Rosalind Franklin University of Medicine and Science North Chicago, IL, United States
Nehal Patel, MD1, Axel Feller, MD2, Mark Conneely, MD2 1Rosalind Franklin University of Medicine and Science, North Chicago, IL; 2Captain James A. Lovell Federal Health Care Center, North Chicago, IL
Introduction: Angioedema is a rare but possibly fatal adverse reaction of angiotensin-converting enzyme inhibitor (ACEi) treatment. The incidence of angioedema is 3.27 per 1000 per year in the first years of treatment with a higher incidence in women and African descendants. Mucosal angioedema of the lips and throat is a known adverse reaction. Rarely, does it involve isolated angioedema of the small bowel. In these cases, patients will usually present with recurrent abdominal pain. This is a case of ACEi-associated angioedema (ACEi-AA) strictly isolated to the small bowel presenting after 7-years on lisinopril therapy.
Case Description/Methods: A 49-year-old female with a history of HTN, presented with a complaint of reoccurring severe band-like abdominal pain. She reported a long-standing history of similar episodes that required multiple admissions and endoscopies. During this evaluation, CT scans, infectious studies, food sensitivities, metabolic etiologies, IBD, and a video pill capsule study were all unremarkable. Ultimately, an MR enterography (MRE) revealed significant wall thickening and edema of the small bowel loops. It was suspected that her abdominal pain was secondary to ACEi-AA, thus lisinopril was immediately discontinued. With normal C1 inhibitor levels and no family history, hereditary angioedema was ruled out. She was treated with steroids and reported near-complete resolution of symptoms. Follow-up imaging 1 and 6 months later showed normal small bowel loops where inflammation was previously seen. Since discontinuing lisinopril, she has remained asymptomatic with no further episodes of abdominal pain.
Discussion: There are only 21 documented cases of ACEi-AA isolated to the small bowel. Patients usually have recurrent and nonspecific abdominal pain despite extensive workup. Moreover, many underwent invasive procedures including endoscopy, intestinal biopsy, exploratory laparotomy, and bowel resections. ACEi-AA is secondary to elevated levels of bradykinin, which increases vasodilation and permeability leading to angioedema. Nearly 180-million adults in the USA have HTN, of those, 30-million adults take hypertensive medications. Intestinal angioedema is a rare condition frequently undiagnosed prompting multiple admissions and diagnostic modalities. The prevalence of ACEi-associated intestinal angioedema could be higher if it were not so difficult to diagnose. This diagnosis should be considered for any patient with recurrent abdominal pain of unknown etiology who is prescribed ACEi therapy.
Figure: Figure 1: Reformatted images in coronal (1A) and sagittal (1B) view: marked wall thickening and edema of a loop of the small bowel (yellow arrows) with adjacent mesenteric edema. A small amount of intraperitoneal fluid is present in the lower abdomen (thin peach arrows).
Figure 2: Coronal reformatted image: showing only normal loops of small bowel where the inflamed loop was previously seen and complete resolution of the adjacent mesenteric edema and peritoneal fluid, at one month follow up.
Disclosures: Nehal Patel indicated no relevant financial relationships. Axel Feller indicated no relevant financial relationships. Mark Conneely indicated no relevant financial relationships.
Nehal Patel, MD1, Axel Feller, MD2, Mark Conneely, MD2. P1977 - A Case of Isolated Intestinal Angioedema, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.