Systemic lupus erythematosus (gastrointestinal manifestations)

Gastrointestinal manifestations in patients with systemic lupus erythematosus are common and may involve any region of the gastrointestinal tract or visceral organs.

Clinical presentation

Patients with abdominal or gastrointestinal involvement by systemic lupus erythematosus may have a variety of presentations including abdominal pain, diarrhea, dysphagia, anorexia, ascites, oral ulcers, gastrointestinal bleeding and malnutrition depending on the organs involved and duration of involvement.

Pathology

Systemic lupus erythematosus may affect any part of the gastrointestinal tract and visceral organs:

• peritoneum: ascites is found in up to 10% of patients due to serositis
• gastrointestinal vasculature
  • vasculitis causing colitis, mucosal ulceration with hemorrhage or perforation, intestinal ischemia, "watermelon stomach" or gastric antral vascular ectasia, esophageal dysmotility or intestinal pseudo-obstruction ⁴
  • thrombosis of the intestinal vessels may also occur in association with antiphospholipid syndrome
• mucosa
  • mouth ulcers in 50% of patients
  • protein-losing enteropathy and fat malabsorption
  • associated ulcerative colitis or Crohn disease
• pancreas: pancreatitis
• liver and biliary tract
  • hepatomegaly, steatosis, hepatitis, cholestasis, primary biliary cholangitis and eventually cirrhosis may be found. 
  • Budd-Chiari syndrome which may be associated with antiphospholipid antibodies in SLE
  • acalculous cholecystitis and benign biliary stricture
• spleen: splenic infarction
• ​adrenal glands
  • adrenal hemorrhage
  • hypoadrenalism

Radiographic features

Barium study

• small bowel series: prominent mucosal pattern because of edema, segments of spiculation, fragmentation and clumping of barium ²
• upper GI series: decreased esophageal peristalsis, reflux, esophageal dilatation

CT

CT findings may include:

• ascites with increased peritoneal enhancement
• circumferential, symmetrical, multisegmented mural thickening usually of the jejunum and ileum with associated submucosal edema (target sign)
• engorgement of mesenteric vessels with a palisade pattern or comb-like appearance
• dilatation of intestinal segments
• mesenteric fat stranding
• diffuse splenic calcification in the typical "onion-skin" pattern due to concentric perivascular lamination of fibrous tissue
• other features and complications of SLE disease may be present (e.g. pancreatitis, intestinal ischemia)