Should I start steroids in a patient with Henoch-Schönlein Purpura (HSP) presenting with melena and no abdominal pain?

Steroid Treatment for HSP with Melena and No Abdominal Pain

Steroids should be initiated in a patient with Henoch-Schönlein Purpura (HSP) presenting with melena even in the absence of abdominal pain, as gastrointestinal bleeding represents significant organ involvement requiring intervention.

Rationale for Steroid Treatment

Melena in HSP indicates active gastrointestinal vasculitis that requires treatment, even without abdominal pain. The evidence supports this approach:

• Gastrointestinal manifestations are common in HSP patients and can present as upper GI bleeding without typical abdominal pain 1
• Corticosteroids have been shown to be effective in treating gastrointestinal symptoms of HSP 2, 3
• Untreated gastrointestinal involvement can lead to serious complications including intussusception, perforation, and significant bleeding

Treatment Protocol

1. Initial steroid therapy:

   • Prednisone 1 mg/kg/day (or equivalent) for 2 weeks 2, 3
   • Followed by gradual tapering over the subsequent 2 weeks

2. For severe presentations (significant bleeding):

   • Consider IV methylprednisolone 500 mg daily initially 1
   • Then transition to oral prednisone taper

3. Monitoring during treatment:

   • Daily stool checks for occult blood
   • Hemoglobin/hematocrit monitoring
   • Renal function assessment (urinalysis, creatinine)
   • Blood pressure monitoring

Treatment Considerations

Benefits of Early Steroid Treatment

• Reduces intensity of gastrointestinal symptoms 2
• May prevent progression to more severe GI complications
• Effective in treating existing renal symptoms if present 2

Potential Limitations

• Does not prevent the development of renal symptoms 2, 4
• Not all studies show benefit in preventing long-term complications 4

Follow-up and Monitoring

• Regular urinalysis to monitor for development of renal involvement
• Follow-up endoscopy if melena persists despite treatment
• Monitor for steroid side effects
• Consider immunosuppressive therapy (e.g., mycophenolate mofetil) if poor response to steroids 1, 5

Special Considerations

• For patients with recurrent or persistent gastrointestinal symptoms despite steroid treatment, mycophenolate mofetil has shown effectiveness 5
• Long-term prognosis depends primarily on renal involvement rather than gastrointestinal manifestations 3
• End-stage renal disease occurs in 1-5% of patients, making renal monitoring essential even when initial presentation is primarily gastrointestinal 3

The presence of melena indicates significant gastrointestinal involvement that warrants treatment with steroids, regardless of the absence of abdominal pain. Early intervention may help prevent further complications and improve outcomes.