Abdominal pain as the presenting feature of systemic lupus erythematosus: DISCUSSION (Part 1)

SLE is a common disorder that affects one in 2500 people, with a female predominance. The classification (but not clinical diagnosis) of SLE is typically based on the 1982 revised criteria of the American Rheumatologic Associaton (ARA) for the classification of SLE (3), which is reported to be 96% sensitive and 96% specific. The ARA critieria require a serial or simultaneous presentation of four of 11 listed symptoms, signs or laboratory findings for a diagnosis of lupus.

Our patient met minimal ARA diagnostic criteria of SLE but did not have any of the classic renal, dermatological (ie, malar or discoid rash), musculoskeletal (ie, polyarthrititis) or neurological features that are included in the ARA criteria. Moreover, evidence of serositis (ie, pleural effusion, ascites) was apparent only on diagnostic imaging. Abdominal pain and evidence of gastrointestinal disease are not included in the ARA criteria but in our patient’s case, a diagnosis of SLE was confirmed by her lymphopenia, hypocomplementemia, positive antinuclear antibody and strongly positive anti-double stranded DNA, anti-SSA, as well as the weakly positive anti-Smith. Therefore, we are confident that her clinical diagnosis was SLE.

Gastrointestinal manifestations of SLE that have been reported in the literature consist of abdominal pain, nausea, vomiting and diarrhea, and are reported to occur in greater than 50% of SLE patients at some time during the course of the disease. Abdominal pain during a lupus flare is usually attributed to polyserositis. In cases of acute abdominal pain, a study of 31 of 39 abdominal computed tomographic scans in known SLE patients were suggestive of ischemic bowel. However, abdominal pain without evidence of active lupus tends to be caused by non-SLE-associated gastrointestinal illnesses. The unique aspect of this case is that abdominal pain was the only clinical manifestation of otherwise occult SLE. It was only after specific rheumatological laboratory investigations were performed during the investigation of otherwise ‘abdominal pain not yet diagnosed’ did the diagnosis of SLE become revealed. To our knowledge there have been no similar cases described in the literature. The abdominal pain was most likely secondary to either mechanical stimulation of visceral pain receptors secondary to the bowel edema, or due to the release of inflammatory mediators that stimulated the mucosal receptors. Shop with pleasure with most reliable pharmacy you have ever seen, paying less for your cheap asthma inhalers always being sure you are being treated with all due respect, being an important customer whose interests are respected and taken into account.

 

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