P1321 - Rheumatoid Vasculitis: An Unusual Cause of Abdominal Pain in an Older Patient

Bharat Misra, MD¹, Liam Delfin, BS², John T. Woeste, BA², Mark Carter, MD^1
1Borland Groover, Jacksonville, FL; ²ENCORE Borland Groover Clinical Research, Jacksonville, FL

Introduction: We report a case of rheumatoid vasculitis (RV), presenting in an older patient with abdominal pain. Extensive imaging and endoscopic work up did not reveal the cause of her abdominal pain. The diagnosis was only revealed by a magnetic resonance arteriography (MRA). A timely diagnosis of RV is critical given its high morbidity and mortality without early treatment.

Case Description/Methods: A 75 year old white female with a history of rheumatoid arthritis (RA) presented with upper abdominal pain and diarrhea. Her pain was not post prandial. She denied any systemic symptoms and weight loss. She was on multiple medications for her RA including prednisone, methotrexate and rituximab. CBC, Chem 12, ESR, amylase and lipase were normal. Stool cultures, C. difficile titers, stool fat, ova and parasites, occult blood, and stool elastase were normal. Upper endoscopy showed mild esophagitis and gastritis, and pathology was non-diagnostic. RUQ ultrasound, MRCP and EUS were normal. MRA abdomen showed moderate to severe stenosis of multiple visceral arteries with high-grade stenosis of the celiac and mesenteric arteries. The superior mesenteric artery (SMA) was 95% stenosed (Figure 1A). A diagnosis of RV was made. Her rheumatologist increased her oral prednisone from 30mg to 60mg daily, gave her two doses of IV methylprednisolone, and started monthly IV cyclophosphamide (375 mg/m2). Her pain and diarrhea quickly improved and resolved by two months. An MRA three months later showed dramatic improvement of vasculitis, with “widely patent” celiac and superior mesenteric arteries and their vascular distributions. A year later, she remains asymptomatic, and a follow up MRA abdomen showed no significant stenosis of her celiac artery and SMA (Figure 1B).

Discussion: Rheumatoid vasculitis (RV) is a cause of unexplained abdominal pain in patients with long standing RA. Its incidence is decreasing and it affects less than 1% of patients with RA. Lab abnormalities are non-specific. Titers of several autoantibodies can be elevated (RF, anti-CCP, ANA, ANCA, etc.). RV affects small and medium sized vessels and can involve other organs like the skin (90%), digits, peripheral nerves, eyes, and heart. Whenever possible, a tissue diagnosis should be obtained as RA is associated with significant morbidity, and treatment requires intensive immunosuppressive therapy. As in our patient, a high index of suspicion along with imaging of the mesenteric circulation (MRA or CTA) is critical to making this diagnosis.



Disclosures:


Bharat Misra, MD¹, Liam Delfin, BS², John T. Woeste, BA², Mark Carter, MD¹. P1321 - Rheumatoid Vasculitis: An Unusual Cause of Abdominal Pain in an Older Patient, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.