We'll move on to our next case now.
We have 54-year-old woman who presents to clinic
with 6 months of intermittent abdominal pain.
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.
She underwent upper endoscopy for these
symptoms last months with no abnormalities.
Her medical conditions include hypertension,
dyslipidemia and a 30-pack year history of smoking.
Her vitals are normal, BMI is 18.
On abdominal exam, a bruit is
heard over the upper abdomen
and dorsalis pedis pulses
are diminished bilaterally.
What is the most likely diagnosis?
So she has chronic intermittent
abdominal pain that is worse after eating,
associated with weight loss and anorexia.
She has multiple risk factor for vascular
disease, with her hypertension, hyperlipidemia,
and history of smoking.
And on physical exam, she is underweight.
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.
So, this woman probably has
chronic mesenteric ischemia.
This is commonly due to atherosclerotic
disease of the mesenteric vessels.
As opposed to acute mesenteric
ischemia, it tends to occur with
intermittent postprandial abdominal
pain, typically about an hour after eating.
Patients may have fear of eating
because of the pain they experience
which leads to unintentional weight loss.
And on exam, you may hear an abdominal
bruit or find reduced peripheral pulses.
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.
So the diagnosis as with acute
ischemia is done with imaging.
You may do a vascular doppler ultrasound,
or CT or a Magnetic Resonance Angiography.
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.
The treatment is with
or you may place a stent
endovascularly to improve blood flow.
So now, let's go back to our case.
Our 54-year old woman who's coming
in with chronic intermittent abdominal pain
worse after eating with
now weight loss and anorexia.
She does have multiple risk factors
for some type of vascular disease.
And her physical exam, confirms
likely peripheral arterial disease.
So the most likely diagnosis
here is chronic mesenteric ischemia
due to her underlying atherosclerosis.