腹型过敏性紫癜45例临床分析

Clinical analysis of 45 cases of abdominal Henoch-Sch?nlein purpura

背景与目的:过敏性紫癜(HSP)是一种小血管受累的多系统血管炎性疾病,可累及皮肤、关节、胃肠道、肾脏等多个部位,临床表现缺乏特异性,在胃肠道症状先于紫癜样皮疹出现的患者中,诊断更加困难。本研究总结分析腹型HSP的临床特点和诊治经验,旨在提高对该病的早期认识。方法:回顾性分析2012年1月-2018年1月在中南大学湘雅医院收治的以腹痛为主要表现的45例HSP患者的临床资料。结果:45例腹型HSP患者中男34例,女11例,男女比3.1:1;平均发病年龄(31.1±18.6)岁,以18岁以下青少年居多;最常见的发病季节为秋冬两季。24例(53.3%)以腹痛为首发表现,部位以中上腹部多见,以阵发性绞痛为主,14例(31.1%)以紫癜样皮疹为首发表现,5例(11.1%)腹痛和皮疹同时出现,其他伴随症状有恶心、呕吐、便血、腹胀以及双膝关节疼痛等。实验室检查中,白细胞计数升高32例(71.1%),其中以中性粒细胞升高为主;尿蛋白阳性13例(28.9%)、尿红细胞阳性13例(28.9%)、白蛋白降低35例(77.8%)、C反应蛋白升高(CRP)27例(60.0%)、大便隐血试验阳性33例(73.3%)、免疫球蛋白A(IgA)升高4例(16.0%);32例行食物不耐受检查,其中含有食物过敏原19例(59.4%),以异种蛋白为主。33例(73.3%)行胃镜检查,病变主要累及十二指肠球降部以及胃窦,26例(57.8%)行肠镜检查,病变主要累及回肠末端,3例(6.7%)行小肠镜检查,病变主要累及回肠中下段;内镜下主要表现为胃肠黏膜的充血水肿及片状糜烂,少数伴有溃疡形成。7例(15.6%)行腹部CT,均表现为肠壁增厚,少数伴有腹膜后及肠系膜淋巴结肿大。12例(26.7%)行病理活检,提示为黏膜非特异性炎症,部分可见嗜酸性粒细胞和浆细胞浸润。所有患者诊断明确后给予综合治疗,40例(88.9%)予以糖皮质激素治疗,消化道症状和皮疹均可得到明显缓解。6例(13.3%)复发,复发时间1~24个月不等。结论:腹型HSP皮疹往往晚于胃肠道症状出现,缺乏特异性症状和体征,容易误诊,临床上可以早期行胃肠镜检查,以提高对该疾病的诊断及认识。

Background and Aims:Henoch-Sch?nlein purpura (HSP) is a multi-system inflammatory disease of the small blood vessels,involving skin,joints,gastrointestinal tract,kidneys and other areas.The clinical manifestations of HSP are nonspecific,and the diagnosis is more difficult for those with gastrointestinal symptoms preceding the onset of purpura rash.This study was conducted to summarize and analyze the clinical characteristics and treatment experience of abdominal HSP for improving the early recognition of this condition.Methods:The clinical data of 45 HSP patients with abdominal pain as the predominant symptom admitted to Xiangya Hospital,Central South University from January 2012 to January 2018 were retrospectively analyzed.Results:Among the 45 patients with abdominal HSP,34 cases were males and 11 cases were females,with a male to female ratio of 3.1:1;the average age of onset was (31.1±18.6) years,and the majority of them were adolescents under 18 years old;autumn and winter were the most common seasons of onset.Twenty-four patients (53.3%) had the abdominal pain as the first symptom,which was most frequently occurred in the middle and upper abdominal regions,and mainly presented as intermittent colicky pain,14 patients (31.1%) had a purpura rash as the first manifestation,and 5 patients (11.1%) had a concomitant abdominal pain and rash,and the other associated symptoms included nausea,vomiting,hematochezia,abdominal distention,and pain in both knees.In the laboratory examination,32 patients (71.1%) had an elevated white blood cell count comprised mainly of neutrophils,13 patients (28.9%) had a positive urinary protein test,13 patients (28.9%) had red blood cells in the urine,35 patients (77.8%) showed decreased albumin level,27 patients (60.0%) showed increased C-reactive protein (CRP) level,33 patients (73.3%) were positive for fecal occult blood test,and 4 patients (16.0%) had an increased immunoglobulin A (IgA) level.Thirty-two patients underwent food intolerance tests,19 cases (59.4%) sensitized to food allergens,which mainly were heterologous proteins.Thirty-three patients (73.3%) underwent gastroscopic examination,and the lesions mainly involved the duodenal bulb and descending duodenum;26 cases had a colonoscopic examination,and the lesions mainly involved the terminal ileum;3 cases were subjected to enteroscopic examination,and the lesions mainly involved the middle and lower ileum.Endoscopic findings were mainly congestion and edema of the gastrointestinal mucosa and lamellar erosion,and some lesions were accompanied by ulcerations.Seven patients (15.6%) underwent abdominal CT examination,all which showed intestinal wall thickening,and some were accompanied by retroperitoneal and mesenteric lymph node enlargement.Twelve cases (26.7%) underwent biopsy,and the results suggested nonspecific inflammation of the mucosa,with infiltration of eosinophils and plasma cells in some cases.All patients received comprehensive treatment after diagnosis,and the gastrointestinal symptoms and rash were significantly relieved 40 cases (88.9%) after glucocorticoid treatment.Recurrence occurred in 6 cases (13.3%),with a time to recurrence ranged from1 month to 24 months.Conclusion:In abdominal HSP,the purpura rash usually appears later than gastrointestinal symptoms,which lacks specific symptoms and signs,and is likely misdiagnosed.Early gastrointestinal endoscopic examination should be performed in clinical practice,so as to improve the diagnosis and understanding of this condition.