Limb Gangrene and Two Types of Vasculitis

Abstract

melaena on the day before admission. Her medication included ibuprofen for osteoarthritis. She was stable on admission; there was some tenderness in the epigastrium and right hypochondrium, but her abdomen was soft and bowel sounds were present. Haemoglobin was 13.9g/dL. On the day after admission, she had a further episode of vomiting without obvious blood. 48 h after admission gastroscopy revealed large quantities of retained secretions in the stomach. This was aspirated and no abnormality was seen in the oesophagus, stomach or duodenum to account for her haematemesis. Soon after gastroscopy, her abdomen and hernial orifices were re-examined and an irreducible right femoral hernia was detected. On the same night a loop of viable small bowel was reduced and the hernia was repaired. She subsequently made an uneventful recovery and returned home to an independent life. COMMENTFemoral hernia accounts for about 20% of hernias in women and 5% in men. Female patients are frequently elderly. Of all hernias it is the most liable to become strangulated, mainly because of the narrowness of the neck of the sac and the rigidity of the femoral ring. In 20% of cases the condition is bilateral1.The symptoms of a femoral hernia may be less pronounced than those of an inguinal hernia. A small femoral hernia can go unnoticed by the patient for years, coming to attention only when it strangulates.Both the patients described here were admitted to medical wards because of the history of haematemesis. The inguinal orifices were not examined and the diagnosis was further delayed while they awaited upper gastrointestinal endoscopy.A review of published work yields no reports of femoral hernia presenting with haematemesis. In these cases the blood loss, which was not severe enough to lower the haemoglobin, may have been the result of mucosal damage such as a Mallory-Weiss tear. In elderly patients, particularly females presenting with haematemesis, where vomiting is a predominant symptom, and in the absence of a significant drop in haemoglobin, the diagnosis of strangulated hernia must be thought of and excluded. Buerger's disease is a rare but well described cause of digital gangrene in smokers. Leucocytoclastic vasculitis is far more common, precipitated by a myriad of common infections. We report a patient who apparently had both. CASE HISTORYA man aged 60 reported foot pain at rest and a pruritic rash. He was a smoker. The left little finger and the first, second and third right toes were ischaemic and he had a purplish macular rash on both shins. Dorsalis pedis pulses were absent on both sides. His erythrocyte sedimentation rate (ESR) was 84mm/h; laboratory screening for markers of vasculitis, connective tissue disorder and diabetes was negative. Femoral arteriograms showed normal vessels down to the ankle level, but the digital vessels were not visible. On renal angiography there was no evidence of polyarteritis nodosa, and an ultrasound scan of the aorta showed no aneurysm. Skin biopsy (Figure 1) revealed dermal small blood vess...