A Rare Cause of Massive Gastrointestinal Bleeding: Henoch-Schönlein Purpura

Abstract

Introduction: Henoch-Schonlein Purpura (HSP) is a vasculitis mediated by IgA immune complex. It is usually seen in children and young adults, but rarely in advanced age. Cases of gastrointestinal bleeding have been reported in the literature. While the patients with digestive system involvement presents with abdominal pain, vomiting, and melena, the findings of imaging techniques are characterized by multifocal mucosal thickening, the presence of skip areas, and mesenteric edema. In this case report, an advancedaged patient with massive gastrointestinal bleeding due to the digestive system involvement of HSP was presented. Case: A 74-year-old male patient was admitted to the emergency unit with the complaints of rash on the hands and feet, abdominal pain, and diarrhea and his physical examination revealed non-blanching maculopapular rashes on the upper and lower extremities. Hematochezia was detected in his digital rectal examination. In the laboratory analysis, the value of erythrocytes in the urine was measured as 3 (+). In hemogram, the value of leukocyte was 31000/mm3, Hgb was 12,3 gr/dl, creatinine was 7,6 mg/dl, and blood urea nitrogen was 89 mg/dl. The result of abdominal computed tomography (CT) without contrast-enhancement, which was performed for the elevated value of urea-creatinine, was reported as increased density in the mesenteric fatty tissue, hyperplasic lymph nodes (panniculitis?), and suspicious wall thickness increase in the distal of the duodenum and in the proximal of the jejunum. The patient was hospitalized in the internal diseases clinic with the pre-diagnosis of the renal and intestinal involvement of HSP, skin biopsy was taken, and steroid was started. Tachycardia and hypotension developed on the next day of hospitalization. In the physical examination, his abdomen was severely distended and the hemoglobin level was 6.7 gr/dl. In the patient whose transfusion was started, hemodynamic stability was not achieved and ultrasound examination showed no evidence of hemoperitoneum. Nasogastric catheter (NGC) was inserted and intense bile was aspirated. Contrast agent was given through NGC and CT was re-performed. It revealed that proximal small bowel was severely dilated and the lumen of the small intestine was obstructed by possible hematoma. The decision of operation was made in the patient with instable hemodynamics. Small intestines were evacuated by enterotomy from the ileum during the operation. An additional enterotomy was performed at 20 cm distal of the Treitz ligament, no bleeding was observed from the proximal loop. A Foley catheter was placed into the proximal loop and the small intestine was irrigated. Proximal enterotomy was repaired when no drainage in favor of active bleeding was observed from the distal enterotomy. The distal end was anastomosed on the abdominal wall as ileostomy. The operation was terminated and the patient was followed up in the intensive care unit. Hemoglobin levels of the patient was stable at postoperative 15th hour, but he died due to cardiopulmonary arrest. The skin biopsy taken during his hospitalization was reported to be consistent with HSP. Conclusion: HSP, which is more common in children and adolescents, is rarely seen in older ages. Gastrointestinal involvement is resistant to steroid treatment and it increases mortality especially in advanced age. In patients presenting with skin rash, renal insufficiency and gastrointestinal bleeding, HSP should be considered in differential diagnosis. Keywords: Henoch-schönlein purpura, gastrointestinal bleeding, advanced age