Post-Prandial Abdominal Angina Resulting in Food Aversion

A 59-year-old female with hypertension and gastroesophageal reflux disease (GERD) presents to the emergency department (ED) with 1 month of severe epigastric discomfort. The pain is episodic and sharp in nature with radiation to her back. Pain is worse after eating and is followed by nausea and vomiting. The patient reports a 20-pound weight loss over the last 6 weeks. Denies drug, alcohol and tobacco use.

Patient was admitted to the hospital and underwent a normal gastric emptying study and colonoscopy. An esophagogastroduodenoscopy (EGD) showed multiple shallows ulcers in the gastric fundus and duodenum. Peptic ulcer disease was treated with a course of proton-pump inhibitor (PPI) therapy. Repeat endoscopy later showed resolution of ulcers. Patient is now being seen in the vascular surgery clinic 6 months after initial presentation. She has lost over 80 pounds secondary to food aversion and severe post-prandial pain.

On physical exam, blood pressure is 128/68 mmHg, pulse is 87 bpm, temperature is 97.9°F, SpO2 is 96% on room air. The patient is in no acute distress, heart rate and rhythm are regular, and no murmurs are appreciated. Lungs are clear to auscultation with normal pulmonary effort. Patient has tenderness on deep palpation to epigastric area. No abdominal bruit, guarding or rebound tenderness is appreciated.

Laboratory work including basic chemistry, complete blood count, troponin, lactate, and lipase are within normal limits. Chest x-ray shows no acute cardiopulmonary disease. Electrocardiogram (ECG) demonstrates normal sinus rhythm.

Computed tomography angiography (CTA) demonstrates severe focal stenosis of proximal celiac trunk (Figure 1 and 2) and chronic occlusion of the proximal superior mesenteric artery (SMA) with reconstitution via inferior mesenteric artery (IMA) collaterals. There is no evidence of acute mesenteric ischemia. Imaging is consistent with chronic mesenteric ischemia.

Figure 1

Figure 1
Figure 1. CTA abdomen demonstrating severe focal stenosis of proximal celiac trunk.

Figure 2

Figure 2
Figure 2. This patient's focal celiac calcification is consistent with atherosclerotic disease. This is in contrast to celiac narrowing seen in median arcuate ligament compression, which demonstrates a characteristic hooked appearance on CTA.1 This distinction is best appreciated in a sagittal plane.

What is the next step in treatment of this patient's chronic mesenteric ischemia?

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