Yamauchi Nao, Iwamuro Masaya, Kawano Seiji, Yamazaki Tatsuhiro, Baba Yuki, Tsumura Tomoko, Hara Yuta, Kataoka Junro, Toyokawa Tatsuya, Okada Hiroyuki
Center for Graduate Medical Education, Okayama University Hospital.
Department of Gastroenterology and Hepatology, Okayama University Hospital.
Nihon Shokakibyo Gakkai Zasshi. 2020;117(1):64-71. doi: 10.11405/nisshoshi.117.64.
A 45-year-old Japanese man presenting with leg purpura, abdominal pain, and arthralgia was diagnosed with IgA vasculitis. His symptoms resolved after the intravenous administration of prednisolone. However, on day 20 of admission, he experienced bloody discharge and hypovolemic shock. The bleeding point was not identified on contrast-enhanced computed tomography scanning. The blood loss was approximately 10800ml and the patient received transfusions of 48 units of concentrated red blood cells, 18 units of fresh frozen plasma, and 30 units of concentrated platelets. Laparotomy and enteroscopy were performed through the incision of the jejunum to detect the bleeding source. Spurting bleeding was observed during the enteroscopy and partial resection of the jejunum was performed. Histopathological examination of the resected specimen revealed large vessels beneath the jejunal ulcer scar, suggesting bleeding from a Dieulafoy's lesion. Leukocytoclastic vasculitis or cytomegalovirus infection was not observed in the resected specimen. Gastrointestinal symptoms in patients with IgA vasculitis usually improve with bowel rest and conservative treatment. Administration of steroids or factor XIII is recommended for patients with severe abdominal pain refractory to conservative management. Rarely, massive bleeding, perforation, intussusception, and/or intestinal obstruction occur in the gastrointestinal tract and these complications affect patients' prognoses. The clinical course in the present patient indicated that severe bleeding from the gastrointestinal tract can occur even after symptom remission in patients with IgA vasculitis. In such cases, prompt treatment, including laparotomy and/or enteroscopy, is essential.
一名45岁的日本男性，出现腿部紫癜、腹痛和关节痛，被诊断为IgA血管炎。静脉注射泼尼松龙后，他的症状得到缓解。然而，在入院第20天，他出现了血性分泌物和低血容量性休克。在对比增强计算机断层扫描中未发现出血点。失血量约为10800ml，患者接受了48单位浓缩红细胞、18单位新鲜冰冻血浆和30单位浓缩血小板的输血治疗。通过空肠切口进行剖腹术和小肠镜检查以检测出血源。小肠镜检查期间观察到喷射性出血，并进行了空肠部分切除术。切除标本的组织病理学检查显示空肠溃疡瘢痕下方有大血管，提示出血来自Dieulafoy病变。在切除标本中未观察到白细胞破碎性血管炎或巨细胞病毒感染。IgA血管炎患者的胃肠道症状通常通过肠道休息和保守治疗得到改善。对于保守治疗难以缓解的严重腹痛患者，建议使用类固醇或因子 XIII。胃肠道很少会出现大量出血、穿孔、肠套叠和/或肠梗阻，这些并发症会影响患者的预后。本患者的临床病程表明，IgA血管炎患者即使在症状缓解后也可能发生胃肠道严重出血。在这种情况下，包括剖腹术和/或小肠镜检查在内的及时治疗至关重要。
