History
The classic description of abdominal angina is abdominal pain that is out of proportion with physical examination findings. The classic feature is abdominal pain that occurs a few minutes after eating and slowly subsides over next few hours. [8] Gradually, most patients develop fear of eating and lose significant weight. A history of peripheral vascular disease and significant smoking is common.
Physical Examination
Physical examination reveals stigmata of weight loss. The abdomen typically is scaphoid and soft, even during an episode of pain.
In one series, approximately 10% of patients had positive test results for guaiac. Abdominal bruit is present in 60-90% of patients, but this is a common finding in many elderly persons who are not affected by this syndrome.
Signs of peripheral vascular disease, particularly aortoiliac occlusive disease, may be present.
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Superior mesenteric artery and inferior mesenteric artery share collateral circulation near splenic flexure of colon. When dilated, this vessel is termed meandering mesenteric artery. As seen on angiography, this is sign of chronic mesenteric ischemia.
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Pancreaticoduodenal arcades are collateral pathways between celiac artery and superior mesenteric artery.
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Lateral aortogram shows abrupt cutoffs at origin of visceral vessels and tapered occlusion of distal aorta. Because these vessels originate from anterior surface of the aorta, stenoses and occlusions are not observed clearly on standard anteroposterior views.
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Arteriogram illustrates meandering mesenteric artery. Appearance of meandering mesenteric artery such as this one supports diagnosis of chronic mesenteric ischemia.
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Celiac artery is exposed at its origin in preparation for antegrade bypass.
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Superior mesenteric artery and several branches are exposed for antegrade bypass.
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Antegrade bypass from aorta to superior mesenteric artery (SMA) and celiac artery (SMA anastomosis is shown) using Dacron graft.
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Completed retrograde bypass to superior mesenteric artery using expanded polytetrafluoroethylene graft material. Image courtesy of Jamal Hoballah, MD, University of Iowa College of Medicine.
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Possible incision for trapdoor aortotomy. Plaque at orifices of visceral vessels is removed after trapdoor incision is lifted. When satisfactory endarterectomy has been achieved, trapdoor is sutured shut.
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Completion duplex ultrasonographic study shows excellent flow at distal anastomosis.
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Upper gastrointestinal series (barium swallow) shows ulcer.
