A 73-year-old man comes to the clinic with epigastric pain that starts 30-40 minutes after meals and does not respond to antacids. The pain is non-radiating and is graded 6/10 in intensity. The patient has lost more than 4.5 kg (10 lb) over the last few months, which he attributes to eating less due to his fear of the pain. He has no vomiting, diarrhea, or urinary symptoms. His past medical history is significant for hypertension, hyperlipidemia, coronary artery bypass grafting, and right-sided carotid endarterectomy. He has smoked a pack of cigarettes daily for 32 years. Upper gastrointestinal endoscopy shows no abnormalities. The underlying pathophysiology of this patient's disease process is most similar to which of the following conditions?

Question

A 73-year-old man comes to the clinic with epigastric pain that starts 30-40 minutes after meals and does not respond to antacids.  The pain is non-radiating and is graded 6/10 in intensity.  The patient has lost more than 4.5 kg (10 lb) over the last few months, which he attributes to eating less due to his fear of the pain.  He has no vomiting, diarrhea, or urinary symptoms.  His past medical history is significant for hypertension, hyperlipidemia, coronary artery bypass grafting, and right-sided carotid endarterectomy.  He has smoked a pack of cigarettes daily for 32 years.  Upper gastrointestinal endoscopy shows no abnormalities.  The underlying pathophysiology of this patient's disease process is most similar to which of the following conditions?

Quizplus · Accepted Answer

This patient's postprandial epigastric pain and associated food aversion/weight loss in the setting of generalized atherosclerosis (eg, coronary and carotid artery disease) is consistent with chronic mesenteric ischemia. When atherosclerosis involves the mesenteric arteries, the bowel can suffer from diminished blood supply. Intestinal hypoperfusion, which can be very painful, is especially pronounced within an hour after meals when more blood is needed for the digestion/absorption of nutrients (intestinal angina). This is analogous to stable cardiac angina, chest pain that occurs with physical exertion due to increased myocardial oxygen demand. The diagnosis can be made with duplex ultrasonography or angiography showing high-grade stenosis in the celiac and mesenteric arteries. (Choice A) Aortic dissection results from an aortic intimal tear with formation of a false lumen that can propagate and obstruct the vessels branching off the aorta (eg, renal, splanchnic, spinal, lower limb). A similar process would be more likely to cause acute end-organ damage (eg, cerebral infarction) rather than chronic, episodic ischemia. (Choice B) Diffuse esophageal spasm is a motility disorder characterized by episodic, painful, non-propulsive esophageal smooth muscle contraction. Biliary colic is similar to esophageal spasm in that gallbladder contraction against an obstructed cystic duct results in postprandial epigastric pain. (Choice C) Peptic ulcer disease is characterized by gastrointestinal erosions/ulcerations and is typically due to Helicobacter pylori infection or nonsteroidal anti-inflammatory drug use. This patient's pain did not respond to antacids and his upper endoscopy is normal, so he is unlikely to have a condition associated with peptic ulcers. (Choice D) Pulmonary embolism is often due to an embolic blood clot lodging in the branches of the pulmonary artery, resulting in acute pulmonary ischemia/infarction. A similar pathogenesis accounts for acute mesenteric ischemia, which can occur with superior mesenteric artery embolism. This condition is more likely to cause sudden, severe abdominal pain rather than recurrent postprandial abdominal pain with food aversion. Educational objective: Chronic mesenteric ischemia is characterized by atherosclerosis of the mesenteric arteries, resulting in diminished blood flow to the intestine after meals. This causes postprandial epigastric pain (intestinal angina) with associated food aversion/weight loss. Its pathogenesis is similar to angina pectoris. __________ References: Chronic mesenteric ischemia: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/21722785)

A 73-Year-Old Man Comes to the Clinic with Epigastric Pain