A 65-year-old female with a past medical history of essential hypertension, type 2 diabetes mellitus, peripheral vascular disease, coronary artery disease, and dyslipidemia presents with epigastric pain for the past two months. The pain is described as, "crampy, dull, and sometimes goes to the back." The pain is worse after eating. Four weeks of over-the-counter omeprazole did not relieve her pain. She also complains of an 8 lb weight loss and decreased desire to eat. Her bowel habits are normal. She had a two-vessel coronary artery bypass surgery three years ago. Her medications include glipizide, metformin, simvastatin, and lisinopril. She also takes naproxen for occasional headaches as needed. She is an ex-smoker with a 42 pack-year smoking history. Her temperature is 36.7C (98F), blood pressure is 172/86 mm Hg, pulse is 90/min, and respirations are 16/min. There is a right-sided carotid bruit. Her abdomen is soft and non-tender. Ultrasound of the abdomen shows a normal gallbladder without any stones. An upper endoscopy shows mild esophagitis and mild antral erythema. A CT scan of the abdomen demonstrates diffuse aortic atherosclerosis. Screening colonoscopy done eight years ago was unremarkable. Which of the following is the most appropriate course of action?

Question

A 65-year-old female with a past medical history of essential hypertension, type 2 diabetes mellitus, peripheral vascular disease, coronary artery disease, and dyslipidemia presents with epigastric pain for the past two months.  The pain is described as, "crampy, dull, and sometimes goes to the back."  The pain is worse after eating.  Four weeks of over-the-counter omeprazole did not relieve her pain.  She also complains of an 8 lb weight loss and decreased desire to eat.  Her bowel habits are normal.  She had a two-vessel coronary artery bypass surgery three years ago.  Her medications include glipizide, metformin, simvastatin, and lisinopril.  She also takes naproxen for occasional headaches as needed.  She is an ex-smoker with a 42 pack-year smoking history.  Her temperature is 36.7C (98F), blood pressure is 172/86 mm Hg, pulse is 90/min, and respirations are 16/min.  There is a right-sided carotid bruit.  Her abdomen is soft and non-tender.  Ultrasound of the abdomen shows a normal gallbladder without any stones.  An upper endoscopy shows mild esophagitis and mild antral erythema.  A CT scan of the abdomen demonstrates diffuse aortic atherosclerosis.  Screening colonoscopy done eight years ago was unremarkable.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: This patient clearly has multiple atherosclerotic risk factors as well as known coronary artery disease and probable right carotid atherosclerotic disease given the bruit heard on physical exam. She has had a fairly extensive evaluation at this point consisting of ultrasound, CT, and endoscopy. Only mild esophagitis and gastric antral erythema have been noted thus far, which is seen in many patients and does not fully account for her pain. The key to making the diagnosis is the worsening of her dull, crampy epigastric pain after eating. Given her known atherosclerotic disease, the most likely diagnosis at this point is chronic mesenteric ischemia. The disease is sometimes referred to as "intestinal angina" since it presents as abdominal pain when there is increased oxygen demand in the bowel after eating, much as patients with cardiac ischemia experience chest pain with increased myocardial oxygen demands. The pain may become so severe that patients avoid food and consequently lose weight. Due to the large number of collateral vessels supplying the bowel, multiple high grade stenoses are typically needed in the mesenteric vasculature before patients become symptomatic. CT angiogram, MR angiogram, and duplex ultrasound are all noninvasive means of making the diagnosis. Angiography remains the gold standard for making the diagnosis, and intervention with angioplasty and/or stenting can be done in the same setting. Noninvasive tests are helpful in localizing the obstruction and to identify the best route it can be reached through with angiography. (Choice B) This patient has had a colonoscopy within the recommended screening window of 10 years and there were no findings on CT to suggest a colonic neoplasm, although this certainly does not exclude the possibility. However, chronic mesenteric ischemia is more likely at this point given the patient's symptoms and vascular disease. (Choice C) H. pylori testing was likely already done at the time of EGD. Even if it was not tested, the mild antral gastritis does not explain the current symptoms. (Choice D) This patient's symptoms appear to be related to ingestion of all foods and not just lactose. Lactose intolerance is also frequently associated with borborygmi and abnormal bulky, watery stools. (Choice E) This patient has no evidence of steatorrhea to suggest malabsorption. Educational objective: Chronic mesenteric ischemia should be considered in patients with crampy epigastric pain that worsens with meals who have had a negative initial workup. The diagnosis can be made noninvasively with CTA, MRA, or duplex ultrasound although angiography remains the gold standard test. Noninvasive tests are helpful in localizing the obstruction and to identify the best route it can be reached with angiography. References: Chronic mesenteric ischemia. Clinical presentation and diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/9146718) Multi-detector row CT angiography in patients with abdominal angina. (http://www.ncbi.nlm.nih.gov/pubmed/15256621) Chronic mesenteric ischemia. (http://www.ncbi.nlm.nih.gov/pubmed/15833694)

A 65-Year-Old Female with a Past Medical History of Essential