Clinical Characteristics and Risk Factors of Gastrointestinal Perforation in Children with Henoch-Schönlein Purpura

Clinical Characteristics and Risk Factors of Gastrointestinal Perforation in Children with Henoch-Schönlein Purpura | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Clinical Characteristics and Risk Factors of Gastrointestinal Perforation in Children with Henoch-Schönlein Purpura Qingyin Guo, Xiaolei Hu, Chundong Song, Xianqing Ren, Wensheng Zhai, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-37348/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Henoch-Schönlein purpura (HSP) is a common small vessel vasculitis in children. Gastrointestinal perforation (GP) rarely presents as a complication of HSP and was not well characterized. This study aimed to investigate the clinical features, diagnosis and risk factors of GP in children with HSP. Methods: We retrospectively reviewed the clinical data of 10791 children with HSP who attended our hospital between January 2014 and June 2018 and analyzed the treatment and clinical risk factors of 11 children with HSP complication with GP. Results: GP occurred in 11 children with HSP, with an incidence of 0.10%. Among the 11 cases HSP with GP, 1 case was gastric perforation and 10 cases were intestinal perforation. CT indicates perforation but ultrasonography did not indicate perforation in 5 cases of GP patients. The average duration of abdominal pain in HSP with GP was 9.3 days, and 9 cases (81.8%) with a duration of abdominal pain over 7 days. 3 cases of HSP with GP were treated by gastric/intestinal perforation repair and the other 8 cases were treated by enterectomy. The type of purpura, abdominal pain lasting more than 7 days, hematochezia, renal damage, and methylprednisolone dose more than 2mg/kg in GP with HSP patients show statistically significant compared with the control group ( P <0.05). Conclusion: The incidence rate of GP in children with HSP was 0.10%. Abdominal (or mixed) HSP, hematochezia, renal damage, abdominal pain lasting more than 7 days, and methylprednisolone dose more than 2mg/kg may increase the risk of GP in children with HSP. CT has a high sensitivity for the diagnosis of GP. Early diagnosis and timely treatment of HSP with GP were very important for good clinical outcomes. Pediatrics Rheumatology Children Henoch-Schonlein purpura Gastrointestinal perforation Retrospective analysis Risk factors Figures Figure 1 Figure 2 Background Henoch-Schönlein purpura (HSP) also known as IgA vasculitis, is a systemic vasculitis based on extensive inflammation of small blood vessels and is the most common vasculitis in childhood [ 1 ]. The incidence of HSP was 20.4 per 100 000 [ 2 ]. Clinical manifestations of HSP include palpable skin purpura, gastrointestinal symptoms, joint symptoms, and renal damage. HSP patients whose main clinical manifestation is gastrointestinal symptoms called abdominal type HSP. Intestinal obstruction and intestinal perforation may occur in severe cases [ 3 , 4 ], if not treated or surgery immediately, it will lead to serious consequences and even death. In current, only a few publications about HSP complicated with GP, it was generally recorded as case reports in previous studies [ 5-7 ]. There still lack large sample investigation data, and no in-depth study on the risk factors related to its onset has been conducted. We herein retrospectively analyzed the clinical data of 11 cases of HSP with GP among 10791 HSP patients and analyzed clinical characteristics, diagnosis, treatment and risk factors. Methods A total of 10791 cases (aged 1~17 years) of children with HSP who attended the Department of Pediatrics, First Affiliated Hospital of Henan University of traditional Chinese medicine from January 2014 to June 2018 were selected as study subjects. All children diagnosed with HSP are based on the European league of rheumatology (EULAR) and the children's rheumatology international (PRINTO) and the children's rheumatology league (PRES) in 2010 [ 8 ]. Clinical data of 11 children with GP (perforation group) were collected, including gender, age, clinical manifestations, time of abdominal pain, hematochezia, renal damage and diagnosis and treatment. 42 of the 10780 HSP children without GP were selected (whose hospital admission number includes the number “111”) as the control group. Gender, age, purpura type, abdominal pain duration, hematochezia, renal damage and other risk factors that may affect GP in children with HSP were analyzed. All the clinical data used in this study were obtained from the paper and electronic medical records of our hospital and approved by the medical ethics committee of the First Affiliated Hospital of Henan University of traditional Chinese medicine. HSP clinical classification The classification of HSP was divided into: Skin purpura: clinical manifestations were simple skin purpura alone; Joint type: in addition to skin purpura, joint swelling and pain symptoms; Abdominal type: in addition to skin purpura, gastrointestinal symptoms and signs, such as abdominal pain nausea and vomiting; Renal type: skin purpura accompanied by hematuria and/or proteinuria specific; Mixed type: in addition to skin purpura, the other three types of two or more. Statistical analysis The descriptive analysis included calculations of various proportions. Chi-squared test and univariate logistic regression were used to analyze the risk factors of HSP complicated with GP. Statistical analyses were performed using SPSS statistical package 22.0 (IBM SPSS Inc., Chicago, IL, USA). A value of p < 0.05 was considered statistically significant. Results Age of onset in children with HSP A total of 10791 cases of children with HSP who attended the department of pediatrics, first affiliated hospital of Henan University of Chinese Medicine between January 2014 and June 2018, including 6278 males and 4513 females. The average age of onset was 8.07±3.18 years. HSP mainly occurred in children aged between 3~14 years, with a total of 10194 cases, accounting for 94.47%. The peak morbidity age was 5~9 years, with a total of 6168 cases, accounting for 57.16%. Detailed results are shown in Figure1. Clinical manifestations of children with HSP The clinical manifestations of HSP were divided skin type, joint type, abdominal type, renal type and mixed type. In this study, clinical manifestations of 10791 children with HSP were classified, as shown in Table 1, among 10791 HSP children, 1992 cases (18.46%) only appear skin purpura, 4434 cases (41.08%) with joint symptoms, 4357 cases (40.75%) with abdominal symptoms, and 4072 cases (37.72%) with renal damage. Clinical characteristics and diagnosis of GP in children with HSP Among 10791 HSP children, total 11 cases developed GP, the incidence was 0.10%. 11 HSP children with GP, including 8 males and 3 females, 5 to 13 years old, the average age is 8.09 years. These 11 cases with GP had a lot of skin purpura accompanied with hematemesis and gastrointestinal symptoms, including 3 cases of facial skin purpura, 8 cases with joint pain, 7 cases with renal damage. Among 11 cases HSP children with GP, 1 case was gastric perforation, 10 cases were intestinal perforation; ileocecal region, terminal ileum and ileum accounted for 4 cases, 1 case and 5 cases, respectively; found the GP from abdominal pain start time minimum 3 days, the most 14 days, an average of 9.3 days. Among the 11 cases, 3 cases were diagnosed by color doppler ultrasound without CT, three cases were all positive, five cases were negative by color doppler ultrasound, then positive by CT. Case 1 (gastric perforation), case 6 (terminal ileum perforation) and case 11 (ileum perforation) due to early detection, the patient had a small perforation and underwent gastric/intestinal repair, while the remaining 8 patients underwent enterectomy, of which case 7 had a small intestinal diverticulum and underwent diverticular resection; due to severe abdominal pollution, 4 and 5 cases underwent intestinal resection and anastomosis plus intraperitoneal fistula, and the fistula was pulled out half a year later. The clinical characteristics and diagnosis and treatment of the children with GP as shown in Table 2. CT diagnosis and surgical treatment of GP in children with HSP (case 6) are shown in Figure 2. Risk factors analysis of GP in children with HSP GP is one of the serious complications of HSP children, diagnosis and surgical treatment should be given in timely. To explore the risk factors of GP in HSP children, 11 cases HSP children with GP as perforation group, 42 cases from the remained 10780 cases HSP children were selected as control group. Chi-squared test and univariate logistic regression were used to analyze the risk factors that might affect the occurrence of GP in HSP children, such as gender, age, purpura type, the time of abdominal pain, hematochezia, renal damage, methylprednisolone dose more than 2mg/kg. As the results showed the abdominal type (or mixed type) HSP, hematochezia, renal damage, abdominal pain lasts more than 7 days, methylprednisolone dose more than 2mg/kg showed statistically significant differences ( p< 0.05) (Table 3), which maybe the potential risk factors of GP in children with HSP. Discussion HSP is a commonly vasculitis in childhood. In this study, we retrospectively analyzed the clinical data of 10791 HSP children who attended our hospital between January 2014 and June 2018. Among the 10791 HSP children, 10194 cases (94.47%) occurring at the age of 3~14 years, 6168 cases (57.16%) occurring at the age of 5~9 years. Gastrointestinal symptoms were frequently observed in children with HSP, accounting for 50%~75% [ 2 , 3 , 9 ], abdominal distention and abdominal pain are the usual clinical manifestations, and the pathological manifestations are erosion, edema and necrosis of gastrointestinal tract mucosa[ 10 ]. Typical endoscopic manifestations of HSP include diffuse mucosal edema, erythema and ecchymosis, or multiple irregular ulcers [ 11 , 12 ]. In our study, we found 11 of the 10791 HSP children developed GP, with an incidence of 0.10%, lower than that reported in the literature of 0.38%[ 13 ]. To our knowledge, the reported 11 patients represent the biggest retrospective case series hitherto published. GP is one of the abdominal complications requiring surgical treatment in HSP children. Other complications include intussusception, massive gastrointestinal bleeding and intestinal necrosis[ 14 ]. The symptoms of children with GP are relatively serious, and delayed treatment may endanger the life of the patients. Hence, we analyzed the possible risk factors of GP in HSP children, including age, gender, purpura type, the time of abdominal pain, hematochezia, renal damage, methylprednisolone dose more than 2mg/kg. In our study, 7 HSP children with GP were associated with renal damage (63.63%), which was significantly higher than that of the control group (26.2%), suggesting that HSP children with renal damage had a greater risk of GP. Some studies indicate that abdominal pain may be one of the important risk factors of HSP children renal damage [ 5 , 15 ], therefore, HSP children with gastrointestinal symptoms should be regularly monitored with routine urine, renal damage. 11 cases HSP children with GP all showed bloody symptoms (100%), while the control group only 3 cases (7.14%) showed bloody symptoms, indicated that bloody symptom is one risk of GP. In addition, HSP children with GP show a large number of skin purpura, and 3 cases show facial purpura. Whether the risk of GP can be identified early according to the severity of skin purpura and site symptoms remains to be further studied and confirmed. The pathogenesis of GP in HSP children was still unclear. It has been reported that thrombus caused by vasculitis may lead to intestinal ischemia, followed by intestinal wall necrosis and perforation [ 16 ]. Ultrasonography or CT signs are useful to confirm the diagnosis of GP. The key to ultrasonographic examination of gastrointestinal perforation is the free gas under the diaphragm and a small amount of gas and fluid next to the perforation. When the perforation is small, the subphrenic gas is less, or the intestinal perforation is wrapped by other surrounding tissue, the gas can’t reach the subdiaphragm, or the patient has a large amount of air in the intestinal loop, it will affect the color ultrasound diagnosis. In our study, ultrasonography did not indicate perforation, but CT indicated perforation of gastrointestinal tract in 5 cases, suggesting that CT was more sensitive than ultrasonography. Therefore, when GP was not detected by ultrasonography but clinical symptoms can’t be excluded, we should perform CT examination to avoid misdiagnosis. In our study, the average duration of abdominal pain of GP in HSP children was 9.3 days, this was consistent with that intestinal perforation of HSP occurred during the second week after hormone application[ 13 ]. There are 9 cases (81.8%) abdominal pain lasted more than a week, while the longest time in the control group is 5 days. HSP children abdominal pain lasting more than a week can be considered as identifying early GP reference. Glucocorticoid can reduce the edema, relieve pain, application of hormone in early stage may reduce the risk of surgical intervention[ 4 , 15 ]. But systemic glucocorticoid therapy may mask symptoms of surgical complications such as abdominal pain and fever[ 15 ]. Some studies have shown that large doses of corticosteroids could reduce mucosal mucus synthesis in the gastrointestinal tract, inhibit the regeneration and healing of the intestinal mucosa, reduce the thickness of the gastrointestinal wall, and reduce lymphatic follicles, all of which increase the risk of intestinal perforation[ 5 , 6 , 13 , 17 ]. Our study indicated that a course of methylprednisolone of more than 7 days and a dose of more than 2mg/kg were risk factors of GP in HSP children. However, hormones were still the most effective treatment options for abdominal symptoms of HSP. Therefore, in the clinical treatment of HSP patients, it is necessary to weigh the advantage and disadvantages of long-term and high-dose hormone use, and to control the dosage and course of hormone use. Conclusions HSP children with severe gastrointestinal symptoms should be evaluated for GP. In the current study, we found that the factors of abdominal or mixed HSP, abdominal pain lasting more than 7 days, hematochezia, renal damage, methylprednisolone dose more than 2mg/kg may increase the risks of GP in HSP children. It’s necessary to cooperate with physical examination and combine with color ultrasound or CT examination to identify and diagnose HSP-related gastrointestinal tract as early as possible, so as to give timely and appropriate surgical intervention measures to reduce the trauma of children. Due to GP is relatively rare in HSP children, the number of cases can be expanded or a multicenter clinical study can be conducted to further study the relationship between HSP and GP and reduce complications. Abbreviations HSP: Henoch-Schönlein purpura GP: Gastrointestinal perforation CT: Computerized tomography Declarations Ethics approval and consent to participate The study protocol was approved by the Research Ethics Commission of the First Affiliated Hospital of Henan University of Chinese Medicine. This study is a retrospective analysis of pre-existing data, and the informed consent of parents or guardians is not required. Consent for publication The authors declare that they agree to submit the article for publication. Availability of data and materials The data used in this study are available upon request of the author Qingyin Guo. The paper and electronic medical record used in this study belong to the First Affiliated Hospital of Henan University of Chinese Medicine and is available only via administrative permission. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Special Project of Chinese Medicine Scientific Research in Henan（2016ZY2030） Author’s contributions All authors contributed to the study conception and design. QG, XZ, MY and MJ reviewed the medical records, analyzed and interpreted the data. CS, XR, WZ and YD coordinated and supervised data collection. XH and JZ collected data and searched literature. The first draft of the manuscript was written by QG and MJ. All authors read and approved the final manuscript. References Trnka P: Henoch-Schonlein purpura in children . Journal of paediatrics and child health 2013, 49 (12):995-1003. Gardner-Medwin JM, Dolezalova P, Cummins C, Southwood TR: Incidence of Henoch-Schonlein purpura, Kawasaki disease, and rare vasculitides in children of different ethnic origins . Lancet 2002, 360 (9341):1197-1202. Yamazaki T, Akimoto T, Iwazu Y, Sugase T, Takeshima E, Numata A, Komada T, Yoshizawa H, Otani N, Morishita Y et al : Henoch-Schonlein purpura complicated with severe gastrointestinal bleeding . CEN case reports 2015, 4 (1):106-111. Subspecialty Group of I, Society of P, Chinese Medical A, Editorial Board of Chinese Journal of P: [Evidence-based recommendations for the diagnosis and management in the children with Henoch-Schonlein purpura] . Zhonghua Er Ke Za Zhi 2013, 51 (7):502-507. Lerkvaleekul B, Treepongkaruna S, Saisawat P, Thanachatchairattana P, Angkathunyakul N, Ruangwattanapaisarn N, Vilaiyuk S: Henoch-Schonlein purpura from vasculitis to intestinal perforation: A case report and literature review . World journal of gastroenterology 2016, 22 (26):6089-6094. Wang HL, Liu HT, Chen Q, Gao Y, Yu KJ: Henoch-Schonlein purpura with intestinal perforation and cerebral hemorrhage: a case report . World journal of gastroenterology 2013, 19 (16):2574-2577. Chahri Vizcarro N, Andreu Solsona V, Barba Sopena S, Sanjaume Feixas M: Intussusception as the main manifestation of Schonlein-Henoch purpura in an adult patient . Gastroenterol Hepatol 2019, 42 (7):443-444. Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, Buoncompagni A, Lazar C, Bilge I, Uziel Y et al : EULAR/PRINTO/PRES criteria for Henoch-Schonlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria . Ann Rheum Dis 2010, 69 (5):798-806. Wang X, Zhu Y, Gao L, Wei S, Zhen Y, Ma Q: Henoch-Schonlein purpura with joint involvement: Analysis of 71 cases . Pediatr Rheumatol Online J 2016, 14 (1):20. Goda F, Maeba T, Usuki H, Karasawa Y, Izuishi K, Ishimura K, Senda S, Maeta H: Colo-colic intussusception associated with Henoch-Schonlein purpura in adults . J Gastroenterol Hepatol 2007, 22 (3):449-452. Louie CY, Gomez AJ, Sibley RK, Bass D, Longacre TA: Histologic Features of Gastrointestinal Tract Biopsies in IgA Vasculitis (Henoch-Schonlein Purpura) . Am J Surg Pathol 2018, 42 (4):529-533. Audemard-Verger A, Pillebout E, Guillevin L, Thervet E, Terrier B: IgA vasculitis (Henoch-Shonlein purpura) in adults: Diagnostic and therapeutic aspects . Autoimmun Rev 2015, 14 (7):579-585. Yavuz H, Arslan A: Henoch-Schonlein purpura-related intestinal perforation: a steroid complication? Pediatrics international : official journal of the Japan Pediatric Society 2001, 43 (4):423-425. Shiohama T, Kitazawa K, Omura K, Honda A, Kozuki A, Tanaka N, Omata A, Ooe K, Suzuki Y: Intussusception and spontaneous ileal perforation in Henoch-Schonlein purpura . Pediatrics international : official journal of the Japan Pediatric Society 2008, 50 (5):709-710. van den Broek RW, van Rossum MA, van Duinen CM: A new surgical complication related to corticosteroids in a patient with Henoch-Schonlein purpura . J Pediatr Surg 1995, 30 (9):1341-1343. Choong CK, Beasley SW: Intra-abdominal manifestations of Henoch-Schonlein purpura . Journal of paediatrics and child health 1998, 34 (5):405-409. Almassinokiani F, Mehdizadeh Kashi A, Musavi A, Khodaverdi S, Tahermanesh K, Ariana S: Rectal perforation in a 42-year-old woman due to Henoch-Schonlein purpura: a case report . Reumatismo 2017, 69 (3):131-133. Tables Table 1. Clinical manifestations of children with HSP Clinical manifestation Skin Joint Abdominal Renal Mixed Abdominal + Renal Abdominal + Joint Joint + Renal Abdominal + Renal + Joint No. of cases 1992 2206 1523 1715 1117 988 511 729 Percent（%） 18.46 20.44 14.11 15.89 10.35 9.16 4.73 6.75 Table 2. Clinical characteristics, diagnosis and treatment of HSP complicated with GP No. Sex Age Days of abdominal pain CT Ultrasound Diagnosis Site Treatment method Facial purpura Joint pain Renal damage Methylprednisolone dose and duration 1 Male 13 16 + - gastric perforation gastral Intestinal perforation repair - + - 3mg/kg/day for 10 days 2 Male 6 9 / + intestinal perforation ileocecal Enterectomy - - + 2.5mg/kg/day for 9 days 3 Female 5 16 + - intestinal perforation ileocecal Enterectomy + + + 2.4mg/kg/day for 17 days 4 Female 5 11 + + intestinal perforation ileocecal Enterectomy+fistula - + + 3mg/kg/day for 12 days 5 Female 7 7 / + intestinal perforation ileocecal Enterectomy+fistula - - + 2.5mg/kg/day for 30 days 6 Male 8 11 + - intestinal perforation terminal ileum Intestinal perforation repair - + - 2.8mg/kg/day for 11 days 7 Male 12 11 + - intestinal perforation ileum Enterectomy + diverticulectomy + + + 2.3mg/kg/day for 11 days 8 Male 9 3 / + intestinal perforation ileum Enterectomy - + - 2.9mg/kg/day for 4 days 9 Male 10 14 + - intestinal perforation ileum Enterectomy - + - 3.2mg/kg/day for 14 days 10 Male 7 5 + + intestinal perforation ileum Enterectomy - + + 3mg/kg/day for 8 days 11 Male 7 9 + + intestinal perforation ileum Intestinal perforation repair + - + 3mg/kg/day for 9 days Note: “+” means positive, “-” means negative, “/” means no test Table 3. The univariate Chi - square test of risk factors of HSP with GP [ n (%)] group Case number Age<10 years Male Abdominal (mixed) allergic purpura Hematochezia Renal damage Abdominal pain lasts longer than 7 days Methylprednisolone dose more than 2mg/kg Perforated group 11 9(81.8) 8(72.7) 11(100.0) 11(100.0) 7(63.6) 9(81.8) 11(100) Control 42 35(83.3) 28(66.7) 27(64.3) 3(7.14) 11(26.2) 0(0) 3(7.14) χ 2 value 0.014 0.147 5.479 38.668 5.449 41.39 38.67 P value 0.905 0.701 0.019 0 0.019 0 0 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-37348","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":701089,"identity":"9f4a2161-f500-48d9-a86c-785eca815330","order_by":0,"name":"Qingyin Guo","email":"","orcid":"","institution":"The First Affiliated Hospital of Henan University of CM","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qingyin","middleName":"","lastName":"Guo","suffix":""},{"id":701090,"identity":"b68826a6-dd75-47ab-9e99-20d128d7e41d","order_by":1,"name":"Xiaolei Hu","email":"","orcid":"","institution":"Henan University of 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05:30:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-37348/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-37348/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1393246,"identity":"ca356ddf-88b3-492c-b095-2336b634a724","added_by":"auto","created_at":"2020-06-22 22:27:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26038,"visible":true,"origin":"","legend":"Age distribution of children with HSP ","description":"","filename":"Fig1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-37348/v1/Fig1.JPG"},{"id":1393247,"identity":"fc8acc58-ccec-4968-918e-947c44141731","added_by":"auto","created_at":"2020-06-22 22:27:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27859,"visible":true,"origin":"","legend":"CT diagnosis and treatment of HSP complicated with GP. a and b, CT image of HSP complicated with GP (case 6); c, Intraoperative image of HSP complicated with GP (case 6). Arrows indicate perforation of the digestive tract.","description":"","filename":"Fig2.JPG","url":"https://assets-eu.researchsquare.com/files/rs-37348/v1/Fig2.JPG"},{"id":13543753,"identity":"85499e69-e2f5-487b-9126-f586f1c87d52","added_by":"auto","created_at":"2021-09-17 01:59:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":666345,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-37348/v1/cedcc51b-67cb-4b91-9c35-bfc932cc19f4.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eClinical Characteristics and Risk Factors of Gastrointestinal Perforation in Children with Henoch-Schönlein Purpura\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHenoch-Sch\u0026ouml;nlein purpura (HSP) also known as IgA vasculitis, is a systemic vasculitis based on extensive inflammation of small blood vessels and is the most common vasculitis in childhood [\u003ca href=\"#_ENREF_1\"\u003e1\u003c/a\u003e]. The incidence of HSP was 20.4 per 100 000 [\u003ca href=\"#_ENREF_2\"\u003e2\u003c/a\u003e]. Clinical manifestations of HSP include palpable skin purpura, gastrointestinal symptoms, joint symptoms, and renal damage. HSP patients whose main clinical manifestation is gastrointestinal symptoms called abdominal type HSP. Intestinal obstruction and intestinal perforation may occur in severe cases [\u003ca href=\"#_ENREF_3\"\u003e3\u003c/a\u003e, \u003ca href=\"#_ENREF_4\"\u003e4\u003c/a\u003e], if not treated or surgery immediately, it will lead to serious consequences and even death. In current, only a few publications about HSP complicated with GP, it was generally recorded as case reports in previous studies [\u003ca href=\"#_ENREF_5\"\u003e5-7\u003c/a\u003e]. There still lack large sample investigation data, and no in-depth study on the risk factors related to its onset has been conducted. We herein retrospectively analyzed the clinical data of 11 cases of HSP with GP among 10791 HSP patients and analyzed clinical characteristics, diagnosis, treatment and risk factors.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA total of 10791 cases (aged 1~17 years) of children with HSP who attended the Department of Pediatrics, First Affiliated Hospital of Henan University of traditional Chinese medicine from January 2014 to June 2018 were selected as study subjects. All children diagnosed with HSP are based on the European league of rheumatology (EULAR) and the children's rheumatology international (PRINTO) and the children's rheumatology league (PRES) in 2010 [\u003ca href=\"#_ENREF_8\"\u003e8\u003c/a\u003e]. Clinical data of 11 children with GP (perforation group) were collected, including gender, age, clinical manifestations, time of abdominal pain, hematochezia, renal damage and diagnosis and treatment. 42 of the 10780 HSP children without GP were selected (whose hospital admission number includes the number \u0026ldquo;111\u0026rdquo;) as the control group. Gender, age, purpura type, abdominal pain duration, hematochezia, renal damage and other risk factors that may affect GP in children with HSP were analyzed. All the clinical data used in this study were obtained from the paper and electronic medical records of our hospital and approved by the medical ethics committee of the First Affiliated Hospital of Henan University of traditional Chinese medicine.\u003c/p\u003e\n\u003ch2\u003eHSP clinical classification\u003c/h2\u003e\n\u003cp\u003eThe classification of HSP was divided into:\u003c/p\u003e\n\u003cp\u003eSkin purpura: clinical manifestations were simple skin purpura alone;\u003c/p\u003e\n\u003cp\u003eJoint type: in addition to skin purpura, joint swelling and pain symptoms;\u003c/p\u003e\n\u003cp\u003eAbdominal type: in addition to skin purpura, gastrointestinal symptoms and signs, such as abdominal pain nausea and vomiting;\u003c/p\u003e\n\u003cp\u003eRenal type: skin purpura accompanied by hematuria and/or proteinuria specific;\u003c/p\u003e\n\u003cp\u003eMixed type: in addition to skin purpura, the other three types of two or more.\u003c/p\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eThe descriptive analysis included calculations of various proportions. Chi-squared test and univariate logistic regression were used to analyze the risk factors of HSP complicated with GP. Statistical analyses were performed using SPSS statistical package 22.0 (IBM SPSS Inc., Chicago, IL, USA). A value of \u003cem\u003ep \u003c/em\u003e\u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eAge of onset in children with HSP\u003c/h2\u003e\n\u003cp\u003eA total of 10791 cases of children with HSP who attended the department of pediatrics, first affiliated hospital of Henan University of Chinese Medicine between January 2014 and June 2018, including 6278 males and 4513 females. The average age of onset was 8.07\u0026plusmn;3.18 years. HSP mainly occurred in children aged between 3~14 years, with a total of 10194 cases, accounting for 94.47%. The peak morbidity age was 5~9 years, with a total of 6168 cases, accounting for 57.16%. Detailed results are shown in Figure1.\u003c/p\u003e\n\u003ch2\u003eClinical manifestations of children with HSP\u003c/h2\u003e\n\u003cp\u003eThe clinical manifestations of HSP were divided skin type, joint type, abdominal type, renal type and mixed type. In this study, clinical manifestations of 10791 children with HSP were classified, as shown in Table 1, among 10791 HSP children, 1992 cases (18.46%) only appear skin purpura, 4434 cases (41.08%) with joint symptoms, 4357 cases (40.75%) with abdominal symptoms, and 4072 cases (37.72%) with renal damage.\u003c/p\u003e\n\u003ch2\u003eClinical characteristics and diagnosis of GP in children with HSP\u003c/h2\u003e\n\u003cp\u003eAmong 10791 HSP children, total 11 cases developed GP, the incidence was 0.10%. 11 HSP children with GP, including 8 males and 3 females, 5 to 13 years old, the average age is 8.09 years. These 11 cases with GP had a lot of skin purpura accompanied with hematemesis and gastrointestinal symptoms, including 3 cases of facial skin purpura, 8 cases with joint pain, 7 cases with renal damage. Among 11 cases HSP children with GP, 1 case was gastric perforation, 10 cases were intestinal perforation; ileocecal region, terminal ileum and ileum accounted for 4 cases, 1 case and 5 cases, respectively; found the GP from abdominal pain start time minimum 3 days, the most 14 days, an average of 9.3 days. Among the 11 cases, 3 cases were diagnosed by color doppler ultrasound without CT, three cases were all positive, five cases were negative by color doppler ultrasound, then positive by CT. Case 1 (gastric perforation), case 6 (terminal ileum perforation) and case 11 (ileum perforation) due to early detection, the patient had a small perforation and underwent gastric/intestinal repair, while the remaining 8 patients underwent enterectomy, of which case 7 had a small intestinal diverticulum and underwent diverticular resection; due to severe abdominal pollution, 4 and 5 cases underwent intestinal resection and anastomosis plus intraperitoneal fistula, and the fistula was pulled out half a year later. The clinical characteristics and diagnosis and treatment of the children with GP as shown in Table 2. CT diagnosis and surgical treatment of GP in children with HSP (case 6) are shown in Figure 2.\u003c/p\u003e\n\u003ch2\u003eRisk factors analysis of GP in children with HSP\u003c/h2\u003e\n\u003cp\u003eGP is one of the serious complications of HSP children, diagnosis and surgical treatment should be given in timely. To explore the risk factors of GP in HSP children, 11 cases HSP children with GP as perforation group, 42 cases from the remained 10780 cases HSP children were selected as control group. Chi-squared test and univariate logistic regression were used to analyze the risk factors that might affect the occurrence of GP in HSP children, such as gender, age, purpura type, the time of abdominal pain, hematochezia, renal damage, methylprednisolone dose more than 2mg/kg. As the results showed the abdominal type (or mixed type) HSP, hematochezia, renal damage, abdominal pain lasts more than 7 days, methylprednisolone dose more than 2mg/kg showed statistically significant differences (\u003cem\u003ep\u0026lt;\u003c/em\u003e0.05) (Table 3), which maybe the potential risk factors of GP in children with HSP.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHSP is a commonly vasculitis in childhood. In this study, we retrospectively analyzed the clinical data of 10791 HSP children who attended our hospital between January 2014 and June 2018. Among the 10791 HSP children, 10194 cases (94.47%) occurring at the age of 3~14 years, 6168 cases (57.16%) occurring at the age of 5~9 years.\u003c/p\u003e\n\u003cp\u003eGastrointestinal symptoms were frequently observed in children with HSP, accounting for 50%~75% [\u003ca href=\"#_ENREF_2\"\u003e2\u003c/a\u003e, \u003ca href=\"#_ENREF_3\"\u003e3\u003c/a\u003e, \u003ca href=\"#_ENREF_9\"\u003e9\u003c/a\u003e], abdominal distention and abdominal pain are the usual clinical manifestations, and the pathological manifestations are erosion, edema and necrosis of gastrointestinal tract mucosa[\u003ca href=\"#_ENREF_10\"\u003e10\u003c/a\u003e]. Typical endoscopic manifestations of HSP include diffuse mucosal edema, erythema and ecchymosis, or multiple irregular ulcers [\u003ca href=\"#_ENREF_11\"\u003e11\u003c/a\u003e, \u003ca href=\"#_ENREF_12\"\u003e12\u003c/a\u003e]. In our study, we found 11 of the 10791 HSP children developed GP, with an incidence of 0.10%, lower than that reported in the literature of 0.38%[\u003ca href=\"#_ENREF_13\"\u003e13\u003c/a\u003e]. To our knowledge, the reported 11 patients represent the biggest retrospective case series hitherto published.\u003c/p\u003e\n\u003cp\u003eGP is one of the abdominal complications requiring surgical treatment in HSP children. Other complications include intussusception, massive gastrointestinal bleeding and intestinal necrosis[\u003ca href=\"#_ENREF_14\"\u003e14\u003c/a\u003e]. The symptoms of children with GP are relatively serious, and delayed treatment may endanger the life of the patients. Hence, we analyzed the possible risk factors of GP in HSP children, including age, gender, purpura type, the time of abdominal pain, hematochezia, renal damage, methylprednisolone dose more than 2mg/kg.\u003c/p\u003e\n\u003cp\u003eIn our study, 7 HSP children with GP were associated with renal damage (63.63%), which was significantly higher than that of the control group (26.2%), suggesting that HSP children with renal damage had a greater risk of GP. Some studies indicate that abdominal pain may be one of the important risk factors of HSP children renal damage [\u003ca href=\"#_ENREF_5\"\u003e5\u003c/a\u003e, \u003ca href=\"#_ENREF_15\"\u003e15\u003c/a\u003e], therefore, HSP children with gastrointestinal symptoms should be regularly monitored with routine urine, renal damage. 11 cases HSP children with GP all showed bloody symptoms (100%), while the control group only 3 cases (7.14%) showed bloody symptoms, indicated that bloody symptom is one risk of GP. In addition, HSP children with GP show a large number of skin purpura, and 3 cases show facial purpura. Whether the risk of GP can be identified early according to the severity of skin purpura and site symptoms remains to be further studied and confirmed.\u003c/p\u003e\n\u003cp\u003eThe pathogenesis of GP in HSP children was still unclear. It has been reported that thrombus caused by vasculitis may lead to intestinal ischemia, followed by intestinal wall necrosis and perforation [\u003ca href=\"#_ENREF_16\"\u003e16\u003c/a\u003e]. Ultrasonography or CT signs are useful to confirm the diagnosis of GP. The key to ultrasonographic examination of gastrointestinal perforation is the free gas under the diaphragm and a small amount of gas and fluid next to the perforation. When the perforation is small, the subphrenic gas is less, or the intestinal perforation is wrapped by other surrounding tissue, the gas can\u0026rsquo;t reach the subdiaphragm, or the patient has a large amount of air in the intestinal loop, it will affect the color ultrasound diagnosis. In our study, ultrasonography did not indicate perforation, but CT indicated perforation of gastrointestinal tract in 5 cases, suggesting that CT was more sensitive than ultrasonography. Therefore, when GP was not detected by ultrasonography but clinical symptoms can\u0026rsquo;t be excluded, we should perform CT examination to avoid misdiagnosis.\u003c/p\u003e\n\u003cp\u003eIn our study, the average duration of abdominal pain of GP in HSP children was 9.3 days, this was consistent with that intestinal perforation of HSP occurred during the second week after hormone application[\u003ca href=\"#_ENREF_13\"\u003e13\u003c/a\u003e]. There are 9 cases (81.8%) abdominal pain lasted more than a week, while the longest time in the control group is 5 days. HSP children abdominal pain lasting more than a week can be considered as identifying early GP reference. Glucocorticoid can reduce the edema, relieve pain, application of hormone in early stage may reduce the risk of surgical intervention[\u003ca href=\"#_ENREF_4\"\u003e4\u003c/a\u003e, \u003ca href=\"#_ENREF_15\"\u003e15\u003c/a\u003e]. But systemic glucocorticoid therapy may mask symptoms of surgical complications such as abdominal pain and fever[\u003ca href=\"#_ENREF_15\"\u003e15\u003c/a\u003e]. Some studies have shown that large doses of corticosteroids could reduce mucosal mucus synthesis in the gastrointestinal tract, inhibit the regeneration and healing of the intestinal mucosa, reduce the thickness of the gastrointestinal wall, and reduce lymphatic follicles, all of which increase the risk of intestinal perforation[\u003ca href=\"#_ENREF_5\"\u003e5\u003c/a\u003e, \u003ca href=\"#_ENREF_6\"\u003e6\u003c/a\u003e, \u003ca href=\"#_ENREF_13\"\u003e13\u003c/a\u003e, \u003ca href=\"#_ENREF_17\"\u003e17\u003c/a\u003e]. Our study indicated that a course of methylprednisolone of more than 7 days and a dose of more than 2mg/kg were risk factors of GP in HSP children. However, hormones were still the most effective treatment options for abdominal symptoms of HSP. Therefore, in the clinical treatment of HSP patients, it is necessary to weigh the advantage and disadvantages of long-term and high-dose hormone use, and to control the dosage and course of hormone use.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eHSP children with severe gastrointestinal symptoms should be evaluated for GP. In the current study, we found that the factors of abdominal or mixed HSP, abdominal pain lasting more than 7 days, hematochezia, renal damage, methylprednisolone dose more than 2mg/kg may increase the risks of GP in HSP children. It\u0026rsquo;s necessary to cooperate with physical examination and combine with color ultrasound or CT examination to identify and diagnose HSP-related gastrointestinal tract as early as possible, so as to give timely and appropriate surgical intervention measures to reduce the trauma of children. Due to GP is relatively rare in HSP children, the number of cases can be expanded or a multicenter clinical study can be conducted to further study the relationship between HSP and GP and reduce complications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eHSP: \u003c/strong\u003eHenoch-Sch\u0026ouml;nlein purpura\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGP: \u003c/strong\u003eGastrointestinal perforation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCT:\u003c/strong\u003e Computerized tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe study protocol was approved by the Research Ethics Commission of the First Affiliated Hospital of Henan University of Chinese Medicine. This study is a retrospective analysis of pre-existing data, and the informed consent of parents or guardians is not required.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they agree to submit the article for publication.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data used in this study are available upon request of the author Qingyin Guo.\u003c/p\u003e\n\u003cp\u003eThe paper and electronic medical record used in this study belong to the First Affiliated Hospital of Henan University of Chinese Medicine and is available only via administrative permission.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis work was supported by the Special Project of Chinese Medicine Scientific Research in Henan（2016ZY2030）\u003c/p\u003e\n\u003ch2\u003eAuthor\u0026rsquo;s contributions\u003c/h2\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. QG, XZ, MY and MJ reviewed the medical records, analyzed and interpreted the data. CS, XR, WZ and YD coordinated and supervised data collection. XH and JZ collected data and searched literature. The first draft of the manuscript was written by QG and MJ. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTrnka P: \u003cstrong\u003eHenoch-Schonlein purpura in children\u003c/strong\u003e. \u003cem\u003eJournal of paediatrics and child health \u003c/em\u003e2013, \u003cstrong\u003e49\u003c/strong\u003e(12):995-1003.\u003c/li\u003e\n\u003cli\u003eGardner-Medwin JM, Dolezalova P, Cummins C, Southwood TR: \u003cstrong\u003eIncidence of Henoch-Schonlein purpura, Kawasaki disease, and rare vasculitides in children of different ethnic origins\u003c/strong\u003e. \u003cem\u003eLancet \u003c/em\u003e2002, \u003cstrong\u003e360\u003c/strong\u003e(9341):1197-1202.\u003c/li\u003e\n\u003cli\u003eYamazaki T, Akimoto T, Iwazu Y, Sugase T, Takeshima E, Numata A, Komada T, Yoshizawa H, Otani N, Morishita Y\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eHenoch-Schonlein purpura complicated with severe gastrointestinal bleeding\u003c/strong\u003e. \u003cem\u003eCEN case reports \u003c/em\u003e2015, \u003cstrong\u003e4\u003c/strong\u003e(1):106-111.\u003c/li\u003e\n\u003cli\u003eSubspecialty Group of I, Society of P, Chinese Medical A, Editorial Board of Chinese Journal of P: \u003cstrong\u003e[Evidence-based recommendations for the diagnosis and management in the children with Henoch-Schonlein purpura]\u003c/strong\u003e. \u003cem\u003eZhonghua Er Ke Za Zhi \u003c/em\u003e2013, \u003cstrong\u003e51\u003c/strong\u003e(7):502-507.\u003c/li\u003e\n\u003cli\u003eLerkvaleekul B, Treepongkaruna S, Saisawat P, Thanachatchairattana P, Angkathunyakul N, Ruangwattanapaisarn N, Vilaiyuk S: \u003cstrong\u003eHenoch-Schonlein purpura from vasculitis to intestinal perforation: A case report and literature review\u003c/strong\u003e. \u003cem\u003eWorld journal of gastroenterology \u003c/em\u003e2016, \u003cstrong\u003e22\u003c/strong\u003e(26):6089-6094.\u003c/li\u003e\n\u003cli\u003eWang HL, Liu HT, Chen Q, Gao Y, Yu KJ: \u003cstrong\u003eHenoch-Schonlein purpura with intestinal perforation and cerebral hemorrhage: a case report\u003c/strong\u003e. \u003cem\u003eWorld journal of gastroenterology \u003c/em\u003e2013, \u003cstrong\u003e19\u003c/strong\u003e(16):2574-2577.\u003c/li\u003e\n\u003cli\u003eChahri Vizcarro N, Andreu Solsona V, Barba Sopena S, Sanjaume Feixas M: \u003cstrong\u003eIntussusception as the main manifestation of Schonlein-Henoch purpura in an adult patient\u003c/strong\u003e. \u003cem\u003eGastroenterol Hepatol \u003c/em\u003e2019, \u003cstrong\u003e42\u003c/strong\u003e(7):443-444.\u003c/li\u003e\n\u003cli\u003eOzen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, Buoncompagni A, Lazar C, Bilge I, Uziel Y\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eEULAR/PRINTO/PRES criteria for Henoch-Schonlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria\u003c/strong\u003e. \u003cem\u003eAnn Rheum Dis \u003c/em\u003e2010, \u003cstrong\u003e69\u003c/strong\u003e(5):798-806.\u003c/li\u003e\n\u003cli\u003eWang X, Zhu Y, Gao L, Wei S, Zhen Y, Ma Q: \u003cstrong\u003eHenoch-Schonlein purpura with joint involvement: Analysis of 71 cases\u003c/strong\u003e. \u003cem\u003ePediatr Rheumatol Online J \u003c/em\u003e2016, \u003cstrong\u003e14\u003c/strong\u003e(1):20.\u003c/li\u003e\n\u003cli\u003eGoda F, Maeba T, Usuki H, Karasawa Y, Izuishi K, Ishimura K, Senda S, Maeta H: \u003cstrong\u003eColo-colic intussusception associated with Henoch-Schonlein purpura in adults\u003c/strong\u003e. \u003cem\u003eJ Gastroenterol Hepatol \u003c/em\u003e2007, \u003cstrong\u003e22\u003c/strong\u003e(3):449-452.\u003c/li\u003e\n\u003cli\u003eLouie CY, Gomez AJ, Sibley RK, Bass D, Longacre TA: \u003cstrong\u003eHistologic Features of Gastrointestinal Tract Biopsies in IgA Vasculitis (Henoch-Schonlein Purpura)\u003c/strong\u003e. \u003cem\u003eAm J Surg Pathol \u003c/em\u003e2018, \u003cstrong\u003e42\u003c/strong\u003e(4):529-533.\u003c/li\u003e\n\u003cli\u003eAudemard-Verger A, Pillebout E, Guillevin L, Thervet E, Terrier B: \u003cstrong\u003eIgA vasculitis (Henoch-Shonlein purpura) in adults: Diagnostic and therapeutic aspects\u003c/strong\u003e. \u003cem\u003eAutoimmun Rev \u003c/em\u003e2015, \u003cstrong\u003e14\u003c/strong\u003e(7):579-585.\u003c/li\u003e\n\u003cli\u003eYavuz H, Arslan A: \u003cstrong\u003eHenoch-Schonlein purpura-related intestinal perforation: a steroid complication?\u003c/strong\u003e \u003cem\u003ePediatrics international : official journal of the Japan Pediatric Society \u003c/em\u003e2001, \u003cstrong\u003e43\u003c/strong\u003e(4):423-425.\u003c/li\u003e\n\u003cli\u003eShiohama T, Kitazawa K, Omura K, Honda A, Kozuki A, Tanaka N, Omata A, Ooe K, Suzuki Y: \u003cstrong\u003eIntussusception and spontaneous ileal perforation in Henoch-Schonlein purpura\u003c/strong\u003e. \u003cem\u003ePediatrics international : official journal of the Japan Pediatric Society \u003c/em\u003e2008, \u003cstrong\u003e50\u003c/strong\u003e(5):709-710.\u003c/li\u003e\n\u003cli\u003evan den Broek RW, van Rossum MA, van Duinen CM: \u003cstrong\u003eA new surgical complication related to corticosteroids in a patient with Henoch-Schonlein purpura\u003c/strong\u003e. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e1995, \u003cstrong\u003e30\u003c/strong\u003e(9):1341-1343.\u003c/li\u003e\n\u003cli\u003eChoong CK, Beasley SW: \u003cstrong\u003eIntra-abdominal manifestations of Henoch-Schonlein purpura\u003c/strong\u003e. \u003cem\u003eJournal of paediatrics and child health \u003c/em\u003e1998, \u003cstrong\u003e34\u003c/strong\u003e(5):405-409.\u003c/li\u003e\n\u003cli\u003eAlmassinokiani F, Mehdizadeh Kashi A, Musavi A, Khodaverdi S, Tahermanesh K, Ariana S: \u003cstrong\u003eRectal perforation in a 42-year-old woman due to Henoch-Schonlein purpura: a case report\u003c/strong\u003e. \u003cem\u003eReumatismo \u003c/em\u003e2017, \u003cstrong\u003e69\u003c/strong\u003e(3):131-133.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" width=\"0\"\u003e\u003ccaption\u003eTable 1. Clinical manifestations of children with HSP\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"103\"\u003e\n\u003cp\u003eClinical manifestation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"47\"\u003e\n\u003cp\u003eSkin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"47\"\u003e\n\u003cp\u003eJoint\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"65\"\u003e\n\u003cp\u003eAbdominal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"38\"\u003e\n\u003cp\u003eRenal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" width=\"399\"\u003e\n\u003cp\u003eMixed\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eAbdominal + Renal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003eAbdominal + Joint\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eJoint + Renal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003eAbdominal + Renal + Joint\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"103\"\u003e\n\u003cp\u003eNo. of cases\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1992\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e2206\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e1523\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"38\"\u003e\n\u003cp\u003e1715\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e1117\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e988\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e511\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e729\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"103\"\u003e\n\u003cp\u003ePercent（%）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e18.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e20.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"65\"\u003e\n\u003cp\u003e14.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"38\"\u003e\n\u003cp\u003e15.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e10.35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e9.16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e4.73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e6.75\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\u003ccaption\u003eTable 2. Clinical characteristics, diagnosis and treatment of HSP complicated with GP\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003eNo.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eSex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eDays of abdominal pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eCT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eUltrasound\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eDiagnosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eSite\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eTreatment method\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eFacial purpura\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eJoint pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eRenal damage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003eMethylprednisolone dose and duration\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003egastric perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003egastral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eIntestinal perforation repair\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e3mg/kg/day for 10 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileocecal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eEnterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e2.5mg/kg/day for 9 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileocecal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eEnterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e2.4mg/kg/day for 17 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileocecal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eEnterectomy+fistula\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e3mg/kg/day for 12 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileocecal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eEnterectomy+fistula\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e2.5mg/kg/day for 30 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eterminal ileum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eIntestinal perforation repair\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e2.8mg/kg/day for 11 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eEnterectomy + diverticulectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e2.3mg/kg/day for 11 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eEnterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e2.9mg/kg/day for 4 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eEnterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e3.2mg/kg/day for 14 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eEnterectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e3mg/kg/day for 8 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"29\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"31\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eintestinal perforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eileum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eIntestinal perforation repair\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e3mg/kg/day for 9 days\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"15\" width=\"0%\"\u003e\n\u003cp\u003eNote: \u0026ldquo;+\u0026rdquo; means positive, \u0026ldquo;-\u0026rdquo; means negative, \u0026ldquo;/\u0026rdquo; means no test\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\u003ccaption\u003eTable 3. The univariate\u0026nbsp;\u003cem\u003eChi\u003c/em\u003e-\u003cem\u003esquare\u003c/em\u003e\u0026nbsp;test of risk factors of HSP with GP [\u003cem\u003en \u003c/em\u003e(%)]\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003egroup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003eCase number\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eAge\u0026lt;10 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eAbdominal (mixed) allergic purpura\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eHematochezia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003eRenal damage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003eAbdominal pain lasts longer than 7 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eMethylprednisolone dose more than 2mg/kg\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003ePerforated group\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e9(81.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e8(72.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e11(100.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e11(100.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e7(63.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e9(81.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e11(100)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e35(83.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e28(66.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e27(64.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e3(7.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e11(26.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e0(0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e3(7.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e2 \u003c/sup\u003evalue\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.014\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e0.147\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e5.479\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e38.668\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e5.449\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e41.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e38.67\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.905\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e0.701\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0.019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"48\"\u003e\n\u003cp\u003e0.019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"137\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Children, Henoch-Schonlein purpura, Gastrointestinal perforation, Retrospective analysis, Risk factors","lastPublishedDoi":"10.21203/rs.3.rs-37348/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-37348/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eHenoch-Schönlein purpura (HSP) is a common small vessel vasculitis in children.\u003cstrong\u003e \u003c/strong\u003eGastrointestinal perforation (GP) rarely presents as a complication of HSP and was not well characterized. This study aimed to investigate the clinical features, diagnosis and risk factors of GP in children with HSP. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We retrospectively reviewed the clinical data of 10791 children with HSP who attended our hospital between January 2014 and June 2018 and analyzed the treatment and clinical risk factors of 11 children with HSP complication with GP. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e GP occurred in 11 children with HSP, with an incidence of 0.10%. Among the 11 cases HSP with GP, 1 case was gastric perforation and 10 cases were intestinal perforation. CT indicates perforation but ultrasonography did not indicate perforation in 5 cases of GP patients. The average duration of abdominal pain in HSP with GP was 9.3 days, and 9 cases (81.8%) with a duration of abdominal pain over 7 days. 3 cases of HSP with GP were treated by gastric/intestinal perforation repair and the other 8 cases were treated by enterectomy. The type of purpura, abdominal pain lasting more than 7 days, hematochezia, renal damage, and methylprednisolone dose more than 2mg/kg in GP with HSP patients show statistically significant compared with the control group (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe incidence rate of GP in children with HSP was 0.10%. Abdominal (or mixed) HSP, hematochezia, renal damage, abdominal pain lasting more than 7 days, and methylprednisolone dose more than 2mg/kg may increase the risk of GP in children with HSP. CT has a high sensitivity for the diagnosis of GP. Early diagnosis and timely treatment of HSP with GP were very important for good clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Clinical Characteristics and Risk Factors of Gastrointestinal Perforation in Children with Henoch-Schönlein Purpura","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-06-22 22:27:03","doi":"10.21203/rs.3.rs-37348/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba685d9f-9235-47f8-be44-f71801f95a9f","owner":[],"postedDate":"June 22nd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":127734,"name":"Pediatrics"},{"id":127735,"name":"Rheumatology"}],"tags":[],"updatedAt":"2020-07-25T16:45:41+00:00","versionOfRecord":[],"versionCreatedAt":"2020-06-22 22:27:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-37348","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-37348","identity":"rs-37348","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}