An 83-year-old woman comes to the office due to a 1-year history of progressively severe, crampy abdominal pain that occurs immediately after she eats. The pain is diffuse but more pronounced in the epigastric area and is associated with frequent bloating and nausea and occasional diarrhea. The patient has had a 15-kg (33-lb) weight loss over the past year. She has lost her appetite since the pain episodes began. Her other medical problems include hypertension, type 2 diabetes mellitus, hypercholesterolemia, peripheral vascular disease, and coronary artery disease. Three years ago, she suffered an inferior wall myocardial infarction, which was treated with a drug-eluting stent. The patient has a 40-pack-year history of smoking but quit 10 years ago. She occasionally drinks a glass of wine. Temperature is 36.8 C (98.2 F), blood pressure is 140/92 mm Hg, pulse is 80/min, and respirations are 14/min. BMI is 24 kg/m². Abdomen is soft, nontender, and nondistended. Bowel sounds are present. Abdominal x-rays reveal no abnormalities. Which of the following is the most likely cause of this patient's current presentation?

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11ec25c8_d3fd_1c04_bc81_0d1d530b4582_MD0003_00 This patient with a history of vascular disease most likely has chronic mesenteric ischemia (CMI). CMI commonly presents with crampy, postprandial epigastric pain (intestinal angina), food aversion, and weight loss. Patients may also report nausea, early satiety, and diarrhea. The anginal pain frequently starts within the first hour of eating and slowly resolves over the next 2 hours. The pathophysiology of the pain is most likely related to shunting of blood away from the small intestine to meet the increased demand of the stomach. In patients with atherosclerosis, the celiac or the superior mesenteric arteries may be narrowed and unable to dilate appropriately to maintain adequate blood flow to the intestines. Physical examination may show signs of malnutrition and may reveal an abdominal bruit in ~50% of patients, but can be otherwise unremarkable. Although abdominal x-ray and CT scans may demonstrate calcified vessels, diagnosis requires better visualization of the vessels. CT angiography is the preferred choice, although Doppler ultrasonography may also be helpful. Treatment involves risk reduction (eg, tobacco cessation), nutritional support, and revascularization. (Choice B) Biliary colic occurs as the gallbladder contracts against an obstructing stone, transiently raising intragallbladder pressure. The pain is often localized to the upper right quadrant and does not occur after every meal. Significant weight loss is very rare. (Choice C) Ventricular aneurysms (scarred myocardium following transmural myocardial infarction) predispose to acute mesenteric ischemia (rather than CMI) due to thrombus formation and embolization. The presentation of acute mesenteric ischemia is abrupt, with severe abdominal pain out of proportion to examination findings. Both in pathophysiology and acuity, acute mesenteric ischemia is analogous to acute myocardial infarction whereas CMI is similar to stable cardiac angina. (Choices D and F) Pain accompanied by malabsorption may be due to chronic pancreatitis or Crohn disease (transmural intestinal inflammation). However, these diseases frequently produce abnormal CT scan and x-ray findings (eg, pancreatic calcifications). In addition, this patient does not have risk factors for pancreatitis (eg, heavy alcohol use). Crohn disease generally presents at an earlier age and usually causes lower right quadrant pain. pancreatic calcifications (Choice E) Irritable bowel syndrome does not usually lead to significant anorexia and weight loss; if present, these features should prompt the consideration of other diagnoses. Educational objective: The diagnosis of chronic mesenteric ischemia should be suspected in patients with unexplained chronic abdominal pain, weight loss, and food aversion. Most cases are due to atherosclerotic changes of the celiac or superior mesenteric arteries. References: Chronic ischaemic bowel diseases in the aged--go with the flow. (http://www.ncbi.nlm.nih.gov/pubmed/15591479) Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities. (http://www.ncbi.nlm.nih.gov/pubmed/26909235)

An 83-Year-Old Woman Comes to the Office Due to a 1-Year