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IMAGES IN EMERGENCY MEDICINE

Intractable abdominal pain in a healthy young man A 23-year-old previously healthy man was admitted to our hospital due to intractable abdominal pain with haematemesis for 1 week. He also presented with fever and painful symmetric polyarthritis involving his wrists and ankles. Laboratory evaluation was unremarkable. CT of his abdomen disclosed remarkable segmental dilatation and wall thickening of the small intestine (figure 1). After 2 days, palpable purpura developed over the dorsal aspect of his feet and ankles (figure 2). A skin biopsy showed leucocytoclastic vasculitis, which is compatible with Henoch –Schönlein purpura (HSP). The abdominal pain and skin lesions resolved after intravenous corticosteroid therapy. The typical first symptom of HSP is purpuric skin lesions. However, up to 24% of patients with HSP have gastrointestinal symptoms 2–21 days before the onset of skin rash.1 Early diagnosis in such patients is problematic. The comb sign refers

Figure 2 Palpable purpura on the ankles and feet.

to hypervascularity of the mesentery with vascular dilatation, tortuosity and prominence of the vasa recta on contrastenhanced CT scans.2 It has been reported in vasculitis (including HSP), mesenteric thromboembolism, strangulated bowel obstruction and ulcerative colitis.2 HSP should be considered especially in young patients with intractable abdominal pain. Ya-Chi Li, Shi-Jye Chu, Tsung-Yun Hou Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Correspondence to Dr Tsung-Yun Hou, Division of Rheumatology/Immunology/ Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, 325, Sec. 2, Cheng-Gong Rd., Neihu, Taipei 114, Taiwan; [email protected] Contributors S-JC was involved in the conception and design of the article. The rest of the manuscript was written by Y-CL, who was directly involved in the clinical assessment and its reporting. T-YH is responsible for the overall content as a guarantor. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.

To cite Li Y-C, Chu S-J, Hou T-Y. Emerg Med J 2015;32:43. Accepted 19 February 2014 Published Online First 20 March 2014 Emerg Med J 2015;32:43. doi:10.1136/emermed-2014-203680

Figure 1 CT of abdomen: long segmental dilatation and wall thickening of the jejunum and engorgement of mesenteric vessels with comb sign.

Pan A, et al. Emerg Med J 2015;32:36–43. doi:10.1136/emermed-2013-202874

REFERENCES 1 2

Zhang Y, Huang X. Gastrointestinal involvement in Henoch-schönlein purpura. Scand J Gastroenterol 2008;43:1038–43. Madureira AJ. The comb sign. Radiology 2004;230:783–4.

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Downloaded from http://emj.bmj.com/ on June 23, 2015 - Published by group.bmj.com

Intractable abdominal pain in a healthy young man Ya-Chi Li, Shi-Jye Chu and Tsung-Yun Hou Emerg Med J 2015 32: 43 originally published online March 20, 2014

doi: 10.1136/emermed-2014-203680 Updated information and services can be found at: http://emj.bmj.com/content/32/1/43

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Intractable abdominal pain in a healthy young man.

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