Correspondence
Case 27-2008: A Man with Abdominal Pain, Nausea, and an Elevated Creatinine Level
N Engl J Med 2008; 359:2501December 4, 2008
- Article
To the Editor:
In the Case Record of a 64-year-old man with abdominal pain and an elevated level of serum creatinine (Aug. 28 issue),1 a kidney-biopsy specimen revealed findings that were diagnostic of acute phosphate nephropathy. Severe abdominal pain was attributed to gastroesophageal reflux after pancreatobiliary disease had been ruled out. Chronic mesenteric ischemia is not mentioned in the discussion. This disorder, which develops in patients with a mean age of 58 years, would account for the uncontrolled severe epigastric pain, nausea, and vomiting (with secondary dehydration and acute renal failure), as well as the anorexia and occult blood in the stool, in a patient with a history of smoking and hypertension. Although the pain in chronic mesenteric ischemia typically occurs within the first hour after eating and diminishes 1 to 2 hours later, it may be continuous, and the absence of a history of weight loss does not rule out the diagnosis. Imaging techniques that permit detailed assessment of the mesenteric vasculature are warranted for early diagnosis in order to avert acute thrombosis of stenotic vessels and the often fatal complication of intestinal infarction.2
2 ReferencesFrancisco Javier Martínez-Marcos, M.D., Ph.D.
María Franco-Huerta, M.D.
Sandra Díaz-Acevedo, M.D.
Juan Ramón Jiménez Hospital, 21005 Huelva, Spain
fcojmtz@telefonica.net 1
Case Records of the Massachusetts General Hospital (Case 27-2008). N Engl J Med 2008;359:951-960
Full Text | Web of Science | Medline2
Moawad J ,Gewertz BL . Chronic mesenteric ischemia: clinical presentation and diagnosis. Surg Clin North Am 1997;77:357-369
CrossRef | Web of Science | Medline
Author/Editor Response
In reply to the comments of Martínez-Marcos et al. regarding chronic mesenteric ischemia, this patient did not report postprandial epigastric pain, nausea, or vomiting. Chronic mesenteric ischemia accounts for less than 5% of all cases of intestinal ischemia and is almost always associated with atherosclerosis of the mesenteric vessels. Occlusion or severe stenosis of at least two of the three major splanchnic arteries should be present for consideration of the diagnosis.
This patient underwent multiple cross-sectional imaging studies that each time showed patency of the celiac trunk and the superior and inferior mesenteric arteries. Six days after the current admission, a contrast-enhanced magnetic resonance imaging scan did not show stenosis of the aorta, proximal celiac trunk, or proximal superior or proximal inferior mesenteric arteries. A diagnosis of distal-vessel disease in the mesentery would require angiographic imaging, and even then, the microvasculature would not be assessed. Thus, the absence of a history of abdominal angina in this patient and negative abdominal imaging studies on three occasions before the hospitalization for what proved to be acute phosphate nephropathy do not support a diagnosis of chronic mesenteric ischemia.
Theodore I. Steinman, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215Anthony Samir, M.D.
Massachusetts General Hospital, Boston, MA 02114
