S4632 Severe Recurrent Gastrointestinal Bleeding Requiring Ileocolectomy in an Adult With IgA Vasculitis

Introduction: Immunoglobulin A (IgA) vasculitis, formerly Henoch-Schönlein purpura, is a small-vessel vasculitis that is more common in children and typically self-limited. In adults, it tends to follow a more severe course with renal and gastrointestinal involvement. Gastrointestinal (GI) involvement, often in the small bowel, can lead to complications such as bleeding or ischemia, though severe hemorrhage requiring surgery is rare. We report a diagnostically challenging case of adult-onset IgA vasculitis complicated by recurrent GI bleeding, requiring extensive endoscopic evaluation and multiple bowel resections. Case Description/Methods: The patient is a 67-year-old man with a history of hypertension, coronary artery disease, and a recent biopsy proven diagnosis of IgA nephropathy who was admitted for pneumonia and later in the hospitalization. GI was consulted for melena. Initial esophagogastroduodenoscopy was unremarkable. Colonoscopy revealed blood in the distal ileum with no identifiable lesions. Push enteroscopy showed Forrest Class III non-bleeding jejunal ulcers, which did not explain the ongoing blood loss. Video capsule endoscopy demonstrated multiple ileal ulcers with active bleeding. Intraoperative enteroscopy confirmed multiple partially circumferential ulcers in the distal ileum with active bleeding, approximately 25 cm in length. He underwent ileocolectomy after the completion of intraoperative enteroscopy. Pathology revealed focal active granulomatous inflammation, consistent with vasculitis. He was also treated with cyclophosphamide and corticosteroids, which along with the ileocolectomy eventually led to the cessation of bleeding. Unfortunately, patient developed an ileocolic anastomotic leak with intra-abdominal abscess which necessitated multiple additional revisions. Discussion: This case highlights the diagnostic complexity and clinical severity of GI manifestations in adult IgA vasculitis. The bleeding source was not identified on standard endoscopy, necessitating capsule and intraoperative enteroscopy. Vasculitis should remain on the differential diagnosis in cases of obscure GI bleeding, especially in patients with systemic inflammation. IgA vasculitis is rare in adults, and its presentation may be aggressive, involving multiple organ systems and requiring surgical intervention. We hope to emphasize the importance of diagnostic evaluation, and multidisciplinary management in cases of GI vasculitis.