Trust your gut

Abstract

Case PresentationMG is a 56-year-old female with no significant past medical history who presented to TJUH in October 007 with a two year history of abdominal pain and weight loss. At presentation, she described her pain as non-radiating, 7 out of 10, gnawing, burning and located in the epigastrum and left upper quadrant. The pain initially occurred approximately 15 minutes postprandially and lasted 0 minutes. Over the two year period, the pain progressed to lasting for hours following meals. Dietary modifications and food consistency did not help the pain. The patient began avoiding oral intake, and her weight declined from 10 to 80 pounds. She denied nausea, vomiting, diarrhea, constipation, hematochezia, melena and change in stool frequency. Over the two years prior to admission the patient had an extensive workup with multiple gastroenterologists. Her initial workup included a colonoscopy, EGD, abdominal ultrasound and computerized tomography (CT) of the abdomen and pelvis. These were all reportedly normal and the patient was diagnosed with irritable bowel syndrome and treated symptomatically with a PPI. Due to lack of improvement, a second gastroenterologist repeated the EGD/colonoscopy and diagnosed her with peptic ulcer disease secondary to multiple gastric ulcers. She was treated with a PPI and carafate. A capsule study showed gastric and jejunal ulcers with cobblestone appearance of the small bowel which led to the diagnosis of Crohn's disease. She was treated briefly with Pentasa. The patient sought care as an outpatient at TJUH Division of Gastroenterology. Mesenteric ischemia was initially high on the differential. An MRA of the abdomen revealed patent mesenteric vessels. Other workup included gastric emptying scan, push enteroscopy, endoscopic ultrasound (EUS), full-thickness biopsy in the operating room, fasting gastrin level, and an NSAID level. These studies were mostly inconclusive. Other studies including an octreotide scan, gastrin levels, and chromogranin A levels were either normal or inconclusive. Furthermore, it was discovered that the gastric pH was ., arguing against a gastrin producing tumor as seen in Zollinger-Ellison Syndrome.At the time of admission, her medications were pantoprazole 0 mg BID and ciprofloxacin 500 mg BID, both of which offered only mild relief. She has a 5 pack year smoking history, does not drink alcohol or use other drugs. Her family history is significant for a brother and father having coronary artery disease. On examination the patient appeared thin and pale. The abdomen was not tender to palpation, however, an abdominal bruit could be auscultated. Admission labs were within normal limits except for a WBC count of 1,000 without a left shift. The question of mesenteric ischemia was again entertained. An abdominal ultrasound with dopplers revealed a greater than 70% stenosis of the superior mesenteric artery (SMA). CT angiography (CTA) of the abdomen revealed occlusion of the celiac artery, near occlusion of the SMA, and stenosis of the inferior mesenteric artery...