A 69-year-old woman with a history of atrial fibrillation, coronary artery disease (CAD) status/post coronary artery bypass graft, type 2 diabetes mellitus (T2DM), and current tobacco use presents to the emergency department with postprandial abdominal pain. She states that the pain started 6 months earlier and is a generalized dull abdominal pain. She reports that the pain usually resolves within 1-2 hours after eating and that defecation sometimes provides relief. She has no nausea, emesis, melena, hematochezia, or changes in bowel/urinary habits. However, she reports a 25 lbs (11 kg) unintentional weight loss during this time frame.
On physical examination, she is in mild distress but hemodynamically stable. There is tenderness of all abdominal quadrants. There is no organomegaly, guarding, rigidity, or costovertebral angle tenderness appreciated.
Which one of the following is the most appropriate next diagnostic test?
Show Answer
The correct answer is: C. Obtain computed tomography angiography of the abdomen and pelvis.
This patient's likely diagnosis was abdominal angina in the setting of chronic mesenteric vascular occlusive disease. She had extensive risk factors for polyvascular atherosclerotic disease (known symptomatic CAD, heavy smoking, hypertension, and T2DM).1,2 Patients with chronic mesenteric ischemia classically present with postprandial abdominal pain, unintentional weight loss, and food avoidance.1,2 Computed tomography (CT) angiography of the abdomen and pelvis can identify mesenteric arteries with atherosclerotic plaque, calcification, and luminal narrowing.
Obtaining a urinalysis is an incorrect choice because her symptoms were inconsistent with a urinary tract infection or other urogenital disorders. One could order a CT of the abdomen and pelvis without contrast if there were concern that a kidney stone could be the cause of her symptoms. However, she did not report urinary tract symptoms and had no costovertebral angle tenderness. Hence, the diagnosis is less likely to be a kidney stone. Obtaining mesenteric ultrasonography with respiration maneuvers could be chosen if there were concern for median arcuate ligament syndrome. However, her presentation did not fit this diagnosis and her comorbidities make atherosclerotic mesenteric ischemia more likely.
References
Huber TS, Björck M, Chandra A, et al. Chronic mesenteric ischemia: clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg 2021;73:87S-115S.
Sardar P, White CJ. Chronic mesenteric ischemia: diagnosis and management. Prog Cardiovasc Dis 2021;65:71-5.
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