Oct. 14 There is no evidence of bowel obstruction or dilatation. 1. Extensive axillary, mediastinal, abdominal, pelvic lymphadenopathy, as above, most stable and some slightly increased in size in comparison to the prior study. This is suggestive of lymphoma, however prior biopsy was negative. 2. No evidence of pneumonia or abscess. 3. Right ovarian cyst, likely physiologic.

Oct. 19 upright

Oct. 19 supine

Oct. 19

Anne Lachiewicz November 20, 2009 Morning Report Anne Lachiewicz November 20, 2009

Am Coll. Rheum. Classification Criteria for SLE (if >= 4/11, Se & Sp >95%) Malar rash Discoid rash Photosensitivity Oral/nasopharyngeal ulcers Nonerosive arthritis Serositis Proteinuria or urinary cellular casts Seizures or psychosis Hemolytic anemia or leukopenia or lymphopenia or thrombocytopenia + ANA + anti-ds-DNA, anti-sm, or antiphospholipid Abs

SLEDAI (SLE Disease Activity Index) Created to standardize outcomes measures in SLE A "weighted" index of 9 organ systems for disease activity in SLE: 8 for central nervous system and vascular 4 for renal and musculoskeletal 2 for serosal, dermal, immunologic 1 for constitutional and hematologic Maximum theoretical score is 105, but few patients have scores greater than 45 Scores < 10 mild, 10-20 moderate, >20 severe Validated

GI manifestations (30%) Not included in classification criteria or in the disease activity index) Dysphagia (25-40%) – usually due to esophageal hypomotility Abdominal pain with N/V (30%) – many reasons, consider SLE meds (steriods, azathi0prine) Peritonitis (60-70% lifetime) Ascites (uncommon)

GI manifestations Peptic ulcer disease (11-50%) - usually gastric, ? SLE meds (NSAIDS, steriods) vs. SLE itself Pancreatitis (2-8%, may be more common) *can see elevated amylase in SLE w/o pancreatitis Liver disease - hepatomegaly & abnormal liver tests are common, but ESLD is rare Protein-losing enteropathy – small series/case reports, young women, 50% have diarrhea

Mesenteric vasculitis & infarction (lupus enteritis) Vasculitis of the small arterial vessels or venules ? More frequent in young women early in the course of SLE ? Correlation with SLEDAI Colicky lower abdominal pain Generally insidious & may be present for months prior to acute abdomen Potentially life-threatening – bowel necrosis, perforation, sepsis, hemorrhage M&M has improved due to early recognition & treatment (more CT scans)

Lupus enteritis: Diagnosis No established diagnostic criteria Most commonly in jejunum & ileum, rectal involvement is rare May be focal or diffuse (involving several vascular territories) CT scan: ascites with peritoneal enhancement, bowel walk thickening, dilated bowel loops & prominence of mesenteric vessels with palisade pattern or comb-like appearance Not associated with any specific antibodies, but relapse may be more common in those with APLA

Oct. 19

Lupus enteritis: Treament NPO, NG tube, IVF/TPN Blood cultures, r/o infection Consult surgery IV methylprednisolone + cyclophosphamide Check lactate & abdominal films regularly as steriods may mask peritonitis

References Kwok S-K, Seo S-H, et al. Lupus enteritis: clinical characteristics, risk factor for relapse and association with anti-endothelial cell antibody. Lupus 2007; 16:803-809. Lee C-K, Ahn MS, et al. Acute abdominal pain in systemic lupus eythematosus: focus on lupus enteritis (gastrointestinal vasculitis). Ann Rheum Dis 2002; 61:546-550. Lian T-Y, Edwards CJ, et al. Reversible acute gastrointestinal syndrome associated with active systemic lupus erythematosus in patients admitted to hospital. Lupus 2003; 12:612-616. Massarotti EM, Schur PH. Gastrointestinal manifestations of systemic lupus erythematosus. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009. Vegara-Fernandez O, Zeron-Medina J, et al. Acute abdominal pain in patients with systemic lupus erythematosus. J Gastrointest Surg 2009; 13:1351-1357.