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Abdotninal angina in a 43,year,old wotnan - Treattnent with percutaneous translurninal angioplasty

NOEL B. HERS! IFIELn, MD, FRCP(C), FACP, ] AMES A.G. KLUETT', MD, JOSEPH E. DESAL'TELS, MD, FRCP(C)

atcly on ingestion. In the six months ABSTRACT: A patient with the clinical presentation of chronic abdominal prior to presem;:ition th e pntiern had angina is reported. The J iagnosis was confirmed by angiographic studies which revealed stenosis of the ccliac axis artery at its origin, as well as significam stenosis of lost 40 lbs in weight. the superior mesenteric artery near its o rigin. Translumi nal angioplasty of the supe­ Physical examination was un­ rior mesenteric artery was performed with success. After o ne year the patient is free remarkable except for epigastric ten­ from rain. This case demonstrates the efficncy of percutaneous cransluminal derness and a loud to an fro epigastm nngioplasty in this condition and t he importance of careful history and physical murmur. Hematological nnabdominal pain. Can J Gastroenterol chemical investigations were negmivc. 1988; 2(1):28-30 Blood pressure was l 10/80 mmHg. There were no p h ysical signs of cardio­ Key Wo rds: Abdominul anginu, Trcmsl"minal ungioplasty vascular disease. Abdominal angiography revealed blockage of th e celi;:i c axis trunk at its 4 3-YEAR-OU) FEMALE \XII 10 I IAD Previous investigations, at another origin. T h e su perior mesenreric nrrcrv a o ne-year h istory of right u pper institution, including u pper G I scries, A was also stenosed and t he pres~urc quadrant pain radiating imo the back endoscopy, ultrasound of th e gradient across the stenosis was 100 presenteJ to th e Foothills H ospital, abdomen and a CAT scan of the mmHg. T h e inferior mesen teric artery Calgary. The pain came o n immeJi­ abdomen, were negative. was paten t and supplied areas of the accly after enting and resulted in The symptoms persisted and the pa­ superior mesenteric nrtery. The i nfen­ sitophob,a with subsequent \\'eight tient ace decreasing nmounts because or mesenceric artery also functioned as loss. food precipitated pain almost immedi- the primary arterial supply for those areas usually supplied by the ccliac axis and its branch es (Figure !). Department of Mcdtcine and De/>anment of Rad1olog1cal Sctences and Dwgnomc lm agmg, Transluminal nngioplasty o f the The Un1t·erS 1C )' of Calgary cH ihe Fooihil/; Hos/>iwl, Calgary, Alberta superior mesem eric artery was per­ Corres pondence ancl repnn1s: D r N. B. Hershfield, Clinical Professor, D epartment of Medtcine, Unit•ersiiy of Calgary, 71 1 S01 ah Tower, 303 1 f-lospiwl Driw NW, Ca/gar;, Alhertc.1 TlN :!TQ formed. After t h e dilatation, th e pres­ l~ eceit•cd for publication October I 987. Acce/ned )an11ary 1988 sure gradient across th e segment was

28 CAN J GASTRL1ENTEROL A bdominal angina in a 43 yelJr old woman

~5 mmHg. After the dilatatio n the pa­ tienr developed right flank pain which resolved in 24 h. The patient was well when discharged from hospital. Two mo nths later the patient rt:­ portcd that she was caring well, the pain had Jisappearcd and she had gamed 20 lbs. H owever, there was re­ sidual right flank pain and the patient had hccome hypem :nsive after the ini tial angiogram. Whereas previously, blood pressure was always recorded as normal, on many occasions at this rime her blood pressure was recorJed as 160/155- 105 mmHg. le was felt that there was the possibil- 1tv of some renal artery d amage sus­ tained after the initial angiogram. However, renal angiograph y revealed a normal superior mcscntcric artery md the collateral Lirculauo n of the in­ ferior mesemeril artery was reversed. The pressure gradient across the supe­ rior mesenteric stenosis was now less Fig. I than 50 mmHg. The angiogram Figure 1) lninal ,mgrogrnrn 1hou-mg com/>kre st<.'nom of the cdwc a.,1, c1rt<.'T\ (l,laLk urrou) ar 1t, showed patency of hoth renal arteries origin; subwwl scenom of th<.' mf>erior m<.'1<.'ntl'flL ,merv (o/1t:n anc111) \t'Jth <1 J!radient of I()() mmH1; and no evidence of arhcroscleroril di~­ acm,s the swnosi.1 . fl/noel /lou co chc .f;<1.1rromrcscint1I rwct u·m /mnc1/>alh· frmn chc in/nior m<.'1en1cr- easc (Figure 2) . 1L arr er. (/,lack arrou·head) l'ia collacernls u·hich /lou eel retro.J!racfr w che ste{>L'rior mL·senrn,c arier., BecausP of continuing right fl ank th<.' n t'l

DISCUSSION Grunrzig a nd Hopff (l) first devel­ oped and described transluminal angioplast y for the treatme nt of ab­ dominal angina. O ther investigato rs have shown that balloon catheter d1- lacat1on of a stenosed vessel is ofte n successful in treating abdo mina l angina (2-4). With percuraneous tra ns­ lummal angioplasty few complicatio ns have occurred. fig. II The present case was unusual in that the Henosis occurred in a 43-year-old female with no other evidence o f ath­ erosclerotic disease. The fact that the Figure 2) Angiogram follotnng {>ercurancous rranduminal angioplascv ret eah a nonnal calibr, of segmental renal vessels sho wed che inferior mesenwric arce1"11 (arrou·head) u.'h1ch nou· carrie.1a nonnal i-olumc of blood . The mpenor fibromuscular hyperplasia suggests mescntem arcen (arrou) fills in a normal cmiegradc mt1nncr (i:rcul1ent is nou _!() mmH1 I Ina ch<.' that the stcnos1s of the superior cdwc axis .1till fill., m a r,•crogradr fashion

Vol. 2 No. I. Marc h 1988 29 HERSHFIELD ec al mesemeric artery was also due Lo that 20% (5,6). Most of these patients, how­ importance of a careful history and condition. ever, had severe generalized vascular physical examination in patients with Alternative treatment of this condi­ disease, refl ected in the high surgical ch ronic abdominal pain and che value tion is a vascular bypass graft, but this mortality rate. o f angioplasty as treatment for the con­ has a mortality rate of approximately This case serves as a reminder of the dition.

REFERENCES Resolution o f mescncer ic an gina with luminal angioplasty in th e treatment I. Gruntzig A, Hopff H. Pcrkutanc percutaneous transluminal angioplasty of abdominal angina. Am J Radio! rckanalisation chronisch er artcricllcr of superior mesen teric artery scenosis 1982; 139:247-9. vcrchlusscc mit cincm ncucn dilata­ using a balloon catheter. Gast rointcst 6. Stoney RJ, Wylie EJ. Recognition and tion skathcrtcr. Modifikation der Kot­ Radiol 1980; 5:367-9. surgical management of visceral tcrtechnik. Dtsch Med Woch enschr 4. Birch MB, Colapinto RF. Trans­ ischcrnil syndromes. Ann Surg 1966; l 974; 99:2502-10. luminal dilatation in t he management 164: 714-2 l. 2. Katzen BT, Chang J. Percutan eous of mesenteric an gina: A report o f two 7. Reul GJ Jr, Wukash DC, Dandiford t ransluminal angioplasty with cases. J D e L 'Association Can adienn e EM, Chiarillo L, Hallman GL, Cooley Gruntzig balloon cath eter. Radiology Des Radiologistes 1982; 33:46-7. DA. Surgical treatment of abdominal 1979; 130:623-6. 5. Golden DA, Ring EJ, McLean GK, angina. Review of 25 patients. Surgery 3. U flackcr R,Goldany MA, ConsrnncS. Freiman DB. Percutan eous trans- 1974; 75:682-9.

Clinical quiz - Answers

SMALL INTESTINE 2. Causes and pathogenesis of intestinal pseudo­ obstruction syndrome Cause Pathogenesis

1 . Causes of vitamin B,2 deficiency and pathogenic Diabetes Autonomic polyneuropathy processes induced Laxative abuse Damaged myenteric plexus Idiopathic Tissue infiltration Cause Pathogenic process Scleroderma Tissue 1nflltrat1on Amylo1d Tissue 1nf1ltrat1on Strict vegans No ingestion of milk or animal products Eos1nophilic Tissue 1nfil trat1on Achlorhydria Elderly gastroenteritis Postoperat,ve Inability to liberate CBL 3. Renal and urinary complications of Crohn's disease Complete lack of IF Pernicious anemia Total gastrectomy Complication Mechanism Exocrine insufficiency Human R protein (stomach) Perirenal abscess Cont1gu1ty of deep disease of descending Achlorhydria colon food buffering compete for CSL Enterovesical fistula Ileum or s1gmo1d colon due to anatomical Bacterial overgrowth relationship of these segments Parasitic 1nfestat1on Gives rise to recurrent urinary infection and (tapeworm) res1stence to usual ant1b1ot1c treatments Diseased or resected Loss of absorptive surface Pyelonephritis Septicemia ileum ( 100 cml Ureter obstruction Contiguity of severe diseased segments of Congenital abnormalities Lack of or abnormal IF (uni- or bilateral) inflammatory mass. May lead to lleal defect (receptors) hydronephros1s and pyelonephros,s lsmelund Nephrolithias1s Oxalate stones and hyperoxaluria fat Grasbeck (23-35%1 malabsorpt1on increases the availability Other Gastrinoma of dietary oxalate absorption from the Hypersecreuon of HCI, prevents IF CSL 111 colon ileum Nephrot1c syndrome Amylo1dos1s

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