Visceral Angioedema Induced by Angiotensin Converting Enzyme Inhibitor: Case Report

Abstract

IntroductionIntestinal angioedema is a rare adverse effect of angiotensin converting enzyme inhibitors.Clinical caseA 42-year old woman presented to the Emergency Department complaining of diffuse abdominal pain, predominantly in the right quadrants, with no other associated symptoms.She had been started on perindopril plus indapamide 72 h before the admission for arterial hypertension. There was no other relevant background.Physical examination suggested peritoneal irritation on the lower quadrants of the abdomen and right flank.Laboratory tests were relevant for mild leukocytosis. Abdomen ultrasound and contrast-enhanced computed tomography scan showed moderate amount of fluid in the pelvic excavation and small intestine wall thickening. She was admitted for observation. Once the hypothesis of intestinal angioedema was admitted, angiotensin converting enzyme inhibitor was withheld and no other-directed therapy was instituted. Within 24 h she showed clinical, analytic and imaging improvement, thus supporting this diagnosis.ConclusionThe diagnosis of intestinal angioedema induced by angiotensin converting enzyme inhibitor can be challenging and time consuming due to its rarity and nonspecific symptoms, which may lead to underdiagnosis of this entity.

A Rare Cause of Abdominal Pain: Intestinal Angioedema

“…Out of these, the most common one is lisinopril [4,8]. ACEs can lead to bradykinin accumulation due to its lack of degradation, causing vasodilation and vascular permeability that in turn result in mucosal edema [2,5,6]. This event can occur any time during ACEI pharmacotherapy, but most of them occur in the first year of use, ranging from days to several years [5,6,8].…”

“…ACEs can lead to bradykinin accumulation due to its lack of degradation, causing vasodilation and vascular permeability that in turn result in mucosal edema [2,5,6]. This event can occur any time during ACEI pharmacotherapy, but most of them occur in the first year of use, ranging from days to several years [5,6,8]. The condition is more common in women and black people and manifests with more frequency in the jejunum, followed by the ileum [6,[9][10][11][12].…”

“…Symptoms are non-specific and not taken into account sometimes, especially when isolated, with no other mucous membranes involved, leading to underdiagnoses [13]. The most referred symptoms are abdominal pain, vomiting and diarrhea (mostly watery) [6,[8][9][10] and the laboratory results are usually normal [6]. Concerning imagiology, the most common finding is the parietal thickening of part of the intestine, sometimes with ascites [5,6].…”

“…It can have several etiologies, from hereditary to a drug reaction, especially from angiotensinconverting enzyme inhibitors (ACEIs) [1]. Its incidence is rising due to the increased use of these drugs, occurring in up to 1% of patients with angioedema [4][5][6][7]. Its diagnostic is difficult because of the non-specific symptoms (abdominal pain, nausea, vomiting or diarrhea) often related with other pathologies, such as gastroenteritis and inflammatory bowel disease (IBD) [4].…”

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.…”