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Polyarteritis nodosa and acute abdomen: A role for laparoscopy?

Asti E, Pogliani L, Tritella S, Bonavina L - Int J Surg Case Rep (2015)

Bottom Line: Mesenteric vasculitis secondary to polyarteritis nodosa represents an atypical but potentially life-threatening cause of bowel ischemia and acute abdomen.Early laparoscopy allowed to rule out proximal bowel necrosis and resection was avoided.The patient was successfully managed with corticosteroid therapy and repeated hemodialysis sessions.

View Article: PubMed Central - PubMed

Affiliation: Department of General Surgery, University of Milan Medical School, IRCCS Policlinico San Donato, Italy.

No MeSH data available.


Related in: MedlinePlus

Pitting edema with petechiae of the legs.
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fig0005: Pitting edema with petechiae of the legs.

Mentions: A 57-year-old Caucasian man with a history of rheumatoid arthritis, poorly controlled arterial hypertension, and transient ischemic attack, was admitted to the Emergency Department for severe abdominal pain of recent onset. Initially he appeared slightly distressed; his temperature was 36.9 °C, blood pressure 120/80 mmHg, pulse 120 beats/min, and oxygen saturation 96% on room air. On physical examination, generalized abdominal guarding and pitting edema of the legs with petechiae was noted (Fig. 1). The laboratory findings were remarkable for elevated white blood cell count (20.960/μL), C-reactive protein (19.9 mg/dL), and impaired renal function (GFR 48 mL/min/1.73 mq, creatinine 1.85 mg/dL, urea 97 mg/dL). Abdominal computed tomography with contrast showed diffuse thickening and edema of the proximal small bowel loops suggestive of mesenteric ischemia (Fig. 2). Wide-spectrum antibiotic therapy was initiated and minimally invasive surgical exploration was planned. At laparoscopy, an edematous jejunal loop without evidence of perforation was found 20 cm distal to the Treitz’s ligament. No resection was performed. The postoperative course was complicated by fever and worsening of the pitting edema of the legs; there was also a further increase of the inflammatory markers and creatinine levels (3.91 mg/dL) with the appearance of proteinuria (250 mg/dL) and hematuria (1 mg/dL). Since the clinical picture was consistent with the diagnosis of polyarteritis nodosa, corticosteroid therapy (Prednisone 75 mg/day) was initiated and multiple sessions of hemodialysis were performed. Serology was negative for hepatitis B and C virus, anti-Beta2-glycoprotein antibodies, anti-nuclear antibodies, anti-cardiolipin antibodies, anti-citrulline antibodies, anti-native DNA autoantibodies, cytoplasmic-Anti-Neutrophil Cytoplasmic Antibodies (ANCA), perinuclear-ANCA, and rheumatoid factor. Repeat abdominal computed tomography with contrast showed kidney hypoperfusion and persistent small bowel edema. Over the following days the pitting edema of the legs decreased and the renal function improved. A skin biopsy eventually confirmed the diagnosis of polyarteritis nodosa.


Polyarteritis nodosa and acute abdomen: A role for laparoscopy?

Asti E, Pogliani L, Tritella S, Bonavina L - Int J Surg Case Rep (2015)

Pitting edema with petechiae of the legs.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4701864&req=5

fig0005: Pitting edema with petechiae of the legs.
Mentions: A 57-year-old Caucasian man with a history of rheumatoid arthritis, poorly controlled arterial hypertension, and transient ischemic attack, was admitted to the Emergency Department for severe abdominal pain of recent onset. Initially he appeared slightly distressed; his temperature was 36.9 °C, blood pressure 120/80 mmHg, pulse 120 beats/min, and oxygen saturation 96% on room air. On physical examination, generalized abdominal guarding and pitting edema of the legs with petechiae was noted (Fig. 1). The laboratory findings were remarkable for elevated white blood cell count (20.960/μL), C-reactive protein (19.9 mg/dL), and impaired renal function (GFR 48 mL/min/1.73 mq, creatinine 1.85 mg/dL, urea 97 mg/dL). Abdominal computed tomography with contrast showed diffuse thickening and edema of the proximal small bowel loops suggestive of mesenteric ischemia (Fig. 2). Wide-spectrum antibiotic therapy was initiated and minimally invasive surgical exploration was planned. At laparoscopy, an edematous jejunal loop without evidence of perforation was found 20 cm distal to the Treitz’s ligament. No resection was performed. The postoperative course was complicated by fever and worsening of the pitting edema of the legs; there was also a further increase of the inflammatory markers and creatinine levels (3.91 mg/dL) with the appearance of proteinuria (250 mg/dL) and hematuria (1 mg/dL). Since the clinical picture was consistent with the diagnosis of polyarteritis nodosa, corticosteroid therapy (Prednisone 75 mg/day) was initiated and multiple sessions of hemodialysis were performed. Serology was negative for hepatitis B and C virus, anti-Beta2-glycoprotein antibodies, anti-nuclear antibodies, anti-cardiolipin antibodies, anti-citrulline antibodies, anti-native DNA autoantibodies, cytoplasmic-Anti-Neutrophil Cytoplasmic Antibodies (ANCA), perinuclear-ANCA, and rheumatoid factor. Repeat abdominal computed tomography with contrast showed kidney hypoperfusion and persistent small bowel edema. Over the following days the pitting edema of the legs decreased and the renal function improved. A skin biopsy eventually confirmed the diagnosis of polyarteritis nodosa.

Bottom Line: Mesenteric vasculitis secondary to polyarteritis nodosa represents an atypical but potentially life-threatening cause of bowel ischemia and acute abdomen.Early laparoscopy allowed to rule out proximal bowel necrosis and resection was avoided.The patient was successfully managed with corticosteroid therapy and repeated hemodialysis sessions.

View Article: PubMed Central - PubMed

Affiliation: Department of General Surgery, University of Milan Medical School, IRCCS Policlinico San Donato, Italy.

No MeSH data available.


Related in: MedlinePlus