2631 Angiotensin Converting Enzyme Inhibitor-Induced Isolated Angioedema of Small Bowel

Abstract

INTRODUCTION: Angiotensin-converting enzyme inhibitors (ACEi) are generally known to cause angioedema, with the face, tongue, and pharynx primarily involved. ACEi-induced small bowel angioedema is relatively rare occurring in 0.1 to 0.7% patients on ACEi. CASE DESCRIPTION/METHODS: Our case report is about a 34-year-old woman who was recently started on lisinopril and diagnosed with angioedema of the stomach and duodenum. The patient presented to our hospital with a 3-week history of nausea and a 2-day history of worsening epigastric pain. She also had one episode of non-bilious emesis and one episode of watery diarrhea. Her home medications included lisinopril 20 mg daily for hypertension, which she started taking 3 weeks ago. She was hemodynamically stable and physical examination revealed mild epigastric tenderness with no organomegaly, guarding or rebound tenderness. Laboratory values were significant for leukocytosis of 12,000, and normal complement and lipase levels. Abdominal computed tomography (CT) scan showed signs of findings of acute severe enteritis involving the duodenum and proximal jejunum, with no pancreatitis. Endoscopy revealed edema of the duodenum. Given the high suspicion for ACEi induced angioedema of the small bowel, her lisinopril was discontinued and the patient showed complete symptom resolution within 24 hours. DISCUSSION: ACEi-induced angioedema of the small bowel is a rare clinical presentation, however, it is an important differential diagnosis to consider when a patient taking an ACEi presents with nausea and abdominal pain. It is important to highlight angioedema of the small bowel can occur at any time after a patient starts taking an ACEi. Although ACEi-induced small bowel angioedema is relatively rare, its recognition is important as ACEi use is high and misdiagnosis can lead to frequent hospital visits and unnecessary surgery. The first line treatment being discontinuation of ACEi, there are other pharmacological options including icaibant, ecallantide which have unproven efficacy from the current trails. Fresh frozen plasma has shown to have success in cases where nothing has worked. The usual dose being used to treat are 2 to 4 units of fresh frozen plasma.