71: Gastrointestinal manifestations of systemic diseases


CHAPTER 71
Gastrointestinal manifestations of systemic diseases


Seth Sweetser


Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA


Many systemic diseases are commonly manifest by gastrointestinal signs or symptoms. The liver or gut may be the principal targets of the disease process or indirectly affected by the disease or by a side‐effect of treatment for the disease. In some instances, the gastrointestinal manifestation may be the presenting sign of the disease and a cause for seeking medical attention. In this chapter, we present select images of systemic diseases which have well‐recognized gastrointestinal manifestations and can be identified by a variety of imaging techniques.


Cardiovascular diseases


Aortic stenosis has been associated with an increased risk of gastrointestinal bleeding secondary to vascular ectasia of the gut (Figure 71.1). Severe abdominal pain can be a presentation of cocaine toxicity due to dissection of the celiac axis (Figure 71.2).


Genetic disease


Adults with type 1 Gaucher disease present with hepatosplenomegaly and pathological bone fractures (Figure 71.3). There are various gastrointestinal manifestations of cystic fibrosis. Alterations in the small bowel mucosa cause physiological dysfunction of the intestine. Distal intestinal obstruction syndrome (Figure 71.4) is complete or partial intestinal obstruction by viscid fecal material in the terminal ileum and proximal colon in adult patients with cystic fibrosis.


Connective tissue diseases and inflammatory disorders


Connective tissue diseases commonly affect the gastrointestinal tract directly, as in the case of scleroderma (Figure 71.5), or as a side‐effect of immunosuppressive treatment, for example esophageal candidiasis in a patient treated with corticosteroids (Figure 71.6). Systemic lupus erythematosus frequently involves the gut. Lupus enteritis (Figure 71.7) may result from mesenteric thrombosis or leukocytoclastic vasculitis due to immune complex deposition. Visceral angioedema may present with recurrent episodes of abdominal pain, vomiting, and diarrhea. The etiology of angioedema is varied but includes medication‐related (e.g., angiotensin‐converting enzyme inhibitors) and hereditary deficiencies of the complement system. Diagnosis of visceral angioedema is often suggested by cross‐sectional imaging (Figure 71.8) showing segmental bowel wall thickening with luminal narrowing.


Endocrine and renal diseases


Diabetes mellitus commonly presents with gastrointestinal complications secondary to autonomic neuropathy such as gastric dilation (Figure 71.9) and colonic dilation (Figure 71.10) or atherosclerosis of mesenteric vasculature (Figure 71.11). Endometriosis can involve the gastrointestinal tract due to anatomical proximity (Figure 71.12). Chronic kidney disease is also associated with vascular ectasia of the gastrointestinal tract (Figures 71.13 and 71.14).


Granulomatous diseases


Granulomas, which are a focal, inflammatory process composed of macrophages and other inflammatory cell types, form in the gastrointestinal tract in association with many noninfectious diseases, such as sarcoidosis (Figure 71.15), and infectious diseases, such as atypical Mycobacterium infection in an HIV‐positive patient (Figure 71.16).


Hematological diseases


Gastrointestinal bleeding can occur in patients with an inherited or acquired deficiency in coagulation factors. Figure 71.17 depicts an uncommon complication of warfarin ingestion presenting with an intramural hematoma of the esophagus. Eosinophilic infiltration and thickening of the gastrointestinal tract wall, as well as infiltration of other organs, can be seen in hypereosinophilic syndrome (Figure 71.18). Hypercoagulability is an important cause of gastrointestinal morbidity. Spontaneous thrombosis of the mesenteric veins can cause intestinal ischemia and infarction (Figure 71.19).

Photo depicts duodenal vascular ectasia in a patient with aortic stenosis.

Figure 71.1 Duodenal vascular ectasia in a patient with aortic stenosis.


Source: Seth Sweetser.

Photo depicts computed tomography angiogram showing irregular narrowing of the true lumen of the celiac axis (arrow) secondary to a cocaine-induced dissection.

Figure 71.2 Computed tomography angiogram showing irregular narrowing of the true lumen of the celiac axis (arrow) secondary to a cocaine‐induced dissection.


Source: Courtesy of Iain Kirkpatrick, MD, Department of Radiology, University of Manitoba.

Photo depicts a patient with Gaucher disease developed left upper quadrant pain, and a computed tomograph (a) showed a heterogeneous mass in the enlarged spleen (arrow), which on splenectomy was found to be lymphoma.

Figure 71.3 A patient with Gaucher disease developed left upper quadrant pain, and a computed tomograph (a) showed a heterogeneous mass in the enlarged spleen (arrow), which on splenectomy was found to be lymphoma. A radiograph of the femur in the same patient shows the characteristic “Erlenmeyer flask deformity” (b), in which the diaphysis is narrow and the metaphysis is flared outwards.


Source: Courtesy of Iain Kirkpatrick, MD, Department of Radiology, University of Manitoba.


Vasculitis


Figure 71.20 shows considerable narrowing of the lumen of the abdominal aorta in a patient with chronic Takayasu arteritis. Intestinal ischemia and infarction may result from vasculitic involvement of the gastrointestinal tract (Figure 71.21).


Cancer


Intestinal metastasis from tumors originating in locations outside the gastrointestinal system can produce significant symptoms (Figures 71.22 and 71.23). Non‐Hodgkin lymphoma can originate primarily in the gastrointestinal tract, for example gastric lymphoma (Figure 71.24). As many as 10% of patients with non‐Hodgkin lymphoma originating from a nongastrointestinal site develop secondary involvement of the gastrointestinal tract (Figure 71.25). Neutropenic enterocolitis is a well‐known complication following chemotherapy‐induced neutropenia, most often in patients with leukemia (Figures 71.26 and 71.27). Neutropenia can also be complicated with hepatosplenic candidiasis (Figure 71.28). Other gastrointestinal complications of cancer treatment include graft‐versus‐host disease following stem cell transplantation (Figure 71.29), Clostridium difficile pseudomembranous colitis induced by broad‐spectrum antibiotic therapy (Figure 71.30),and postirradiation proctitis (Figure 71.31). Checkpoint inhibitor therapy may cause an immune‐mediated enterocolitis (Figure 71.32).

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Nov 27, 2022 | Posted by in GASTROENTEROLOGY | Comments Off on 71: Gastrointestinal manifestations of systemic diseases
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