Case Presentation: A 22 year-old male presented to the emergency department with a three week history of abdominal pain which occurred typically within an hour after meals. This had worsened over the past four days and was associated with poor appetite, nausea, vomiting, and loose bowel movements. The pain had been non-responsive to acid suppression therapy. The patient’s history was remarkable for a recent diagnosis one month prior of non-ischemic cardiomyopathy with biventricular heart failure secondary to suspected viral myocarditis. He therefore had a recent coronary angiogram negative for coronary artery disease and an echocardiogram showing left ventricular ejection fraction of 10-15% with reduced right ventricular function.

On examination, the patient had tenderness mainly in the epigastric area without peritoneal signs. The abdomen was non-distended and without evidence of ascites. Bowel sounds were active. The patient was afebrile, with a heart rate of 106 and blood pressure of 102/65. Laboratory results showed transaminitis with AST 188 IU/L and ALT 169 IU/L, and normal lipase and lactate levels. An abdominal ultrasound showed no gallbladder or liver pathology. The assessment of the cardiology team was that the abdominal symptoms were suspicious for mesenteric ischemia due to low output state from his heart failure. They advised admission to the cardiac unit and commencing the patient on continuous infusion of milrinone, an inotropic agent. The patient’s symptoms responded rapidly to milrinone and he remained pain-free for the remainder of his hospital course. He was also kept on intravenous heparin. Further workup was not necessitated given his positive response. Unfortunately he remained milrinone-dependent and overall chance of ventricular recovery from his severe cardiomyopathy was deemed poor. He was eventually transferred to another facility for heart transplant evaluation.

Discussion: Low output states such as heart failure can cause abdominal pain. The most concerning condition in this context is non-occlusive mesenteric ischemia (NOMI), which represents only 20% of mesenteric ischemia cases but is associated with a high mortality rate of 40-50%. The condition presents more variably and often more subtly than acute mesenteric ischemia of thrombotic or embolic origin, which can make diagnosis difficult. In our case the patient presented with an acute worsening of a longer history of postprandial abdominal pain. This case is particularly unique given the severity of this patient’s non-ischemic cardiomyopathy in combination with his young age and absence of atherosclerotic risk factors that may obscure this diagnosis in other patients. In cases of NOMI due to heart failure or sepsis, inotropic agents such as dobutamine and milrinone are preferred to support cardiac function and hemodynamics. Vasoconstrictive agents should ideally be avoided given the compromised intestinal blood supply.

Conclusions: In patients with severe low-output heart failure and abdominal pain, non-occlusive mesenteric ischemia is an important diagnosis to consider.