Abdominal angina

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• Abdominal angina (a.k.a. bowelgina) is postprandial abdominal pain that occurs in individuals with insufficient blood flow to meet visceral demands. The term angina is used in reference to angina pectoris, a similar symptom due to obstruction of the coronary artery. The American Heritage Stedman’s Medical Dictionary defines abdominal angina (bowelgina) as “Intermittent abdominal pain, frequently occurring at a fixed time after eating, caused by inadequacy of the mesenteric circulation. Also called intestinal angina; bowelgina.” ^[1]
• Mesenteric ischemia is a type of peripheral vascular disease that occurs when the blood supply can not meet the metabolic demands of visceral organs. Acute mesenteric ischemia is a surgical emergency that presents severe abdominal pain which is described as “pain out of proportion to physical examination.” However, chronic mesenteric ischemia (CMI) usually presents with vague abdominal pain that may be difficult to differentiate from other, more common causes of abdominal pain^[2]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Abdominal angina is an unusual cause of intermittent abdominal pain.The term angina is used because the pain develops only after eating, due to diminshed arterial supply that’s needed to meet the increased demands to support digestion ^[1]. It’s due to reduced mesenteric blood flow, the reduced oxygen content of red blood cells distributed via the mesenteric arterial circulation, or mesenteric venous stasis, any of which can lead to tissue hypoxia and ischemic injury^[1]

• The pathophysiology is similar to that seen in angina pectoris and intermittent claudication.
• Abdominal angina occurs due to narrowing of the mesenteric vessels that causes decreased blood flow.^[2]
• Atherosclerotic vascular disease at ostia of the mesenteric vessels is the most common cause of abdominal angina . Superior mesenteric artery occlusion is often found in patients presenting symptomatic occlusive mesenteric ischemia. Patients with abdominal angina are unable to increase flow in the mesenteric vessels in response to eating and that’s why they develop postprandial pain.^[2]
• Low perfusion can cause intestinal injury when mesenteric perfusion pressure is reduced to about 30 mmHg or reduction of 45 mmHg in mean mesenteric arterial pressure. Physiologically, the intestine can compensate for about a 75% decrease in mesentery blood flow for 12 hours without significant injury due to vasodilation of collateral circulation and increased oxygen extraction. But after an extended period of low perfusion or hypoxemia, progressive vasoconstriction leads to diminished collateral flow and subsequently full-thickness necrosis of the intestinal wall and perforation. Reperfusion injury after ischemia can be observed due to the release of toxic byproducts of ischemic injury, free oxygen radicals, and neutrophil activation.^[3]

• Acute mesenteric arterial embolism has usually cardiogenic origin and commonly affects the superior mesenteric artery, it can occur following atrial tachyarrhythmia, congestive heart failure, myocardial ischemia or infarction, cardiomyopathy, and ventricular aneurysm, which results in thrombus formation that can embolizes to cause ischemia. Patients with acute mesenteric arterial thrombosis commonly have an underlying atherosclerotic disease. Vasospasm in the superior mesenteric artery usually accompanies non-occlusive mesenteric ischemia secondary to cardiac failure, peripheral hypoxemia, or reperfusion injury. Rarely, vasopressors (e.g., cocaine and norepinephrine) and ergotamines may cause non-occlusive mesenteric ischemia. These agents cause vasoconstriction and decreased blood flow in the mesentery, which may result in ischemia of the bowel^[4].

• The mesenteric circulation consists mainly of three vessels that supply blood to the small and large bowel: the celiac artery, superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). Blood flow through these arteries raises within an hour post-prandially due to an increase in metabolic demand of the intestinal mucosa. Diffuse atherosclerosis, often occurring at the origin of these vessels, is the primary mechanism and accounts for 95% of Chronic mesenteric ischemia. Chronic occlusion of a single vessel allows collateral blood flow to compensate, but symptoms do not typically manifest until at least two primary vessels are occluded. Less common causes include vasculitis, fibromuscular dysplasia, and radiation.^[5]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The primary cause of abdominal angina is insufficient blood flow to meet mesenteric visceral demands, especially after meals.

• Atheroma
• Atherosclerosis^[1]
• Henoch-Schonlein purpura
• Ortner’s syndrome II
• Peripheral artery occlusive disease
• Renovascular Disease
• Vasculitis

• Dunbar Syndrome, Celiac artery compression syndrome, Median arcuate ligament syndrome^[2][3]
• Cancer of Papilla of Vater^[4]
• Takayasu arteritis^[5]

Abdominal angina should be differentiated from the various types of gastrointestinal cancer, such as stomach cancer, gallbladder cancer or colorectal cancer. The symptoms may be similar.

• Chronic Pancreatitis
• Intra abdominal malignancy
• Chronic cholecystitis
• Peptic ulcer disease

• Inflammatory bowel disease

• Angioedema^[1]
• Radiation induced enterocolitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Although mesenteric ischemia (MI) is rare medical condition ,it’s accounts for 0.1% of all hospital admissions , The mortality rate of mesenteric ischemia is ranging from 24% to 94%. The incidence of colonic ischemia is approximately 16 cases per 100,000 person per years, and it is rising by time . Ischemic colitis is reported for 1 in 2000 hospital admissions.^[1]

• female to male ratio is 3:1^[2].

• There’s no available data for the incidence and prevalence of abdominal angina among different races^[3].

• The average age of patients with mesenteric ischemia is slightly older than 60 years, but it has also been reported in younger patients^[2].

• There are few reported cases of abdominal angina outside the united states.^[2]

Smoking is an associated risk factor. In most studies, approximately 75-80% of patients smoke.

• Smoking
• Hyperlipidemia^[1][2]

Increased incidence is seen in patients with Cardiac failure, H/O atrial fibrillation, Peripheral arterial occlusion, recent surgery^[3]

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Complications include access site hematoma, pseudoaneurysm and thrombosis, particularly if surgical treatment is delayed.

Prognosis depends on whether the patient is treated by early surgery in order to prevent complications. The prognosis of abdominal angina depends on the following:

• Whether the patient is treated by early surgery.
• Whether reocclusion happens or not
• Whether complications such as access site hematoma, pseudoaneurysm or thrombosis appear.