Mrs A was a 65-year-old patient who presented at the practice eight months ago. She wanted some medication for some intermittent abdominal pains.
On closer questioning, Mrs A was suffering from lower abdominal pains which came on about 30 minutes after eating her meals. The pain was more localised in her right iliac fossa and lasted for between 10 and 30 minutes.
These pains had made her apprehensive about eating so her intake of food had reduced over the past three months, since the symptoms began. She had some constipation but no other symptoms of note. She had lost about 12kg in weight over the preceding three months.
She had a history of peripheral vascular disease - she had had a stent inserted in her aorta and common iliac artery four years ago. She also had hypertension and hypercholesterolemia. Her only other medication was aspirin.
Unsurprisingly, she was a heavy smoker, smoking approximately 30 cigarettes a day, but did not drink any alcohol. She was quite fit and active, having recently retired from a job as a cleaner at a local school.
General examination (including a rectal examination) was unremarkable but the concern was her weight loss, so she had some blood tests and was referred to the local gastroenterologist for further investigations.
Blood tests were unremarkable, other than a raised ESR. A gastroscopy and abdominal ultrasound were both entirely normal. A CT scan of her abdomen was arranged, which was normal.
The scan report noted the stent and that the rest of her vessels were severely atherosclerotic.
Mrs A continued to lose weight, her intake of food continued to deteriorate and the abdominal pain persisted and worsened. Over the following month she lost a further 6kg.
One month after her initial presentation at the surgery she was admitted to hospital as an emergency with acute onset generalised abdominal pain and sadly died.
A post-mortem examination showed mesenteric infarction.
Abdominal angina is a descriptive term for abdominal pain that can occur postprandially in patients with occlusive mesenteric vascular disease due to insufficient increase in blood flow (leading to mesenteric ischaemia).
The three arteries supplying the gut are the coeliac, superior mesenteric and inferior mesenteric. There need to be significant stenoses or actual occlusion of at least two of the three vessels for this to occur.
Chronic occlusive mesenteric ischaemia is usually a long-standing process characterised by postprandial abdominal pain, progressive food intolerance and weight loss.
The abdominal pain is a consequence of bloodflow not being able to meet visceral demand and is therefore thought to be similar to angina pectoris in patients with coronary artery disease or claudication in those with peripheral vascular disease.
Atherosclerotic vascular disease is the most common cause and, as such, smoking is an associated risk factor in 75-80 per cent of affected patients. Interestingly, it is more common in women than men and uncommon in patients with diabetes. The mean age of affected patients is slightly over 60 years.
The most important prognostic factor has been shown to be the time interval between the onset of symptoms and surgery. However, it is not unusual for patients to have a delayed diagnosis because they are initially thought to have an underlying malignancy. This obviously occurred in the case of Mrs A.
A mesenteric artery angiogram is the investigation of choice for patients with suspected mesenteric ischaemia. However, calcification of mesenteric vessels on radiography is suggestive.
Surgery is the management of choice but it is not without risks.1
Acute occlusive mesenteric ischaemia (AMI) presents with the abrupt onset of severe abdominal pain, which if not diagnosed and treated immediately can cause bowel necrosis and prove fatal.2
AMI is still a disease with a consistently high mortality rate (60-80 per cent).3
- Dr Newson is a GP in the West Midlands.
1. Kitzing B. Abdominal angina in occlusive mesenteric vascular disease: a case report. Cases J 2009; 2: 82.
2. Wain R A, Hines G. Surgical management of mesenteric occlusive disease: a contemporary review of invasive and minimally invasive techniques. Cardiol Rev 2008; 16: 69-75.
3. Ritz J, Germer C, Buhr H. Prognostic factors for mesenteric infarction: multivariate analysis of 187 patients with regard to patient age. Ann Vasc Surgery 2005; 19: 328-34.