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Background Gastro-intestinal manifestations in systemic lupus erythematosus (SLE) can affect up to 40% of patients, including enteritis presenting as mesenteric vasculitis, pseudo-obstruction or protein-losing enteropathy. We present a case of lupus enteritis successfully treated with anti-TNFalpha inhibitor. Methods A 28-year-old woman was evaluated for diarrhea, abdominal pain, fever and rectal bleeding not responsive to antibiotics. She had a thirteen-year history of SLE in remission with Mycophenolate Mofetil and previous muco-cutaneous and haematologic relapses, myocarditis and end-stage renal disease (IV-class glomerulonephritis). She previously underwent multiple immunosuppressants including ciclophosphamide, cyclosporine,anti-CD20, immunoglobulins. One month before the onset of symptoms she discontinued MMF for worsening anemia. Simultaneously we reported signs of lupic flare (low C3, haemolytic anemia, lymphopenia, fever, arthralgias and malar rash). Pulse-steroids and IVIg followed by cyclosporine were initially performed with only temporary benefit. Enteric CT-scan and endoscopy revealed chronic and acute colo–rectal and gastric inflammation (cryptitis, erosions, necrosis, microgranulomas). Anti-TNFalpha inhibitor Infliximab (5 mg/kg) was added to Azathioprine 50 mg/daily. Within a month we observed clinical and serological sustained remission. Results Typically, mesenteric vasculitis involves small arteries or venules. Histological examination reveals submucosal and muscular layers infiltration and necrotizing vasculitis, with panmural predominant eosinophilic, neutrophilic or mixed infiltrate. The distinction of inflammatory bowel disease (IBD) from enteric-SLE can be challenging. In this case, an early anti-flogistic therapy may have led to uncomplete microscopic patterns not fullfilling criteria neither for enteric vasculitis nor IBD. A lupic flare with predominant gastro-enteric presentation is the most plausible hypothesis because of the infrequent association between SLE and IBD and simultaneous extra-intestinal lupic features. Abdominal involvement in a patient previously treated with high dosage cyclophosphamide (10 g) and the lack of response to azathioprine lead to the introduction of anti-TNFalpha inhibitor. Conclusion The role of TNFalpha in SLE is controversial and TNFalpha inhibitors are reported to control SLE-arthritis. Further studies are needed to evaluate their role in the management of gastro-enteric SLE.

This review outlines the technical aspects and diagnostic performance parameters of nuclear medicine procedures used on patients with disorders of the lower gastrointestinal tract, with the exclusion of techniques using tumor-seeking radiopharmaceuticals. Chronic disorders of the lower gastrointestinal tract often reduce the quality of life because of discomfort from constipation or diarrhea. Five classes of radionuclide procedures are used to characterize these disorders: transit scintigraphy, searches for ectopic gastric mucosa in Meckel's diverticulum, scintigraphy of active inflammatory bowel disease, scintigraphic defecography, and scintigraphy to detect sites of gastrointestinal bleeding. Protocols for these procedures and their relative merit in patient management are discussed, with special emphasis on their potential for semiquantitative assessment of the pathophysiologic parameter investigated. Quantitation is particularly relevant for prognostic purposes and for monitoring the efficacy of therapy.

INTRODUCTION Although in CD mucosal healing is regarded as a major therapeutic end-point, the mere mucosal examination can underestimate disease activity in a tipically transmural disease. A reliable assessment of parietal inflammation should be part of the diagnostic work up and, if regularly performed during treatment, it could contribute to evaluate the therapeutic response and to decide if and when to stop therapy Contrast Enhaced Ultrasound (CEUS) is a promising, non invasive tool which is able to quantify the gut wall inflammation allowing a more accurate assessment of disease activity in CD patients AIMS The aim of the study was to evaluate if CEUS is a useful tool to quantify the variation of parietal inflammation in patients with small bowel CD before and after therapy PATIENTS AND METHODS Fifteen CD patients (6 males, 9 females; mean age 38 yrs) with luminal disease confined to terminal ileum (L1B1 sec. Montreal classification) on maintenance therapy with biologics underwent clinical (CDAI), biological (serology and faecal markers) and CEUS assessment before and 12 months after starting therapy. Bowel wall thickness (BWT) was measured in all patients and quantification of wall gut inflammation was obtained by applying a digital image processing software based on Sun-Java and released in public domain (Image J). The analysis of intensity light was performed within particular Region of Interest (ROI) drawn by the operator within the ileum avoiding perivisceral structures. Time-signal intensity curves were processed and maximum enhancement (ME) was analyzed. Statistical analysis was performed by using Wilcoxon's signed rank test and Spearman's rank correlation coefficient. RESULTS All patients were in clinical remission after 12 months of therapy. Overall results (mean+/-SD) are shown in table 1 A significant correlation was found between ME and CDAI (r=0.73 p=0.004), PCR (r=0.69 p=0.007), Faecal calprotectin (r= 0.54 p=0.044). CONCLUSION In small bowel CD, CEUS may be a helpful non-invasive procedure to quantify the transmural inflammation and to follow the inflammatory process during therapy Table 1