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Gastrointestinal: Abdominal pain, vomiting, and fatal intra‐abdominal hemorrhage in a patient with Sjögren's syndrome

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A 49-year-old woman presented with 40 days of epigastric pain, abdominal distension, and vomiting. Contrast-enhanced computed tomography revealed thickened duodenum, transverse colon, and partial ascending colon (Fig. 1a–d). Because the… Click to show full abstract

A 49-year-old woman presented with 40 days of epigastric pain, abdominal distension, and vomiting. Contrast-enhanced computed tomography revealed thickened duodenum, transverse colon, and partial ascending colon (Fig. 1a–d). Because the symptoms were not relieved after conventional treatment, she underwent exploratory laparotomy in another hospital. During the operation, it was observed that the horizontal part of the duodenum and partial jejunum was slightly dilated and edematous. Besides, approximately 500 mL yellow clear ascites was found. The symptoms were greatly relieved after the surgery. However, abdominal pain and vomiting recurred 10 days later. Endoscopy showed slight swelling, significant erythema, and a few erosions in the stomach, duodenum, and transverse colon (Fig. 1e–h). The biopsy showed mucosa edema, congestion, and infiltration of lymphocytes and neutrophilic granulocytes. The results of laboratory tests were listed as follows: slight decreased hemoglobin (114 g/L, normal value: 115–150), normal liver function, renal function and urine test, exudative ascites with negative acid-fasting smear and no tumor cells, and negative hepatitis B/C virus and human immunodeficiency virus test. It was noteworthy that she had suffered from xerostomia and saprodontia for 8 years, and the immunology test (positive antinuclear, anti-SSA, and anti-SSB antibodies), the Schirmer’s test (4.2 mm/5 min), and the unstimulated whole saliva flow rate (0.9 mL/15 min) suggested the diagnosis of Sjögren’s syndrome (SS). The symptoms gradually attenuated after methylprednisolone was prescribed. But after 6-day treatment with methylprednisolone, severe abdominal pain and distension relapsed with sudden development of shock. Non-coagulative blood was demonstrated by abdominocentesis. At emergency laparotomy, approximately 3 L of blood was seen to spurt out from the middle colic artery near the left transverse colon. Although hemostasis was achieved by ligation, she developed renal failure and died after 5 days. Although SS mainly affects small vessels, about 4% SS developed vasculitis of medium-sized arteries. Intra-abdominal hemorrhage is even less reported. Intra-abdominal hemorrhage following aneurysm rupture was reported in a case with pulmonary fibrosis, SS, and parotid lymphoproliferative disease. They considered that vasculitis gave rise to aneurysm. Therefore, the middle colic artery of this case might have developed aneurysm due to SS, and the sudden rupture of the aneurysm resulted in death.

Keywords: pain vomiting; abdominal hemorrhage; intra abdominal; abdominal pain

Journal Title: Journal of Gastroenterology and Hepatology
Year Published: 2018

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