“Circular reddish lesions”: a possibly characteristic endoscopic finding in Henoch–Schönlein purpura

Henoch–Schönlein purpura is a systemic vasculitis that presents with palpable purpura, abdominal pain, arthritis, and hematuria [1]. The initial clinical symptom of the characteristic purpura makes diagnosis easy. However, the disease is often under-recognized in the 10 % – 15 % of patients in whom gastrointestinal symptoms precede the cutaneous lesions [2]. We report some possibly characteristic endoscopic findings in two cases of Henoch–Schönlein purpura that would be useful in diagnosing precisely this clinical manifestation of the condition.

Our first patient was a man in his forties with Henoch–Schönlein purpura who had been treated with 30 mg prednisolone for proteinuria and was admitted with abdominal colic, melena, diarrhea and purpura. A computed tomography (CT) scan showed segmental wall thickening in the small and large intestines ([Fig. 1]). Colonoscopy showed scattered but distinct circular areas of redness ([Fig. 2]) throughout the colon. Histological examination of biopsy specimens revealed typical leukocytoplastic vasculitis. Video capsule endoscopy revealed multiple circular areas of redness in the ileum ([Video 1]) and patchy erosions throughout the jejunum ([Fig. 3]). The second patient was also a man in his forties with a past history of Henoch–Schönlein purpura and admitted for abdominal colic, diarrhea, and purpura. An abdominal CT scan showed multiple areas of segmental wall thickening in the jejunum ([Fig. 4]). Single balloon enteroscopy showed scattered circular hyperemic lesions in the duodenum ([Fig. 5]). Both patients thus showed the endoscopic finding of “circular reddish lesions” and were diagnosed as having Henoch–Schönlein purpura-associated enteritis. The lesions resolved after dose escalation (patient 1) or administration of oral prednisolone (patient 2).

Fig. 1 Computed tomography (CT) scan in a man with known Henoch – Schönlein purpura (patient 1) showing segmental wall thickening in the ascending colon (arrow) and terminal ileum (arrowhead).

Fig. 2 Colonoscopy in patient 1 showing the possibly characteristic circular ulcerative lesions interposed with normal mucosa (arrowheads).

Fig. 3 Capsule endoscopic findings of multiple erosions in the jejunum (arrow) in patient 1.

Fig. 4 Computed tomography (CT) scan in a man with a past history of Henoch–Schönlein purpura, admitted for abdominal colic and diarrhea (patient 2), showing segmental wall thickening in the third portion of the duodenum (arrowheads).

Fig. 5 Single balloon enteroscopy in patient 2 showing circular reddish lesions with ulceration (arrowheads).

Capsule endoscopy in patient 1 demonstrating an area of circular red lesions in the ileum.

In some cases of Henoch–Schönlein purpura, laparotomy has been carried out for “acute abdomen” when the patient ideally should have been treated conservatively [3]. Although endoscopy is required to confirm the diagnosis of Henoch–Schönlein purpura with gastrointestinal manifestations, characteristic endoscopic findings of the disease in the small intestine have not yet been elucidated [4]. Our two cases suggest that “circular reddish lesions” in the gastrointestinal tract, including the small intestine, are a characteristic of Henoch–Schönlein purpura, and that, along with the segmental wall thickening of the intestine evident on CT, this endoscopic finding could be useful in confirming the diagnosis of this rare but important form of this disease.

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• References

• 1 Zhang Y, Huang X. Gastrointestinal involvement in Henoch-Schönlein purpura. Scand J Gastroenterol 2008; 43: 1038-1043
• 2 Trapani S, Micheli A, Grisolia F et al. Henoch Schönlein purpura in childhood: epidemiology and clinical analysis of 150 cases over a 5-year period and review of literature. Semin Arthritis Rheumatol 2005; 35: 143-153
• 3 Katz S, Borst M, Seekri I et al. Surgical evaluation of Henoch-Schönlein purpura. Experience with 110 children. Arch Surg 1991; 126: 849-853
• 4 Esaki M, Matsumoto T, Nakamura S et al. GI involvement in Henoch-Schönlein purpura. Gastrointest Endosc 2002; 56: 920-923