Case Presentation: An 84-year-old female presented to an outside hospital with one year of intermittent cramping abdominal pain with constipation requiring daily laxatives . Laxative use was associated with bloating and increased abdominal cramps. Her pain was unrelated to meals and she had a 20-pound weight loss. One month prior, she underwent gastrointestinal endoscopy, revealing a colonic and multiple mid-jejunal ulcers. She was treated at that institution with PPI, holding anti-coagulation/anti-platelet and analgesia.Due to persistent abdominal pain and worsening anemia she was transferred to our institution for expert bloodless management. Her medical history included coronary, cerebrovascular disease and hypertension. Repeat endoscopy revealed atrophic gastric mucosa and we were concerned of possible mesenteric ischemia, therefore abdominal visceral arterial duplex was performed. This showed 70% stenosis of superior mesenteric, celiac and renal arteries. Bloodless angioplasty with stenting to the celiac artery was done. Post intervention, she had gradual resolution of abdominal pain and constipation.
Discussion: Chronic Mesenteric ischemia with clinical manifestations is rare. An estimated 18% of those over 65 years in the general population have asymptomatic significant superior mesenteric or celiac artery stenosis (1). It is more common in females with a 3:1 occurrence compared to males (2) and typically in smokers and those with Cardiovascular disease (3).
With regards to epidemiology, our patient is typical however her symptoms were unusual.
Four typical characteristic clinical symptoms occur in chronic mesenteric ischemia which are post prandial abdominal pain, weight loss, adapted eating and diarrhea (4). In our patient, her abdominal pain was unrelated to meals hence she did not adapt her meals and had constipation needing laxatives instead of diarrhea. The multiple intestinal ulcers she had and consequent symptomatic anemia were likely due to her mesenteric ischemia.
Conclusions: Atherosclerotic disease in mesenteric arteries often remain asymptomatic. However in patients with risk factors, a high index of suspicion should be raised, even if symptoms are atypical. This will prevent misdiagnosis which can cause significant morbidity and mortality, especially in elderly patients.