1. 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.

2. Oct. 19
upright

3. Oct. 19
supine

4. Oct. 19

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

6. 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

7. 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, moderate, >20 severe
Validated

8. 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)

9. 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

10. 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)

11. 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

12. Oct. 19

13. 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

14. 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:
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:
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:
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: