How IgA Vasculitis Causes Upper Gastrointestinal Bleeding
IgA vasculitis causes upper gastrointestinal bleeding through IgA-mediated small vessel vasculitis that leads to bowel wall inflammation, mucosal erosion, and ulceration of the intestinal tract, with the duodenum being one of the most commonly affected sites (54.90% of cases). 1
Pathophysiologic Mechanism
IgA vasculitis (formerly Henoch-Schönlein purpura) is an IgA-mediated systemic small vessel vasculitis that deposits IgA immune complexes in vessel walls throughout the gastrointestinal tract. 2, 3 This immune-mediated process specifically targets small vessels in the bowel wall, resulting in:
- Vascular inflammation and leukocytoclastic vasculitis affecting the small vessels of the intestinal mucosa 3
- Direct mucosal injury leading to congestion, erosion, and ulceration visible on endoscopy 1
- Bowel wall thickening (present in 58.14% of cases on imaging) as a consequence of the inflammatory vasculitic process 1
Anatomic Distribution and Clinical Presentation
The duodenum and ileum are the most frequently involved sites (each affecting 54.90% of patients with both imaging and endoscopic evaluation), making upper GI bleeding a significant manifestation. 1 The clinical presentation includes:
- Acute abdominal pain (92.59% of adult patients) as the most common presenting symptom 1
- Hematemesis and hematochezia indicating active bleeding from erosions and ulcers 4, 3
- Severe or massive intestinal bleeding requiring multiple blood transfusions in some cases 4
Endoscopic and Imaging Findings
When upper endoscopy is performed (which should be the first diagnostic approach for suspected UGIB per standard guidelines 5, 6), the characteristic findings in IgA vasculitis include:
- Congestion and erosion (47.76% of cases) 1
- Erosion with ulcers (31.34% of cases) 1
- Multiple or migrating lesions that can shift location even during treatment 7
Important Clinical Context
IgA vasculitis tends to be more severe in adults than children, with increased mortality risk. 2, 3 Several critical features distinguish this condition:
- Gastrointestinal symptoms may precede the characteristic purpuric rash, making early diagnosis challenging 1
- Laboratory findings typically show elevated WBC, neutrophil-to-lymphocyte ratio, CRP, D-dimer, and fibrinogen, with decreased albumin 1
- Patients presenting with GI symptoms before purpura have significantly higher WBC (p<0.05) and NLR (p<0.01) compared to those presenting with purpura first 1
Treatment Implications
The bleeding in IgA vasculitis responds to immunosuppressive therapy rather than standard UGIB management alone:
- High-dose corticosteroids (oral or intravenous methylprednisolone) are the mainstay of treatment 4, 7
- Intravenous immunoglobulin (IVIG) has been successfully used for massive bleeding refractory to corticosteroids 4
- Standard supportive measures including proton pump inhibitors, volume resuscitation, and blood transfusions remain important 3
- Careful steroid tapering is essential as abdominal symptoms and intestinal lesions can recur or migrate with premature dose reduction 7