A 22yearold woman with a history of systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome on chronic immunosuppression and anticoagulation presented with one week of postprandial upper abdominal pain and fevers. Her vital signs were unremarkable and her abdominal exam was benign. Abdominal CT revealed multiple gallstones without evidence of cholecystitis. With concerns for choledocholithiasis, she underwent an uncomplicated laparoscopic cholecystectomy with improvement in her abdominal pain and fevers. On postoperative day 4, in the setting of a supratherapeutic heparin drip, she became hemodynamically unstable and was found to have a large intraperitoneal bleed. Hemostasis was achieved by splenic artery embolization. Visceral angiography revealed a previously undiagnosed panvasculitis with hundreds of pseudoaneurysms of small, medium, and large mesenteric arteries. The pathology of her gallbladder revealed chronic cholecystitis and active small and medium vessel vasculitis. Given evidence of severe, active vasculitis, she was treated with a course of highdose cyclophosphamide. Unfortunately, she failed to respond to aggressive therapy and developed recurrent small bowel ischemia from vasculitis. Eight weeks into her hospital course, she became pulseless and unresponsive and was unable to be revived despite prolonged cardiopulmonary resuscitation. Autopsy revealed multiple pseudoaneurysms and evidence of treated panvasculitis involving multiple abdominal vessels.
Hospitalists may face patients with lupus who present with abdominal pain and should recognize that mesenteric vasculitis is a common cause. While lupus mesenteric vasculitis (LMV) affects a minority of SLE patients, it actually accounts for more than half of patients with active SLE who present with acute abdominal pain. LMV is typically a small vessel vasculitis, thought to be secondary to immunecomplex deposition in vessel walls and/or thrombotic events caused by antiphospholipid antibodies. Medical management involves highdose IV steroid therapy, however cyclophosphamide can be used in steroidrefractory patients. Infrequent, severe sequelae of LMV include bowel ischemia and perforation, which often require surgical intervention.
LMV affects a minority of SLE patients, but should be kept high on the differential diagnosis when patients present with acute abdominal pain. Bowel ischemia caused by LMV can lead to perforation and hemorrhage, and has a high mortality of up to 50%.
Figure 1Visceral angiogram showing hundreds of pseudoaneurysms of small, medium and large mesenteric arteries.
To cite this abstract:Waltman B, Rennke S, Gaeta S, Kesh S. Not Just the Joints: Abdominal Pain in Lupus. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 98025. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/not-just-the-joints-abdominal-pain-in-lupus/. Accessed November 22, 2019.