S6121 Isolated Duodenal Ischemia: A Rare Case of Intestinal Angina

Introduction: Intestinal angina or chronic mesenteric ischemia (CMI) is caused by episodic intestinal hypoperfusion resulting in dull, crampy, postprandial pain. However, most individuals are asymptomatic due to an extensive collateral vascular network. Symptoms are more likely to occur in individuals >60 years of age, with dyslipidemia, atherosclerosis or tobacco use. Isolated duodenal ischemia has been rarely reported and can have up to a 40% mortality rate. We report a highly unusual case of isolated duodenal ischemia which was managed with angioplasty. Case Description/Methods: A 74-year-old man with hypertension, dyslipidemia, chronic kidney disease, 20-pack year smoking history, chronic back pain with nonsteroidal anti-inflammatory drug use and recent gastrointestinal bleed presented with 1 week of melena, abdominal pain and fatigue. Exam revealed diffuse abdominal tenderness and melena on rectal exam. Labs were significant for hemoglobin of 11.5 g/dL and computed tomography abdomen/pelvis showed possible enteritis and mild small-bowel ileus. A push enteroscopy showed LA Grade D esophagitis without bleeding, pale gastric mucosa, non-bleeding ulcers in gastric antrum and duodenal bulb and diffuse severely friable mucosa with longitudinal ulcerations and areas of gangrenous tissue between the second and third portions of the duodenum consistent with intestinal ischemia. Biopsies of the area revealed small pieces of necrotic tissue with congestion and nonspecific reactive changes. A computed tomography angiogram uncovered extensive atherosclerotic disease with moderate stenosis of the proximal celiac artery and mild stenosis of the proximal superior mesenteric artery. The patient was treated with antibiotics, intravenous fluids and bedrest. Angioplasty of the proximal SMA resulted in improvement of the stenosis. There was no recurrent bleeding, thus he was discharged in stable condition. Discussion: CMI is a complex vascular disorder predominantly caused by the atherosclerotic occlusion of the mesenteric arteries, leading to postprandial pain and weight loss due to inadequate splanchnic blood supply or factors such as fear of eating. Due to its rarity and slow onset nature, it can be challenging to diagnose, requiring a high index of clinical suspicion. Revascularization is the definitive treatment for symptomatic CMI. Although surgery has been historically favored, endovascular interventions like percutaneous angioplasty and stenting have become the preferred initial approach due to lower perioperative morbidity and shorter hospital stays.