At this point our differential diagnoses included mesenteric/portal vein thrombosis, inflammatory bowel disease, small bowel ischemia, lupus/autoimmune enteritis, vasculitis or malignancy.
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Explore This IssueFebruary 2021
A gastroenterologist was consulted, and an abdominal ultrasound with duplex was recommended to look for Budd-Chiari syndrome, an angiogram to evaluate the mesenteric vasculature and a push enteroscopy with biopsies of the stomach and small bowel.
Paracentesis revealed a total WBC count of 498 cells/µl: 81% monocytes, 12% lymphocytes, 6% neutrophils and 1% eosinophils. The red blood cell count was 454 cells/µl, glucose 42 mg/dL, lactate dehydrogenase 169 U/L and serum-ascites albumin gradient was <1.1 g/dL. Cultures for bacteria, acid fast bacilli and fungus were negative. Cytology revealed reactive mesothelial cells and chronic inflammation, with no malignancy.
An abdominal ultrasound with duplex revealed a patent main portal vein and middle hepatic vein, with appropriate direction of flow and a moderate volume of abdominopelvic ascites. A right pleural effusion was partially visualized. The trace, right hydroureteronephrosis had improved from the prior exam.
Stool studies were negative. Her anti-dsDNA antibodies were 594 IU/mL (reference range: 0–99 IU/mL), C3 was 35 mg/dL (lower limit of normal: 88 mg/dL) and C4 was 7 mg/dL (lower limit of normal: 16 mg/dL).
A diagnosis of lupus enteritis was made, and our patient was treated with 1,000 mg of intravenous, pulse-dose methylprednisolone per day for presumed lupus enteritis and then intravenous methylprednisolone taper. With this therapy she improved clinically. She was then initiated on mycophenolate mofetil with a slow up-titration plan at discharge and a plan to start hydroxychloroquine in the outpatient setting.
Abdominal Pain in SLE
The incidence of abdominal pain in patients with SLE ranges from 8–40%.1 Common triggers are infections and medication side effects. Symptoms are often masked by treatment with glucocorticoids and/or immunosuppressive medications, which can lead to a delay in diagnosis.
Autopsy studies have shown peritonitis in 60–70% of patients with SLE, but clinically, it is described in only 10% of cases.2
Mortality among SLE patients with acute abdominal pain is 11%.2
When evaluating patients, considerations must be given to SLE-related causes, side effects related to medications (e.g., NSAIDs, steroids, hydroxychloroquine, azathioprine) and non-SLE-related causes (e.g., if ascites is present, rule out infection with paracentesis). Table 1 lists the most common causes of acute abdominal pain in SLE patients. Table 2, from a review article by Brewer and Kamen, shows the anatomic distribution of GI involvement among patients with SLE.2
Table 1: Leading Causes of Acute Abdominal Pain in SLE Patients3