Gut and Liver 2016; 10(4): 542-548 https://doi.org/10.5009/gnl15198 Endoscopic Findings of Upper Gastrointestinal Involvement in Primary Vasculitis
Author Information
Eun Jeong Gong1, Do Hoon Kim1, Joo Hyun Chun1, Ji Yong Ahn1, Kwi-Sook Choi1, Kee Wook Jung1, Jeong Hoon Lee1, Kee Don Choi1, Ho June Song1, Gin Hyug Lee1, Hwoon-Yong Jung1, Jin Ho Kim1, In Hye Song2, and Yong-Gil Kim3
1Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, 2Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, 3Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to: Do Hoon Kim, Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea, Tel: +82-2-3010-3193, Fax: +82-2-476-0824, E-mail: dohoon.md@gmail.com
© The Korean Society of Gastroenterology, the Korean Society of Gastrointestinal Endoscopy, the Korean Society of Neurogastroenterology and Motility, Korean College of Helicobacter and Upper Gastrointestinal Research, Korean Association the Study of Intestinal Diseases, the Korean Association for the Study of the Liver, Korean Pancreatobiliary Association, and Korean Society of Gastrointestinal Cancer. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Background/Aims

Gastrointestinal involvement in vasculitis may result in life-threatening complications. However, its variable clinical presentations and endoscopic features, and the rarity of the disease, often result in delayed diagnosis.

Methods

Clinical characteristics, endoscopic features, and histopathological findings were reviewed from medical records.

Results

Of 6,477 patients with vasculitis, 148 were diagnosed as primary vasculitis with upper gastrointestinal involvement. Of these, 21 cases (14.2%) were classified as large-vessel vasculitis, 17 cases (11.5%) as medium-vessel vasculitis, and 110 cases (74.3%) as small-vessel vasculitis. According to the specific diagnosis, IgA vasculitis (Henoch-Schönlein purpura) was the most common diagnosis (56.8%), followed by Takayasu arteritis (14.1%), microscopic polyangiitis (10.1%), and polyarteritis nodosa (6.8%). Gastrointestinal symptoms were present in 113 subjects (76.4%), with abdominal pain (78.8%) the most common symptom. Erosion and ulcers were striking endoscopic features, and the second portion of the duodenum was the most frequently involved site. Biopsy specimens were obtained from 124 patients, and only eight (5.4%) presented histopathological signs of vasculitis.

Conclusions

Diagnosis of vasculitis involving the upper gastrointestinal tract is difficult. Because of the widespread use of endoscopy, combining clinical features with endoscopic findings may facilitate making appropriate diagnoses; however, the diagnostic yield of endoscopic biopsy is low.

Keywords: Vasculitis, Gastrointestinal tract, Endoscopy
Abstract

Background/Aims

Gastrointestinal involvement in vasculitis may result in life-threatening complications. However, its variable clinical presentations and endoscopic features, and the rarity of the disease, often result in delayed diagnosis.

Methods

Clinical characteristics, endoscopic features, and histopathological findings were reviewed from medical records.

Results

Of 6,477 patients with vasculitis, 148 were diagnosed as primary vasculitis with upper gastrointestinal involvement. Of these, 21 cases (14.2%) were classified as large-vessel vasculitis, 17 cases (11.5%) as medium-vessel vasculitis, and 110 cases (74.3%) as small-vessel vasculitis. According to the specific diagnosis, IgA vasculitis (Henoch-Schönlein purpura) was the most common diagnosis (56.8%), followed by Takayasu arteritis (14.1%), microscopic polyangiitis (10.1%), and polyarteritis nodosa (6.8%). Gastrointestinal symptoms were present in 113 subjects (76.4%), with abdominal pain (78.8%) the most common symptom. Erosion and ulcers were striking endoscopic features, and the second portion of the duodenum was the most frequently involved site. Biopsy specimens were obtained from 124 patients, and only eight (5.4%) presented histopathological signs of vasculitis.

Conclusions

Diagnosis of vasculitis involving the upper gastrointestinal tract is difficult. Because of the widespread use of endoscopy, combining clinical features with endoscopic findings may facilitate making appropriate diagnoses; however, the diagnostic yield of endoscopic biopsy is low.

Keywords: Vasculitis, Gastrointestinal tract, Endoscopy
INTRODUCTION

Vasculitis is an inflammatory disease of blood vessels, which alter vascular blood flow and can damage dependent organs.1,2 The clinical course of vasculitis is variable and depends on the size and type of vessels affected. The clinical manifestations of vasculitis with gastrointestinal involvement range from mild symptoms to life threatening complications such as perforation, acute mesenteric ischemia, and bowel infarction.3,4 Therefore, accurate diagnosis and early treatment are mandatory to avoid a poor prognosis, and endoscopic examination helps to identify the site and extent of involvement and assess prognosis.

Diagnosis of gastrointestinal involvement of vasculitis is difficult and often relies on comprehensive investigations including clinical features, laboratory data, radiologic evaluation, and histopathological examination.58 Suspicion based on clinical manifestations, notably the presence of gastrointestinal symptoms, is important. However, gastrointestinal manifestations are variable, and this can make diagnosis more difficult. In such cases endoscopic examination may be performed to define the extent and nature of the lesion, and endoscopic biopsy might give a clue for diagnosis. We therefore investigated the clinical features of vasculitis with upper gastrointestinal (UGI) involvement, especially from the point of view of endoscopic findings.

MATERIALS AND METHODS

A total of 6,477 subjects diagnosed as vasculitis at the Asan Medical Center from June 1990 to July 2013 were eligible. Clinical characteristics, endoscopic features, and histopathologic findings were reviewed from medical records.

Primary vasculitis was defined according to the criteria proposed by the American College of Rheumatology and Chapel Hill Consensus Conference nomenclature.9 Gastrointestinal involvement of vasculitis was defined as follows: (1) gastrointestinal symptoms that present at the time of the diagnosis of vasculitis and respond to specific therapy for vasculitis; (2) gastrointestinal symptoms that occur during a relapse or flare-up of vasculitis and respond to specific therapy for vasculitis; and/or (3) gastrointestinal involvement considered to be associated with vasculitis based on radiologic findings, endoscopic findings, or histopathological examination. Vasculitis is further classified by the size of vessels usually affected; large-sized, medium-sized, or small-sized arteries. Behçet’s disease is vasculitis affect vessels of any size and regarded as primary vasculitis rather than vasculitis associated with systemic disease because of the frequency of vasculitis. However, we excluded Behçet’s disease in the analyses because there have been several reports regarding the endoscopic features of Behçet’s disease.10,11

Endoscopy was performed in cases of clinically suspected gastrointestinal tract involvement, and biopsy specimens were taken upon endoscopists’ suspicion. Symptoms were categorized as abdominal pain, nausea or vomiting, diarrhea, and gastrointestinal bleeding. This study was approved by the Institutional Review Board of the Asan Medical Center (2014–0255).

RESULTS

1. Clinical characteristics of patients with vasculitis involving the upper gastrointestinal tract

During the study period, 912 of 6,477 subjects diagnosed as vasculitis underwent endoscopic examination, and a total of 148 patients were diagnosed as primary vasculitis with UGI involvement. The median age of these 148 patients was 49 years (interquartile range, 13 to 65 years) and the male-to-female ratio was 0.97:1. IgA vasculitis (Henoch-Schönlein purpura [HSP]) was the most common diagnosis (n=84, 56.8%), followed by Takayasu arteritis (n=21, 14.1%), microscopic polyangiitis (n=15, 10.1%), and polyarteritis nodosa (n=10, 6.8%). Three patients died before a specific diagnosis was made; they were classified as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis which includes granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis), eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss syndrome). The characteristics of these patients are summarized in Table 1.

Gastrointestinal symptoms were present in 113 of the patients (76.4%). Abdominal pain was the most common symptom (n=89, 78.8%), and 43 patients (38.1%) had gastrointestinal bleeding such as melena, hematochezia, and hematemesis. Thirty-five patients (23.6%) had systemic symptoms including dyspnea, chest pain, headache, or peripheral edema. Symptoms were improved by the treatment for the vasculitis, and some symptoms even resolved without specific therapy, especially in patients with HSP.

2. Endoscopic findings

Endoscopic examination was performed in advance to the diagnosis of vasculitis was made in 22 cases (14.9%). Otherwise, endoscopic examination was performed in patients with clinical features suspicious of vasculitis or patients already diagnosed as vasculitis. Endoscopic findings included erosion, petechiae, nodular change, edema, submucosal hemorrhage, nodularity, and ulcer (Figs 13). Since some of these features can be due to abnormalities of mixed nature, more than one finding could be encountered in a single patient. Nonspecific inflammatory changes such as gastritis, esophagitis, and duodenitis were common (77.7%), however, we did not include these findings as endoscopic manifestations because they are common in the general population and their origin is ill-defined. Erosion and ulcer were striking features of vasculitis, and the second portion of the duodenum and gastric antrum were the most frequent sites involved. Stricture was found in four patients; in three cases in the duodenum, and one case in the jejunum. Endoscopic examination revealed no specific abnormality in six patients. Detailed data on these patients are presented in Table 2.

Biopsy specimens were obtained in 124 subjects. Histopathologic examination of the biopsy specimens revealed signs of vasculitis in only eight patients (5.4%); seven patients with duodenal involvement of the HSP and one patient with granulomatous angiitis presenting as gastric ulcer (Figs 4 and 5). The median number of biopsy specimens was three in these eight patients. The biopsy specimens of the other patients revealed nonspecific inflammation only.

DISCUSSION

In the present study, we investigated the clinical features of primary vasculitis with UGI involvement. Of 148 patients, 113 patients (76.4%) had gastrointestinal symptoms including abdominal pain and gastrointestinal bleeding. Endoscopic examination during diagnosis revealed erosion, petechiae, submucosal hemorrhage or ulcers in 142 (95.9%) of the patients, and the second portion of the duodenum was the site most frequently involved. Endoscopic examination played important role for establishing the diagnosis of vasculitis in only 22 patients (14.9%) and the diagnostic yield of endoscopic biopsy was low.

Gastrointestinal involvement of vasculitis has been reported variously depending on the diagnosis of vasculitis; 50% to 85% for HSP, 14% to 65% for polyarteritis nodosa, 3% to 71% for ANCA-associated vasculitis, and 1% to 15% for Takayasu arteritis.1218 Gastrointestinal symptoms were mainly acute abdominal pain, but other symptoms including nausea or vomiting, diarrhea, and gastrointestinal bleeding can be presenting symptoms.14,1921 In addition, gastric outlet obstruction, intussusception, and duodenal necrosis have been reported.22,23 In our study, the most common primary vasculitis with UGI involvement was HSP (56.8%) and 76.4% of patients with primary vasculitis had gastrointestinal symptoms, abdominal pain being the most common.

The endoscopic findings commonly described in systemic vasculitis are diffuse redness, petechiae, hemorrhagic erosion, nodular change, and ulcer.16,19,24 The specific appearance of lesions and their site preference are important clues that can help differentiate vasculitis from peptic ulcer or drug-induced ulcer. However, the variable clinical presentation and endoscopic features of UGI involvement of systemic vasculitis, and the rarity of the disease, often result in delayed diagnosis. In one report, duodenum and small intestine were the most frequently involved in patients with HSP, and ulcers were rare.13 In contrast, in another report, ulcers in the small bowel including duodenum were frequent in these patients.19 In our study, the ulcers caused by vasculitis were usually multiple, irregular, and uneven based, and duodenal involvement of the vasculitis usually presented as submucosal hemorrhage, mucosal congestion, and multiple ulcers in the second portion of the duodenum. Recognizing these features in such clinical settings may provide clues to the diagnosis of vasculitis. However, the role of endoscopic examination is still limited.

The clinical presentation of gastrointestinal vasculitis may be life-threatening because of complications such as severe ischemia, infarction, and perforation. Gastrointestinal involvement of systemic vasculitis has been reported to be associated with severe complications and poor outcomes especially in patients with polyarteritis nodosa, microscopic angiitis, and granulomatosis with polyangiitis.14,2528 Therefore, accurate diagnosis and early treatment is important to avoid fatal outcomes, and endoscopic examination helps to define the site and extent of involvement and to assess prognosis. However, the diagnosis of vasculitis is difficult and endoscopic findings do not always correlate with presenting symptoms. In addition, endoscopic biopsy has low sensitivity to diagnose vasculitis.3,29,30 In one study, biopsy specimens were taken from 23 patients, and none of the UGI biopsies showed evidence of vasculitis whereas lower gastrointestinal tract biopsies revealed signs of vasculitis in three of six patients.21 In agreement with these reports, the diagnostic yield of endoscopic biopsy was 5.4% in this study. This is because most biopsies are limited to the superficial mucosa.10,12,20,31 Endoscopic examination could not be used to exclude UGI involvement of primary vasculitis but to exclude other diseases.32 In addition, the diagnosis of vasculitis should be made with consideration of all clinical and pathologic information, and neither of these findings should be interpreted in isolation.

Our study has several limitations. First, there may be a selection bias because endoscopic examination and endoscopic biopsies were performed upon the decision of the attending physician. In addition, the large proportion of patients were HSP, and this could lead to bias. Second, many factors can be associated with the occurrence of inflammatory changes and ulcers, including Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs. Finally, since the study was retrospective study, most patients did not undergo follow-up endoscopy, and we could not investigate the clinical course of these lesions.

In conclusion, the diagnosis of vasculitis with UGI involvement is difficult. With the wider use of endoscopy, the combination of clinical or radiological features with endoscopic findings may help to make accurate diagnoses; however, the diagnostic yield of endoscopic biopsy is low.

Figures
Fig. 1. Endoscopic findings of the esophageal involvement of vasculitis. (A) Erosion and petichia. (B) Submucosal hemorrhage. (C) Multiple, large geographic ulcers on the esophageal body.
Fig. 2. Endoscopic findings of gastric involvement of vasculitis. (A) Multiple erosions on the antrum. (B) Scattered petechia on the greater curvature of the lower body. (C) Edematous mucosa with submucosal hemorrhage on the greater curvature of the high body. (D) Single deep ulcer with elevated margin on the lesser curvature of the antrum. (E) Multiple ulcers with hematins on the lesser curvature of the lower body.
Fig. 3. Endoscopic findings of duodenal involvement of vasculitis. (A) Multiple erosions on the bulb. (B) Scattered petechia on the bulb. (C) Edematous mucosal fold change on the second portion of the duodenum. (D) Submucosal hemorrhage and circular ulcer on the bulb. (E) Diffuse nodular change of the second portion of the duodenum. (F) Single ulcer on the bulb. (G) Multiple circular ulcers with mucosal hyperemia on the second portion of the duodenum.
Fig. 4. Representative microscopic images of a small bowel segmental resection specimen of a patient with Henoch-Sch?nlein purpura. (A) Acute and chronic transmural inflammation with hemorrhage and lymphoid hyperplasia are observed (H&E stain, ×200). (B) Neutrophilic infiltration is observed in the small-to-medium sized vessel walls (leukocytoclastic vasculitis) (H&E stain, ×400).
Fig. 5. Pathological findings in a stomach wedge resection specimen of a patient with allergic granulomatous angiitis. (A) Eosinophilic infiltration is evident in small, medium, and large-sized vessels (eosinophilic vasculitis) (H&E stain, ×40). (B) There is diffuse and marked eosinophilic infiltration in the gastric wall (H&E stain, ×200).
Tables

Clinical Characteristics of Patients with Primary Vasculitis with Upper Gastrointestinal Involvement

CharacteristicValue
Age, yr49 (13–65)
Male sex73 (49.3)
Classification of vasculitis
 Large-vessel vasculitis
  Takayasu arteritis21 (14.1)
 Medium-vessel vasculitis
  Polyarteritis nodosa10 (6.8)
  Kawasaki disease7 (4.7)
 Small-vessel vasculitis
  ANCA-associated vasculitis3 (2.0)
  Granulomatosis with polyangiitis (Wegener’s)7 (4.7)
  Microscopic polyangiitis15 (10.1)
  Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)1 (0.7)
  IgA vasculitis (Henoch-Schönlein)84 (56.8)
Symptoms*113 (76.3)
 Abdominal pain89 (78.8)
 Gastrointestinal bleeding43 (38.1)
 Nausea or vomiting18 (15.9)
 Diarrhea4 (3.5)

Data are presented as median (interquartile range) or number (%).

ANCA, antineutrophil cytoplasmic antibody.

*The sum exceeds 100% because multiple symptoms were possible.

Endoscopic Findings of Vasculitis

ErosionPetechiaeEdemaSubmucosal hemorrhageNodularityUlcer

SingleMultiple
Esophagus1101006
Stomach
 Antrum489320513
 Body23936056
 Fundus6623001
Duodenum
 Bulb23344169
 2nd portion24519139128
 3rd portion42964012
Jejunum0020002
References
  1. Babian, M, Nasef, S, and Soloway, G (1998). Gastrointestinal infarction as a manifestation of rheumatoid vasculitis. Am J Gastroenterol. 93, 119-120.
    Pubmed CrossRef
  2. Bailey, M, Chapin, W, Licht, H, and Reynolds, JC (1998). The effects of vasculitis on the gastrointestinal tract and liver. Gastroenterol Clin North Am. 27, 747-782.
    CrossRef
  3. Collins, DA, and Duke, O (1995). Systemic vasculitis presenting with massive bowel infarction. J R Soc Med. 88, 692-693.
    Pubmed KoreaMed
  4. Mosley, JG, Desai, A, and Gupta, I (1990). Mesenteric arteritis. Gut. 31, 956-957.
    Pubmed KoreaMed CrossRef
  5. Fraioli, P, Barberis, M, and Rizzato, G (1994). Gastrointestinal presentation of Churg Strauss syndrome. Sarcoidosis. 11, 42-45.
    Pubmed
  6. Gayraud, M, Guillevin, L, and le Toumelin, P (2001). Long-term followup of polyarteritis nodosa, microscopic polyangiitis, and Churg-Strauss syndrome: analysis of four prospective trials including 278 patients. Arthritis Rheum. 44, 666-675.
    Pubmed CrossRef
  7. G?n?reau, T, Lortholary, O, Royer, I, Lhote, F, Darras-Joly, C, and Guillevin, L (1997). Digestive manifestations of periarteritis nodosa. Gastroenterol Clin Biol. 21, 503-510.
  8. Pinkney, JH, Clarke, G, and Fairclough, PD (1991). Gastrointestinal involvement in Wegener’s granulomatosis. Gastrointest Endosc. 37, 411-412.
    Pubmed CrossRef
  9. Jennette, JC, Falk, RJ, and Bacon, PA (2013). 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum. 65, 1-11.
    CrossRef
  10. Hokama, A, Kishimoto, K, and Ihama, Y (2012). Endoscopic and radiographic features of gastrointestinal involvement in vasculitis. World J Gastrointest Endosc. 4, 50-56.
    Pubmed KoreaMed CrossRef
  11. Ebert, EC (2009). Gastrointestinal manifestations of Beh?et’s disease. Dig Dis Sci. 54, 201-207.
    CrossRef
  12. Ahn, E, Luk, A, Chetty, R, and Butany, J (2009). Vasculitides of the gastrointestinal tract. Semin Diagn Pathol. 26, 77-88.
    Pubmed CrossRef
  13. Esaki, M, Matsumoto, T, and Nakamura, S (2002). GI involvement in Henoch-Sch?nlein purpura. Gastrointest Endosc. 56, 920-923.
    Pubmed CrossRef
  14. Latus, J, Koetter, I, and Fritz, P (2014). Gastrointestinal involvement in granulomatosis with polyangiitis and microscopic polyangiitis: histological features and outcome. Int J Rheum Dis. 17, 412-419.
    Pubmed CrossRef
  15. Lee, EL, Smith, HJ, Miller, GL, Burns, DK, and Weiner, H (1984). Ischemic pseudomembranous colitis with perforation due to polyarteritis nodosa. Am J Gastroenterol. 79, 35-38.
    Pubmed
  16. Szer, IS (1996). Henoch-Sch?nlein purpura: when and how to treat. J Rheumatol. 23, 1661-1665.
    Pubmed
  17. Ebert, EC, Hagspiel, KD, Nagar, M, and Schlesinger, N (2008). Gastrointestinal involvement in polyarteritis nodosa. Clin Gastroenterol Hepatol. 6, 960-966.
    Pubmed CrossRef
  18. Ha, HK, Lee, SH, and Rha, SE (2000). Radiologic features of vasculitis involving the gastrointestinal tract. Radiographics. 20, 779-794.
    Pubmed CrossRef
  19. Nishiyama, R, Nakajima, N, and Ogihara, A (2008). Endoscope images of Sch?nlein-Henoch purpura. Digestion. 77, 236-241.
    CrossRef
  20. Zhang, Y, and Huang, X (2008). Gastrointestinal involvement in Henoch-Sch?nlein purpura. Scand J Gastroenterol. 43, 1038-1043.
    CrossRef
  21. Pagnoux, C, Mahr, A, Cohen, P, and Guillevin, L (2005). Presentation and outcome of gastrointestinal involvement in systemic necrotizing vasculitides: analysis of 62 patients with polyarteritis nodosa, microscopic polyangiitis, Wegener granulomatosis, Churg-Strauss syndrome, or rheumatoid arthritis-associated vasculitis. Medicine (Baltimore). 84, 115-128.
    CrossRef
  22. Rathore, M, Shrivastava, R, Goyal, R, Radotra, BD, and Thapa, BR (2014). Henoch Sch?nlein purpura presenting as duodenal ulcer and gastric outlet obstruction. Indian J Pediatr. 81, 189-190.
    CrossRef
  23. Becker, A, Mader, R, Elias, M, Lev, A, and Sayfan, J (2002). Duodenal necrosis as the presenting manifestation of polyarteritis nodosa. Clin Rheumatol. 21, 314-316.
    Pubmed CrossRef
  24. Tomomasa, T, Hsu, JY, Itoh, K, and Kuroume, T (1987). Endoscopic findings in pediatric patients with Henoch-Schonlein purpura and gastrointestinal symptoms. J Pediatr Gastroenterol Nutr. 6, 725-729.
    Pubmed CrossRef
  25. Hiraike, Y, Kodaira, M, and Sano, M (2013). Polyarteritis nodosa diagnosed by surgically resected jejunal necrosis following acute abdomen. World J Gastroenterol. 19, 2830-2834.
    Pubmed KoreaMed CrossRef
  26. Shepherd, HA, Patel, C, Bamforth, J, and Isaacson, P (1983). Upper gastrointestinal endoscopy in systemic vasculitis presenting as an acute abdomen. Endoscopy. 15, 307-311.
    Pubmed CrossRef
  27. Guillevin, L, Lhote, F, and Gayraud, M (1996). Prognostic factors in polyarteritis nodosa and Churg-Strauss syndrome: a prospective study in 342 patients. Medicine (Baltimore). 75, 17-28.
    CrossRef
  28. Levine, SM, Hellmann, DB, and Stone, JH (2002). Gastrointestinal involvement in polyarteritis nodosa (1986?2000): presentation and outcomes in 24 patients. Am J Med. 112, 386-391.
    Pubmed CrossRef
  29. Wilson, RT, Dean, PJ, Upshaw, JD, and Wruble, LD (1987). Endoscopic appearance of Wegener’s granulomatosis involving the colon. Gastrointest Endosc. 33, 388-389.
    Pubmed CrossRef
  30. Leen, EJ, Rees, PJ, Sanderson, JD, Wilkinson, ML, and Filipe, MI (1996). A case of Churg-Strauss syndrome: tissue diagnosis established by sigmoidoscopic rectal biopsy. Gut. 38, 299-301.
    Pubmed KoreaMed CrossRef
  31. Ebert, EC (2008). Gastrointestinal manifestations of Henoch-Schonlein Purpura. Dig Dis Sci. 53, 2011-2019.
    Pubmed CrossRef
  32. Nov?k, J, Ottlak?n, A, and T?th, K (1995). Colonic biopsy in Henoch-Sch?nlein purpura. Gastrointest Endosc. 41, 519.
    CrossRef
Tables

Clinical Characteristics of Patients with Primary Vasculitis with Upper Gastrointestinal Involvement

CharacteristicValue
Age, yr49 (13–65)
Male sex73 (49.3)
Classification of vasculitis
 Large-vessel vasculitis
  Takayasu arteritis21 (14.1)
 Medium-vessel vasculitis
  Polyarteritis nodosa10 (6.8)
  Kawasaki disease7 (4.7)
 Small-vessel vasculitis
  ANCA-associated vasculitis3 (2.0)
  Granulomatosis with polyangiitis (Wegener’s)7 (4.7)
  Microscopic polyangiitis15 (10.1)
  Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)1 (0.7)
  IgA vasculitis (Henoch-Schönlein)84 (56.8)
Symptoms*113 (76.3)
 Abdominal pain89 (78.8)
 Gastrointestinal bleeding43 (38.1)
 Nausea or vomiting18 (15.9)
 Diarrhea4 (3.5)

Data are presented as median (interquartile range) or number (%).

ANCA, antineutrophil cytoplasmic antibody.

The sum exceeds 100% because multiple symptoms were possible.

Endoscopic Findings of Vasculitis

ErosionPetechiaeEdemaSubmucosal hemorrhageNodularityUlcer

SingleMultiple
Esophagus1101006
Stomach
 Antrum489320513
 Body23936056
 Fundus6623001
Duodenum
 Bulb23344169
 2nd portion24519139128
 3rd portion42964012
Jejunum0020002
Figures
Fig. 1. Endoscopic findings of the esophageal involvement of vasculitis. (A) Erosion and petichia. (B) Submucosal hemorrhage. (C) Multiple, large geographic ulcers on the esophageal body.
Fig. 2. Endoscopic findings of gastric involvement of vasculitis. (A) Multiple erosions on the antrum. (B) Scattered petechia on the greater curvature of the lower body. (C) Edematous mucosa with submucosal hemorrhage on the greater curvature of the high body. (D) Single deep ulcer with elevated margin on the lesser curvature of the antrum. (E) Multiple ulcers with hematins on the lesser curvature of the lower body.
Fig. 3. Endoscopic findings of duodenal involvement of vasculitis. (A) Multiple erosions on the bulb. (B) Scattered petechia on the bulb. (C) Edematous mucosal fold change on the second portion of the duodenum. (D) Submucosal hemorrhage and circular ulcer on the bulb. (E) Diffuse nodular change of the second portion of the duodenum. (F) Single ulcer on the bulb. (G) Multiple circular ulcers with mucosal hyperemia on the second portion of the duodenum.
Fig. 4. Representative microscopic images of a small bowel segmental resection specimen of a patient with Henoch-Sch?nlein purpura. (A) Acute and chronic transmural inflammation with hemorrhage and lymphoid hyperplasia are observed (H&E stain, ×200). (B) Neutrophilic infiltration is observed in the small-to-medium sized vessel walls (leukocytoclastic vasculitis) (H&E stain, ×400).
Fig. 5. Pathological findings in a stomach wedge resection specimen of a patient with allergic granulomatous angiitis. (A) Eosinophilic infiltration is evident in small, medium, and large-sized vessels (eosinophilic vasculitis) (H&E stain, ×40). (B) There is diffuse and marked eosinophilic infiltration in the gastric wall (H&E stain, ×200).
Search for
Article
Archives