Isolated Visceral Angioedema Induced by Angiotensin-Converting Enzyme Inhibitor

Abstract

Visceral angioedema is a rare complication of therapy with angiotensin-converting enzyme (ACE) inhibitors. Clinical presentation includes nausea, vomiting, abdominal pain and diarrhea. Early detection of this entity can prevent recurrent episodes and unnecessary invasive procedures, including surgery.This article describes a 46-year-old-woman who presented to the emergency department with abdominal pain, associated with nausea and vomiting. She had been taking ramipril for 15 days.A computed tomography was performed which revealed thickening of a jejunal segment, with submucosal edema.ACE inhibitor-associated angioedema was suspected and the medication was discontinued, with resolution of symptoms in 48 h.After 7 months of follow-up, the patient is asymptomatic.Despite of its rarity, ACE inhibitor-induced small-bowel angioedema should be included in the differential diagnosis when patients receiving ACE inhibitor therapy present with abdominal complaints.

Lisinopril Induced Visceral Angioedema

“…In addition, other medications, including aspirin, have been found to have higher rates of AE when combined with ACE-I (Hoover, Lippmann, Grouzmann, Marceau, & Herscu, 2010). In our patient, the short duration from ACE inhibitor exposure to the development of abdominal symptoms suggests other factors may be involved, possibly aspirin intake (Brown & Vaughan, 1998;Ana, Inê s, Rita, Alexandra, & Jorge, 2016). The mildly elevated inflammatory markers did raise suspicion for an infectious etiology initially.…”

“…Angiotensin I, resulting in a decreased production of both Ang II and Aldosterone, resulting in the desired cardioprotective effects by limiting vasoconstriction and free water retention, respectively (Herman, Padala, Annamaraju, et al, 2020;Page, 2014). Inhibition of ACE also leads to the accumulation of bradykinin and Substance P, locally acting hormones that promote vasodilation and increased vascular permeability (Brown & Vaughan, 1998;Ana, Inê s, Rita, Alexandra, & Jorge, 2016).…”

“…Under normal circumstances, these hormones have only transient effects, and they are quickly degraded to their inactive forms. However, ACE-I fosters an environment whereby these molecules have a prolonged effect, resulting in localized fluid extravasation, the proposed mechanism behind ACE-I Angioedema (Brown & Vaughan, 1998;Ana, Inê s, Rita, Alexandra, & Jorge, 2016).…”

Acute or Recurrent Abdominal Pain: The Eyes Can Only See What the Mind Knows!

“…In the present Journal, visceral angioedema have been described in two Portuguese young women who presented at Emergency Department for acute (<24 h) abdominal pain that occurred two days and 15 days following ramipril and perindopril therapy, respectively. 9 , 10 Typical ‘target sign’ on intestinal wall and ascites were detected at CT. Both patients promptly recovered following ACEI therapy withdrawal.…”