HSP and Intussusception

 

We have discussed intussusception before and have noted that it can be a difficult diagnosis to make as the “classic” triad of colicky abdominal pain, vomiting, and currant jelly stools only occurs in 21% of cases.  Furthermore, the precipitating condition that produced the lead point that caused the intussusception can also distract you from making the diagnosis.  Is this colicky abdominal pain due to the viral illness the child has or is it due to telescoped intestine that started at the hypertrophied Peyer’s Patch?  Another great example of this is Henoch-Schonlein Purpura (HSP).

HSP is the most common vasculitis affecting children.

  1. It is self-limiting and generally resolves after ~4 weeks, but nephritis can persist.
  2. Clinical manifestations are due to widespread leukocytoclastic vasculitis from IgA deposition in blood vessel walls.
  3. Dominant Features (ARENA):
    1. Abdominal Pain (occurs in 65% of cases)
      1. May precede rash.
      2. Colicky pain, vomiting, and GIB are common (sounds like intussusception).
      3. May mimic acute surgical abdomen.
      4. Intussusception is rare, but known complication.
    2. Rash (occurs in 100% of cases)
      1. Sine qua non
      2. Purpura, classically palpable. Starts on legs and buttocks. Not itchy.
      3. Not associated with thrombocytopenia!
      4. May be preceded briefly by urticarial or maculopapular rash.
    3. Edema
      1. Angioedema of the scalp, eyelids, back, feet, and/or perineum.
      2. Less common in older children.
    4. Nephritis (occurs in 40% of cases)
      1. Hallmark is hematuria.
      2. Substantial proportion will have gross hematuria.
      3. May not develop for weeks to months after diagnosis (needs close follow-up).
      4. May become a chronic problem.
    5. Arthritis (occurs in 75% of cases)
      1. Commonly involves knees and ankles.
      2. Self-limiting and non-deforming.
      3. Can be severely painful.
      4. May precede the rash and, thus, confound diagnosis.

 

Intussusception and HSP

  1. Intussusception can be seen as a complication of HSP in 2-6% of cases.
  2. HSP associated intussusception generally occurs in children >2yrs of age.
  3. 70% occur in ileoileal locations, with only 30% being ileocolic (unlike typical intussusception, which occurs most commonly at ileocolic locations.
    1. Contrast enema may not diagnose it, because of the ileoileal location.
    2. Ultrasound is preferred imaging modality, augmented by serial examinations.
    3. Upper GI Series with small bowel follow-through may be necessary as well.

 

Saulsbury FT. Henoch-Schonlein Purpura. Current Opinion in Rheummatology: Jan. 2001; Vole 13(1). Pp.35-40.

Little KJ, Danzl DF. Intussusception associated with Henoch-Schonlein Purpura. The Journal of Emergency Medicine: 1991; Vole 9 (supp 1). Pp. 29-32.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

8 Responses

  1. Tracy Tierney says:

    What if any are the complications of an Intussusception in later life ? My son had HSP and an Intussusception at age 2

    • Sean Fox says:

      Once it has been reduced, it should not lead to lasting issues. If there is an underlying cause of the intussusception (i.e., a lead point), then there may be related issues due to that cause.

      Hope your son is doing well,
      sean

  1. August 14, 2013

    […] jelly stools and vomiting is only seen in one fifth of patient with intussusception (see a great post on Pediatric EM Morsels about […]

  2. July 4, 2014

    […] are familiar with the dominant features of HSP… let’s review […]

  3. July 7, 2014

    […] have previously discussed several kidney related issues: Hypertension Crisis, Kidney Stones, HSP, Rhabdomyolysis and Proteinuria. Wanting to remain vigilant for the big, bad, and ugly conditions […]

  4. October 16, 2015

    […] Does this fit the “illness script” of HSP? […]

  5. March 31, 2016

    […] We have also covered that the diagnosis of intussusception can be challenging and associated with other conditions. […]

  6. May 5, 2017

    […] HSP […]

Leave a Reply

Your email address will not be published. Required fields are marked *