Case Presentation: A 59-year-old woman presented with acute worsening of chronic abdominal pain and nausea. Her past medical history included a stable type-B aortic dissection. Over the previous year, she had multiple hospitalizations for postprandial abdominal pain associated with nausea and vomiting. The pain had been increasing in severity and had led to a 10-pound weight loss. The patient had an extensive workup, including EGD, colonoscopy, gastric emptying study, and video capsule endoscopy, all of which were unrevealing. Her symptoms were managed as functional abdominal pain in the outpatient setting. During the current admission, the patient underwent another unrevealing EGD and had a mesenteric duplex ultrasound showing widely patent mesenteric arteries. Her aortic dissection was stable on CT angiogram. Given the classic history of intestinal angina accompanied by weight loss, the team asked the radiologist to review the CT angiogram again. Upon further review, the radiologist noted that while the mesenteric circulation itself did not show stenosis, the true aortic lumen supplying the celiac trunk was significantly smaller than the false lumen created by the dissection. A percutaneous fenestration of the aortic dissection was performed to improve blood flow to the true lumen and ultimately the celiac artery. After the procedure, the patient had resolution of her postprandial pain and was able to tolerate full meals for the first time in over a year.
Discussion: Chronic mesenteric ischemia often presents with postprandial abdominal pain, nausea, vomiting, diarrhea, early satiety, and weight loss secondary to restricted food intake. In more than 90% of cases the primary etiology is progressive atherosclerotic disease impairing mesenteric circulation. While many of our patient’s symptoms were consistent with an ischemic etiology, the lack of risk factors for atherosclerotic disease and normal mesenteric duplex ultrasound made ischemia seem unlikely. Non-ischemic causes of postprandial pain, such as peptic ulcer disease, biliary disease, and gastroparesis had been ruled out by the previous workup, so the idea of ischemia was revisited. In patients with acute aortic dissection, mesenteric ischemia is a rare complication, occurring in less than 4% of patients. In chronic aortic dissection, mesenteric ischemia is an even rarer phenomenon. Our review of the literature found it described in just two cases of stable chronic aortic dissection. Both cases were successfully treated with fenestration. Fenestration is an endovascular procedure that involves puncturing the septum separating the false lumen and true lumen. Balloon dilation of the fenestrations subsequently provides channels for equalization of blood flow and pressure between the two lumens, thereby improving mesenteric perfusion. The diagnosis is challenging in the absence of the typical risk factors and imaging findings. In our case, a diagnostic time-out, in which we considered the case anew and recognized the possibility of anchoring, was an important step in arriving at the right diagnosis.
Conclusions: In patients with aortic dissection, it is important to explore diminished flow in the true aortic lumen as a cause of postprandial abdominal pain.