What is abdominal angina? What is its clinical significance?
Abdominal angina is an uncommon cause of intermittent abdominal pain. Patients with abdominal angina report severe cramping abdominal pain that begins 15 to 30 minutes after eating. This postprandial pain persists for 2 to 3 hours. Additional ingestion of food aggravates the patient’s pain, forcing the patient to stop eating.
Weight loss is common. As the disease progresses, malabsorption and diarrhea occur as a result of mucosal and mural injury, which further exacerbates the patient’s weight loss.
Abdominal angina refers to chronic, recurrent abdominal pain caused by a decrease in arterial blood flow through the mesenteric arteries, usually resulting from stenosis from atherosclerotic lesions.
The postprandial state can be regarded as an exercise stimulus; food entering the stomach causes an increase in oxygen demand thereby decreasing blood flow to the intestines (steal phenomenon).
Pain begins to occur within 30 to 90 minutes and can last for up to four hours. Initially, abdominal angina is usually minimal; however, it progressively increases in severity over weeks to months. Long-term hypoxia of the small intestinal mucosa can cause villous atrophy leading to diarrhea, protein-losing enteropathy, steatorrhea, weight loss, and malnutrition.
The cause of abdominal angina is arterial vascular insufficiency. The term angina is used because the pain occurs only after eating, when the insufficient fixed arterial supply is unable to meet the increased demands needed to support digestion. The most common cause of abdominal angina is stenosis of the celiac artery with inadequate collateralization. Aneurysms of the superior mesenteric artery, the vasculitides, fibromuscular hyperplasia, and tumor encroachment on the celiac artery also have been implicated as causes of abdominal angina.
What are the Symptoms of Abdominal Angina
Physical examination of a patient with abdominal angina reveals diffuse abdominal tenderness. Mild abdominal distention may be present. Signs of acute peritoneal irritation suggestive of perforated viscus, such as rebound tenderness, are absent. The patient may exhibit frequent defecation of mucoid stools, diarrhea, and vomiting. The patient appears systemically ill, but not septic.
How is Abdominal Angina diagnosed?
The diagnosis of abdominal angina is based on clinical history. Angiography of the celiac artery provides proof of vascular insufficiency and often identifies the cause of the problem. Barium enema shows the classic finding of thumbprinting that is strongly suggestive of mucosal ischemia. Colonoscopy reveals localized hemorrhage and ulceration of the affected mucosa. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, erythrocyte sedimentation rate, and stool and blood cultures for infectious enteritis, may be indicated.
Given the possibility that the patient’s abdominal angina is due to vasculitis, a collagen-vascular workup is indicated in all patients with abdominal angina. Computed tomography (CT) of the abdomen with oral and intravenous contrast material is indicated if an occult mass or abscess is suspected. Magnetic resonance angiography (MRA) of the celiac and mesenteric vessels also can help clarify the diagnosis and aid in planning a treatment strategy, as can ultrasonographic and Doppler flow studies.
Any disease process that can produce ischemic bowel can mimic the pain of abdominal angina. The vasculitides, including polyarteritis nodosum and Henoch-Schönlein purpura, also can cause the symptoms of abdominal angina. Embolic disease that may cause occlusion of the vascular supply to the gut also should be considered. The possibility of infectious enteritis always must be included in the differential diagnosis. Other causes of abdominal pain, including diverticulitis, bowel obstruction, and appendicitis, may occur in conjunction with abdominal angina.
The only definitive treatment of abdominal angina is correction of the arterial insufficiency via either angioplasty, stent placement, and/or surgical revascularization. Careful attention to the patient’s fluid and metabolic status is crucial to avoid complications. Anticholinergics such as dicyclomine and antiperistaltics such as loperamide can help decrease diarrhea. Small, frequent feedings also may help palliate the postprandial pain.
The potential for complications in patients with abdominal angina is high. Spontaneous bowel perforation, stenosis, fistula formation, bleeding, and malabsorption occur with sufficient frequency to complicate the management of this painful condition. Untreated, abdominal angina frequently progresses to bowel infarction.
The treatment of the symptoms associated with abdominal angina is difficult, and ultimately, correction of the vascular insufficiency is required. Vigilance for life-threatening complications of abdominal angina, including bowel infarction, is mandatory to avoid disaster.