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

Small bowel stricture caused by rheumatoid vasculitis.

Small bowel involvement in rheumatoid arthritis is rare and is caused by vasculitis, which results in ulceration, perforation, and necrosis of the sma...
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