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Progressive Acute Abdominal Pain

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 50s with a history of systemic lupus erythematosus, congestive heart failure, and type 2 diabetes presented to the emergency department with worsening abdominal pain 1 day after discharge from an admission for similar abdominal pain. The patient described a 4-day history of progressively worsening abdominal pain and diarrhea and denied fevers, chills, diaphoresis, or any previous similar episodes. Her abdomen was distended and mildly tender, and her pain was disproportionate to the findings of her physical examination. There were no abnormal laboratory test findings. The abdominal computed tomography (CT) scan from her initial admission (Figure, A) and the abdominal CT angiogram on readmission (Figure, B) showed dramatic progression of her disease.

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C. Lupus enteritis

The patient was admitted to the medical intensive care unit. A rheumatology consultation was obtained, and she was given intravenous methyprednisolone, 1000 mg daily, for 4 days. The patient’s abdominal pain improved within 8 hours of methyprednisolone administration, and by hospital day 2, she was tolerating a diet of solid food.

Systemic lupus erythematosus is an autoimmune-mediated chronic inflammatory disease with the potential to affect every organ system.1 Systemic lupus erythematosus affects the hematologic, renal, and central nervous systems most commonly, and presentations can be variable.1 Enteritis is a relatively rare sequela of systemic lupus erythematosus, typically presenting with signs and symptoms similar to those of mesenteric ischemia, with pain out of proportion to the findings on physical examination.2 In some studies, lupus enteritis is referred to as the most frequent possible cause of abdominal pain in patients with systemic lupus erythematosus2; alternatively, in other studies, lupus enteritis is cited as a relatively rare cause of abdominal pains, illustrating our lack of knowledge about this disease secondary to its relative rarity.3 Laboratory test findings are nonspecific and usually positive only for inflammatory markers.4 Computed tomography scans demonstrate severe bowel wall thickening (ie, target sign). Mesenteric fat stranding and engorged mesenteric vessels are also commonly observed.5 Bladder wall thickening is frequently found on CT scans. The patient also presented with a moderate degree of ascites.

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Article Information

Corresponding Author: Daniel J. Gross, MD, Department of Surgery, State University of New York University Hospital of Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 (daniel.gross@downstate.edu).

Published Online: October 18, 2017. doi:10.1001/jamasurg.2017.3838

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Tan  EM, Cohen  AS, Fries  JF,  et al.  The 1982 revised criteria for the classification of systemic lupus erythematosus.  Arthritis Rheum. 1982;25(11):1271-1277.PubMedGoogle ScholarCrossref
2.
al-Hakeem  MS, McMillen  MA.  Evaluation of abdominal pain in systemic lupus erythematosus.  Am J Surg. 1998;176(3):291-294.PubMedGoogle ScholarCrossref
3.
Medina  F, Ayala  A, Jara  LJ, Becerra  M, Miranda  JM, Fraga  A.  Acute abdomen in systemic lupus erythematosus: the importance of early laparotomy.  Am J Med. 1997;103(2):100-105.PubMedGoogle ScholarCrossref
4.
Janssens  P, Arnaud  L, Galicier  L,  et al.  Lupus enteritis: from clinical findings to therapeutic management.  Orphanet J Rare Dis. 2013;8(67):67.PubMedGoogle ScholarCrossref
5.
Byun  JY, Ha  HK, Yu  SY,  et al.  CT features of systemic lupus erythematosus in patients with acute abdominal pain: emphasis on ischemic bowel disease.  Radiology. 1999;211(1):203-209.PubMedGoogle ScholarCrossref
6.
Smith  LW, Petri  M.  Lupus enteritis: an uncommon manifestation of systemic lupus erythematosus.  J Clin Rheumatol. 2013;19(2):84-86.PubMedGoogle ScholarCrossref
7.
Koo  BS, Hong  S, Kim  YJ, Kim  Y-G, Lee  C-K, Yoo  B.  Lupus enteritis: clinical characteristics and predictive factors for recurrence.  Lupus. 2015;24(6):628-632.PubMedGoogle ScholarCrossref
8.
Kim  YG, Ha  HK, Nah  SS, Lee  C-K, Moon  H-B, Yoo  B.  Acute abdominal pain in systemic lupus erythematosus: factors contributing to recurrence of lupus enteritis.  Ann Rheum Dis. 2006;65(11):1537-1538.PubMedGoogle ScholarCrossref
9.
Yuan  S, Ye  Y, Chen  D,  et al.  Lupus mesenteric vasculitis: clinical features and associated factors for the recurrence and prognosis of disease.  Semin Arthritis Rheum. 2014;43(6):759-766.PubMedGoogle ScholarCrossref
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