Chronic Mesenteric Ischemia with Case

00:01 We'll move on to our next case now.

00:03 We have 54-year-old woman who presents to clinic with 6 months of intermittent abdominal pain.

00:10 Her pain worsens an hour after eating and is associated with anorexia, nausea, and non-bloody diarrhea She is now afraid to eat and has lost 9 kilograms in the last 6 months.

00:21 She underwent upper endoscopy for these symptoms last months with no abnormalities.

00:28 Her medical conditions include hypertension, dyslipidemia and a 30-pack year history of smoking.

00:34 Her vitals are normal, BMI is 18.

00:37 On abdominal exam, a bruit is heard over the upper abdomen and dorsalis pedis pulses are diminished bilaterally.

00:47 What is the most likely diagnosis? So she has chronic intermittent abdominal pain that is worse after eating, associated with weight loss and anorexia.

00:59 She has multiple risk factor for vascular disease, with her hypertension, hyperlipidemia, and history of smoking.

01:07 And on physical exam, she is underweight.

01:10 In addition, she has an abdominal bruit, with reduced DP pulses which would prompt you to consider that it's a diagnosis of peripheral arterial disease.

01:21 So, this woman probably has chronic mesenteric ischemia.

01:25 This is commonly due to atherosclerotic disease of the mesenteric vessels.

01:30 As opposed to acute mesenteric ischemia, it tends to occur with intermittent postprandial abdominal pain, typically about an hour after eating.

01:40 Patients may have fear of eating because of the pain they experience which leads to unintentional weight loss.

01:47 And on exam, you may hear an abdominal bruit or find reduced peripheral pulses.

01:52 So here on the right, you can see a normal blood vessel that allows blood flow after eating and the existence of atherosclerosis with a plaque that then leads to chronically reduced blood flow and can lead to chronic ischemia.

02:07 So the diagnosis as with acute ischemia is done with imaging.

02:12 You may do a vascular doppler ultrasound, or CT or a Magnetic Resonance Angiography.

02:18 Here on the right, you can see an example of a CT angiogram where the arrow points to an area of stenosis, likely from an atherosclerotic plaque of the superior mesenteric artery.

02:32 The treatment is with surgical revascularization or you may place a stent endovascularly to improve blood flow.

02:41 So now, let's go back to our case.

02:43 Our 54-year old woman who's coming in with chronic intermittent abdominal pain worse after eating with now weight loss and anorexia.

02:51 She does have multiple risk factors for some type of vascular disease.

02:55 And her physical exam, confirms likely peripheral arterial disease.

02:59 So the most likely diagnosis here is chronic mesenteric ischemia due to her underlying atherosclerosis.