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      Abdominal Pain in the Elderly: An Unusual Case of Chronic Mesenteric Ischemia in the Emergency Department

      case-report

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          Abstract

          Chronic mesenteric ischemia (CMI) is a rare cause of abdominal pain with the potential for significant morbidity and mortality. An infrequently described complication of CMI is acalculous cholecystitis. Historically, acalculous cholecystitis is thought to be multifactorial and usually occurs in the setting of severe illness. In CMI, the etiology is more likely chronic ischemia to the gallbladder leading to inflammation. We present a case of acalculous cholecystitis that presented insidiously in a patient with CMI.

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          Microangiopathy in acute acalculous cholecystitis.

          T Hakala, P Nuutinen, E T Ruokonen … (1997)
          Acute acalculous cholecystitis is a well recognized complication of many acute illnesses. Ischaemia of the gallbladder seems to have an important role in its pathogenesis.
          Article 0 comments Cited 18 times – based on 0 reviews     Review now
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            Mesenteric stenosis, collaterals, and compensatory blood flow

            Andre S van Petersen, Jeroen Kolkman, Robbert Meerwaldt … (2014)
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              Diagnosis and treatment of chronic mesenteric ischemia: An update.

              Jeroen Kolkman, Robert Geelkerken (2017)
              Although the prevalence of mesenteric artery stenoses (MAS) is high, symptomatic chronic mesenteric ischemia (CMI) is rare. The collateral network in the mesenteric circulation, a remnant of the extensive embryonal vascular network, serves to prevent most cases of ischemia. This explains the high incidence of MAS and relative rarity of cases of CMI. The number of affected vessels is the major determinant in CMI development. Most subjects with single vessel mesenteric stenosis do not develop ischemic complaints. Our experience is that most subjects with CA and SMA stenoses with abdominal complaints have CMI. A special mention should be made on patients with median arcuate ligament compression (MALS). There is ongoing debate whether the intermittent compression, caused by respiration movement, can cause ischemic complaints. The arguments pro and con treatment of MALS will be discussed. The clinical presentation of CMI consists of postprandial pain, weight loss, and an adapted eating pattern caused by fear of eating. In end-stage disease more continuous pain, diarrhea or a dyspepsia-like presentation can be observed. Workup of patients suspected for CMI consists of three elements: the anamnesis, the vascular anatomy and proof of ischemia. The main modalities to establish mesenteric vessel patency are duplex ultrasound, CT angiography or MR angiography. Assessing actual ischemia is still challenging, with only tonometry and visual light spectroscopy as tested candidates. Treatment consists of limiting metabolic demand, treatment of the atherosclerotic process and endovascular or operative revascularisation. Metabolic demand can be reduced by using smaller and more frequent meals, proton pump inhibition. Treatment of the atherosclerotic process consists of cessation of smoking, treatment of dyslipidemia, hypertension, hyperglycaemia, and medication with trombocyte aggregation inhibitors.
              Article 0 comments Cited 14 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clin Pract Cases Emerg Med
                Journal ID (iso-abbrev): Clin Pract Cases Emerg Med
                Title: Clinical Practice and Cases in Emergency Medicine
                Publisher: University of California Irvine, Department of Emergency Medicine publishing Western Journal of Emergency Medicine
                ISSN (Electronic): 2474-252X
                Publication date Collection: August 2019
                Publication date (Electronic): 01 July 2019
                Volume: 3
                Issue: 3
                Pages: 275-277
                Affiliations
                University Hospitals Cleveland Medical Center, Department of Emergency Medicine, Cleveland, Ohio
                Author notes
                Address for Correspondence: Vicki Noble, MD, University Hospitals Cleveland Medical Center, Department of Emergency Medicine, 11100 Euclid Ave, Cleveland, OH 44106. Email: julieta.lacey@ 123456uhhospitals.org .
                Article
                Publisher ID: cpcem-3-275
                DOI: 10.5811/cpcem.2019.5.41886
                PMC ID: 6682238
                PubMed ID: 31403102
                SO-VID: 7aacf907-d8e0-46a0-8a53-a71a46d6e0cc
                Copyright © Copyright: © 2019 Lacey et al
                License:

                This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/

                History
                Date received : 03 December 2018
                Date revision received : 02 May 2019
                Date accepted : 16 May 2019
                Categories
                Subject: Case Report

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