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.