Stephen
E. Kuehne,
MD
Small Bowel by Rheumatoid Small bowel toid arthritis
involvement is rare and
bowel
3-week
stricture.
history
bloating,
of daily
patient
study
logic
of a resected
examination
stricture
bowel
was
vasculitis.
MD
a a
had and
demonstrated obstruction. Patho-
proved
caused
To the
Shortsleeve,
postprandial
cramping,
vomiting. Barium partial small bowel of the small
#{149} MichaelJ
in rheumais caused by
The
abdominal
MD
Stricture Caused Vasculitis’
vasculitis, which results in ulceration, perforation, and necrosis of the small boweL The authors present a case of rheumatoid vasculitis associated with small
P. Gauvin,
#{149} Gregory
by
segment
that the rheumatoid
authors’
knowledge,
this is the first reported case of such association in the radiology literature.
an
Index
terms: Arteritis, 742.619, 742.629 e thritis, rheumatoid, 30.71 e Intestines, stenosis or obstruction, 742.621 #{149} Vasculitis, 742.621 Radiology
1992;
184:215-216
Figure 1. Barium study of the demonstrates a short, concentric of the middle of the ileum with small bowel dilatation.
E
XTRAARTICULAR
rheumatoid known. Small
manifestations
arthritis
is rare
caused by vasculitis, ulceration, perforation, the involved bowel. case
bowel
narrowing proximal
Figure shows ters.
2. Segment of resected stricture (bracket). Scale
small bowel is in centime-
of
arthritis are well bowel involvement
rheumatoid
usual
small
and
in
is
which results in and necrosis of We present an un-
of rheumatoid
vasculitis
asso-
ciated with a small bowel stricture. To our knowledge, this is the first reported case
of such
an
association.
CASE A 65-year-old
3-week
REPORT
white
history
had a postprandial
man
of daily
and vomiting, which would spontaneously subside 2 hours later accompanied by copious diarrhea. The patient had had severe rheumatoid arthritis for more than 10 years; the arthritis was controlled with gold treatments. Physical examination revealed severe rheurnatoid arthritis, mild abdominal distention, and borborygmus.
bloating,
I
From
the
Departments
of Radiology
(S.E.K.,
M.J.S.) and Pathology (G.P.G.), Mount Auburn Hospital, 330 Mount Auburn St. Cambridge, MA 02238. Received December 17, 1991; revision requested January 22, 1992; revision received March 2; accepted March 4. Address reprint re-
quests 0
to MIS.
RSNA,
1992
abdominal
Barium
study
1) demonstrated
struction
cramping,
of the small partial
caused
by a fixed,
cumferential narrowing segment of the middle
bowel was
proximal dilated,
small
normal
(Fig
bowel
abrupt
ob-
cir-
of a 4-cm-long of the ileurn. The
to the stenotic with
bowel
fold
segment thickness.
Figure 3. Photomicrograph of mediumsized artery in the region of the stricture shows vasculitis with fibrinoid necrosis (arrow).
The distal portion of the iteum was of normal caliber. The patient underwent surgical resection of the stenotic segment of the iteum. The resected segment of the small bowel (Fig 2) demonstrated a smoothly tapered, benign-appearing stricture. The mucosa was erythematous and had a few small ulcerations. There was no evidence of a weblike mucosal narrowing of the lumen, and the stricture was caused by transmural fibrosis. Micro215
scopically, litis with
there fibrinoid
branches 3). The
was evidence of vascunecrosis in several
of the rnesentenc pathologic
arteries
findings
(Fig
demon-
strated that the small bowel stricture was caused by rheumatoid vasculitis. There was no evidence of inflammatory bowel disease. The patient is asymptomatic 2#{189} years after surgery.
arthritis
and
patients
at postmortem
As in other
in rheumatoid in up to 25%
extraarticular
of rheumatoid preponderance. leukocystoclastic
(1).
manifestations
arthritis, there is a mate Periarteritis nodosa and vasculitis are the two
most common forms ated with rheumatoid cystoctastic vasculitis small venules of the
advanced
articular
eases.
to a 75% mortality rate. The remaining 25% of patients underwent resection of a necrotic segment of the small bowel. Early recognition of im-
of
examination
and
manifestations (1). Clinically apparent rheumatoid vasculitis that affects the small bowel is a rare, life-threatening condition in which patients often present with an acute
abdomen. In a recent review of intestinat rheumatoid vasculitis (3), bowel per-
DISCUSSION is common is found
Vasculitis
complement,
of vasculitis associarthritis. Leukousually involves skin and is not ra-
foration
ted
pending institution
bowel
infarction
and
prompt
of therapy may improve of patients with this rare, condition.
survival threatening
The differential
diagnosis
of a fixed
circumferential
narrowing
of
bowel
primary
carcinoma,
includes
metastatic
carcinoma,
phoma,
strictures
(ie,
emia,
the appropriate
tures
must
necrosis
and
inflam-
endometriosis,
be found;
oid necrosis
diagnostic
in the vessel
vasculitis
to the above-listed
#{149} Radiology
bowel
stricture.
Although rheumatoid vasculitis rarely affects the bowel, it should be considered in any patient with rheumatoid arthritis with severe abdominal symptoms.
To
our
knowledge,
this
the first
is
case of rheumatoid vasculitis associated with a small bowel stricture, presurnably caused by vasculitis-induced ischemia. The possibility of a rheumatoid vasculitis-induced stricture should be considered in a patient with rheumatoid arthritis and clinical or radiographic findings of small bowel obstruction. U
ciation to Ruth manuscript.
We express McNeill
sincere
for preparation
appreof the
watts
must
1.
2.
3.
fibrin-
was
long-term drugs
causes
References
nonmay
be
of a
4.
Scott DGI, Bacon PA, Tribe CR. Systemic rheumatoid vasculitis: a clinical and laboratory study of 50 cases. Medicine 1981; 60: 288-297. ChurgJ, Churg A. Idiopathic and secondary vasculitis: a review. Mod Pathol 1989; 2:144-160. deBrum-Fernandes AJ, Lucenda-Fernandes MF, Caloo I, Rodrigues CJ, deSouza AE. Small bowel necrosis: a rare, life-threatening complication of rheumatoid arthritis. J Rheumatol 1988; 15:1313-1315. Bjarnason I, Price AB, Zaneffi G, et al. Clinicopathological features of nonsteroidal anti-inflammatory drug-induced small intestinal strictures. Gastroenterology 1988; 94: 1070-1074.
small bowel stricture. There are no specific radiologic features to distinguish a
stricture resulting from culitis from that caused
216
fea-
case,
a diaphragm-like mucosal pronarrowing the bowel lumen
(4). Rheumatoid
added
vasculitic
in our
seen. Patients receiving steroidal anti-inflammatory
develop liferation,
of a small
history differential
disease, tuberculosis, with long-standing
segmental
fibrinoid
diagnosis
Acknowledgment: tym-
ischemia, and nonvasculitic ischemia. An ischernic stricture caused by vasculitis may appear identical to an ischernic stricture from other causes such as atherosclerosis or cholesterol ernboli. To determine the cause of the isch-
in the arterial wait with subsepolymorphonuclear leukocyte inifitration. The damaged arterial wall is predisposed to thrombosis and resultant infarction. Periarteritis nodosa caused the small bowel stricture in our patient. This form of rheumatoid vasculitis is usually found in severe cases with a high rheumatoid factor, low serum
disease,
The patient’s clinical help to narrow the
small
diographically demonstrable. Periarteritis nodosa typically affects small to medium-sized arteries and is the form of vasculitis most commonly identified radiographically in patients with rheumatoid arthritis (2). In periarteritis nodosa, there is initial mation quent
celiac
Crohn associated
the
malignant
drug-associated
potassium), stricture
the life-
should
rheumatoid by other
vasdis-
July 1992