Small Bowel Perforation Secondary to Rheumatoid Arthritis Associated Vasculitis

Summary: Small Bowel Perforation Secondary to Rheumatoid Arthritis Associated Vasculitis Zefr Chao, MD, Marco A. Campos, BS, Ronald Orozco, MD, Kim Reiter, MD, Joseph Glass, MD, Anthony Vigil, MD Background Rheumatoid arthritis (RA) is one of the most common chronic autoimmune diseases, characterized by systemic inflammation that primarily affects the joints. However, RA-related extra articular manifestations (EAMs) can have significant clinical and pathologic implications. Typically, cardiovascular, and pulmonary EAMs are the largest contributors to morbidity and mortality, but rheumatoid vasculitis is an uncommon yet potentially devastating EAM that can often manifest through the development of necrotizing vasculitis of small or medium-sized vessels. Bowel involvement in rheumatoid vasculitis is a complication that carries high mortality. We present a case from our institution and review of the documented cases of rheumatoid arthritis associated vasculitis (RAAV). Case Presentation A male in his 60s with known seropositive RA and cerebral vasculitis presented with abrupt onset lower back and abdominal pain. The patient developed peritonitis which led to an exploratory laparotomy. During the procedure, jejunal ischemia, necrosis, and a perforation, necessitating subsequent bowel resection were discovered. On final surgical pathology the patient had mesenteric vessel intramural inflammation indicative of vasculitis, in the setting of his known RA. Discussion Mesenteric vasculitis results from chronic vascular intramural inflammation, most responsive to long-term medical management. Early intervention is crucial in preventing irreversible bowel injury. In cases presenting with an acute abdomen, surgical intervention is warranted. However, cases requiring surgical exploration have high mortality rate. The use of perioperative immunomodulators in acute settings may increase complication risk without providing immediate benefit. Ongoing advances in therapies that target autoimmune diseases continue to lead to a reduction in the incidence of vasculitis and improve the management of comorbidities. Despite advancements in RA therapies, challenges such as loss to follow-up and noncompliance persist. Conclusion A high index of suspicion for mesenteric vasculitis should be considered in patients presenting with abdominal pain, especially patients with inflammatory autoimmune conditions. The high mortality represented by gastrointestinal involvement in RAAV warrants investigation in high-risk patients, despite its low prevalence. Considering RAAV in the differential diagnosis of patients with chronic RA and abdominal symptoms is critical. Prompt recognition and treatment of RAAV is imperative to ensure early intervention and coordination of specialist care. Treatment may consist of high-dose corticosteroids, immunosuppressive agents and biologic therapies that target the underlying autoimmune process and reduce inflammation.