightly elevated, hypoalbuminemia and anemia, and multiple serous effusions.
In summary, considering the diagnosis of SLE, he was treated with hormones and gamma globules combined with immunosuppressive agents and significantly improved without recurrence.
In this case, the acute abdomen of the young women is outstanding and does not have specificity.
Moreover, gastrointestinal symptoms are not one of the diagnostic criteria for SLE.
SLE has no gastrointestinal specific antibodies, and early diagnosis is difficult.
In previous reports, patients with SLE had acute abdominal pain or diarrhea as the first symptoms, and went to general surgery, emergency department or gastroenterology department.
Misdiagnosis and treatment were often encountered.
Some patients even died due to missed diagnosis and treatment.
If not treated promptly and effectively, it can lead to intestinal ischemia with bleeding, gastrointestinal perforation, sepsis, and even diffuse intestinal necrosis.
The condition is dangerous.
The fatality rate of SLE combined with acute abdominal pain is up to 50%. The Department of Rheumatology and Immunology is a young subject with a late start.
The current understanding of rheumatic immune diseases is still limited, and the rate of missed diagnosis and misdiagnosis is high.
Seeing both trees and forest: From acute abdomen to rheumatic immune disease, we need to understand the manifestations of gastrointestinal lesions related to connective tissue diseases.
The pathological basis of SLE is vasculitis, which can lead to mild symptoms such as abdominal pain, diarrhea, nausea, vomiting, and loss of appetite, as well as mesenteric vasculitis, acute pancreatitis, pseudo-intestinal obstruction, serositis, ascites, and protein-losing bowel.
Sickness etc.
SLE with acute abdomen as the first manifestation is not common in clinical practice, and the prevalence is between 0.
2% and 9.
7%.
Early diagnosis and timely treatment are very important to improve the prognosis of patients with rheumatism.
In clinical work, attention should be paid to a comprehensive physical examination and detailed medical history.
SLE can affect multiple systems, and the initial manifestations are also diverse.
This patient was diagnosed early and received timely treatment, and the prognosis has been significantly improved.
It also suggests that multidisciplinary collaboration can help improve the survival rate of rheumatism patients.
References: [1]Paul T.
Kröner, Tolaymat OA, Bowman AW, et al.
Gastrointestinal Manifestations of Rheumatological Diseases[J].
American Journal of Gastroenterology, 2019:1.
[2] Lv Liangjing, Lin Yanwei.
Pay attention to systemic erythema Gastrointestinal involvement of lupus[J].
Chinese Journal of Digestion, 2020, 40(05):289-291.
