Endoscopic findings of immune thrombocytopenic purpura: “gastric footprints”

Idiopathic or immune thrombocytopenic purpura (ITP) is an acquired disorder characterized by isolated thrombocytopenia. The pathogenesis is related to increased platelet destruction along with the inhibition of megakaryocyte platelet production [1]. The diagnosis is made after other causes of thrombocytopenia have been excluded [2]. The clinical manifestations are usually mucocutaneous; however, as in our case, severe bleeding – for example, gastrointestinal bleeding – can occur [3].

An 81-year-old woman without a significant past medical history presented to the emergency department with epistaxis and gingival bleeding of 1 week’s duration. Physical examination showed multiple red-purple lesions – petechiae and ecchymoses – distributed mainly in the upper and lower limbs. Laboratory work-up revealed thrombocytopenia (10 × 10⁹/L) and a hemoglobin concentration of 7.5 g/dL with a normal leukocyte count. The diagnosis of ITP was established after the results of a peripheral blood smear and bone marrow aspiration and biopsy were normal. Following treatment with oral prednisolone (1 mg/kg per day) and intravenous immune globulin, the platelet count increased to 79 × 10⁹/L. However, on day 7 of treatment, the hemoglobin level fell to 6.5 g/dL, and the patient had melenic stools. Esophagogastroduodenoscopy revealed multiple petechiae, subepithelial hemorrhages, and ecchymoses in the gastric fundus ([Fig. 1]), incisura angularis ([Fig. 2]), antrum ([Fig. 3]), and body ([Fig. 4]). These lesions were not actively bleeding at the time of endoscopy. Nonetheless, they were the likely cause of the gastrointestinal bleeding. The result of stool antigen testing for Helicobacter pylori was negative. Colonoscopy did not show any colorectal lesions.

Fig. 1 Retroflexion endoscopic view of the gastric fundus with multiple ecchymoses and petechiae.

Fig. 2 Image detail of an ecchymosis occupying the gastric incisura angularis.

Fig. 3 Multiple ecchymoses and petechiae in the gastric antrum.

Fig. 4 Multiple ecchymoses and petechiae distributed in the gastric body.

To the best of our knowledge, this is the first case reported in the literature of the endoscopic visualization of gastric manifestations of ITP.

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• References

• 1 Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med 2002; 346: 995-1008
• 2 George JN, Woolf SH, Raskob GE et al. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. Blood 1996; 88: 3-40
• 3 Cortelazzo S, Finazzi G, Buelli M et al. High risk of severe bleeding in aged patients with chronic idiopathic thrombocytopenic purpura. Blood 1991; 77: 31-33