Leucocytoclastic Vasculitis (Hypersensitivity Angiitis) of the Small Bowel Presenting with Severe Gastrointestinal Hemorrhage

A case of leucocytoclastic vasculitis involving theentire small bowel is reported. A high index of suspicionand recognition of the early palpable purpuric skinlesions in patients with acute abdominal pain and gas-trointestinal hemorrhage might avert unnecessary sur-gical exploration in some patients.INTRODUCTIONLeucocytoclastic vasculitis (LCV) and Henoch-Schonlein purpura (HSP) are syndromes characterizedby vasculitis ofthe postcapiUary venules and "palpablepurpura" as the clinical hallmark (1-5). Gastrointes-tinal involvement associated with vasculitis has beenwell recognized in children with HSP (7-11) and inpatients with polyarteritis nodosa (12-14), but infor-mation regarding diagnosis and management of leuco-cytoclastic vasculitis with gastrointestinal involvementis limited to few reports (I, 15-17). This report illus-trates a case of LCV with severe gastrointestinal hem-orrhage and emphasizes the systemic nature of thisdisease and urges restraint before performing explora-tory surgery on such patients.CASE REPORTA 35-yr-oId white man sustained 10% bums of hisright upper extremity after a firework accident on July4, 1984. He underwent partial and full thickness skingrafts at a local hospital. He was recovering well untilJuly 24th. when he developed crampy abdominal painassociated with nausea., vomiting, and passage of mela-notic stools per rectum. He was transferred to theUniversity of Michigan Hospitals for management.His past medical history was remarkable for hepatitis-A in 1968 and traumatic partial amputation ofthe leftfifth finger. There was no history of intravenous drugabuse or previous blood transfusions.At the time of admission to the University Hospitalhis vital signs were within normal limits except for aresting tachycardia of n6/min without orthostaticchanges. The physical examination including ausculta-tion of the chest was unremarkable. The abdominalexamination revealed mild periumbilical tendernesswithout rebound or rigidity. The rectal examinationrevealed melena and no other abnormalities.The admission laboratory findings revealed Hb of16.6 g. hematocrit 50.4%. white blood cell count of24,300/mm^ with a slight left shift, and normal plateletcount. The blood urea nitrogen was 11, creatinine 0.9,and the serum electrolytes were normal. The proteinelectrophoresis showed mild hypogammaglobulinemiaand antinuclear antibody screening was negative. Hisurinalysis showed no evidence of proteinuria.Plain abdominal radiographs revealed an abnormalloop of small bowel in the left side of the abdomenshowing thickened mucosa and thumbprinting (Fig.Iv4), scattered gas in the small bowel, and minimaldistension of the transverse colon. Upper endoscopyshowed no significant abnormality in the esophagus,stomach, and duodenum. Flexible sigmoidoscopy wasnormal up to 40 cm. A small bowel follow throughexamination revealed marked submucosal edema ofthe jejunum and proximal small bowel (Fig. \B). Theabdominal pain persisted with intermittent melanoticstools. Visceral angiography was performed on the 3rdday after admission which showed normal mesentericvasculature. Twenty-four hours after angiography hisabdominal pain became constant and increased in in-tensity. Repeat stool examination revealed bright redblood. The skin examination at ihis time revealed twopetechiae and purpuric spots on his lower extremities.His Hb dropped to 10.5 g and the hematocrit to 48%.The white blood count increased from 24,300/mm-^ to38.700/mm^ Bowel ischemia with possible infarctionwas suspected and the patient underwent exploratorylaparotomy on the 4th day after admission. At surgerythe entire small bowel was inflammed with numerousscattered patches of petechia! hemorrhages on the se-rosal surface. These changes were more severe in thejejunum and proximal small bowel. No mechanicalobstruction or mass lesion was found. The colon wasnormal and the remainder of the abdominal explora-tion was unremarkable. The bowel was viable and no