Klinisch redeneren: chronische mesenteriële ischemie in de huisartsenpraktijk

Clinical reasoning: chronic mesenteric ischemia in primary care Case-report: A 73-year-old male presented with progressively worsening abdominal pain, anorexia and weight loss since 4 months. The ex-smoker had a history of peripheral vascular disease, coronary artery disease and arterial hypertension. Clinical examination revealed cachexia, an abdominal murmur and diffuse abdominal tenderness. The patient was worried and sought treatment for his symptoms. Differential diagnosis: The inner circle of our diagnostic landscape with central point of interest ‘73-year-old male with chronic postprandial abdominal pain’ consisted mainly of vascular, oncological and cardiac diseases. Minor gastro-enterological diseases were found in the outer circle. After further evaluation, the following differential diagnoses remained: thoracic aortic aneurysm, gastro-intestinal cancer, chronic mesenteric ischemia and chronic pancreatitis. Case progression: An urgent CT scan showed extensive mesenterial atherosclerosis, which led the gastroenterologist to confirm our diagnosis of abdominal angina. After revascularization and a prolonged hospital stay, our patient’s symptoms improved. Unfortunately, he passed away a year later from acute-on-chronic mesenteric ischemia. Discussion: Chronic mesenteric ischemia (CMI) develops because of inadequate blood supply to the gastrointestinal tract. Our patient had an occlusive variant, caused by atherosclerosis and partially Median Arcuate Ligament Syndrome (MALS). Early diagnosis is crucial to prevent progression to acute-on-chronic mesenteric ischemia, which has 60 percent 30-day mortality. Nevertheless, diagnosis is mostly delayed by 6 months due to lack of a gold standard test, weak positive likelihood ratios of the symptoms and limited awareness of the disease. Clinical findings, medical history and imaging are used to assess the risk of CMI.