Presentation
Herein, we present a case presenting with recurrent episodes of abdominal pain and rash, which was diagnosed with idiopathic angioedema and was not responsive to first-line treatment. [ncbi.nlm.nih.gov]
Bradykinin mediated angioedema may sometimes present with gastrointestinal symptoms alone. [practicalgastro.com]
The patient’s allergist was called and notified of the patient’s presentation to the ED. [westjem.com]
[…] after presentation, another at 48 hours, and the last at 72 hours after presentation. [ajronline.org]
CASE REPORT A 63-year-old woman with no known medical history presented to the emergency room complaining of severe abdominal pain of acute onset. [journals.lww.com]
Entire Body System
- Ascites
CT findings included small-bowel wall thickening and ascites [21, 22]. [ajronline.org]
CT bowel changes long segment concentric thickening of the bowel submucosa jejunum more often affected mural stratification straightening of bowel loops no obstruction mild mesenteric edema ascites no lymphadenopathy Treatment and prognosis In cases of [radiopaedia.org]
More cephalad section of the same computed tomography revealing areas of dependant ascites (arrows). [westjem.com]
[…] vessels, thickened omentum, moderate ascites, and a normal appearance of the pericolic fat. [practicalgastro.com]
Contrast-enhanced CT scans often demonstrate findings that include intestinal wall and mucosal thickening, which is consistent with bowel edema and ascites [8]. [ncbi.nlm.nih.gov]
- Severe Pain
Case Report A 45-year-old Hispanic female presented to the emergency department with a chief complaint of severe abdominal pain for the last several days that progressed to severe pain over the last 24 hours. [hindawi.com]
Clinical symptoms of intestinal angioedema include abdominal pain, nausea, vomiting, and diarrhea. Pain can be severe and may be mistaken for small-bowel ischemia. [ajronline.org]
Table 3 provides a summary of the SF-MPQ results ordered by the average severity score of the pain descriptor (scale: 0 = none; 3 = severe). [bmcgastroenterol.biomedcentral.com]
- Surgical Procedure
Prophylaxis may be administered short term in anticipation of a procedure or period of stress, or long term for the reduction of attack rates.29 Two agents are currently FDA approved for both long term and short term prophylaxis in the United States: [practicalgastro.com]
Trauma, surgical procedures, and stress are common nonspecific triggers for angioedema attacks. [emedicine.medscape.com]
- Collapse
Dial 999 for an ambulance if you, or someone with you, has swelling and: sudden or worsening breathing problems feels faint or dizzy passes out or collapses These are signs of a serious allergic reaction (anaphylaxis). [nhs.uk]
Gastrointestinal
- Abdominal Pain
Herein, we present a 34-year-old female who presented with recurrent episodes of abdominal pain. She underwent extensive workup for her abdominal pain and rash, and all was unrevealing except for high Immunoglobulin E (Ig E). [ncbi.nlm.nih.gov]
As her facial angioedema resolved, so did her abdominal pain. The abdominal pain did not return after discontinuing the ACE inhibitor, leading to this diagnosis of exclusion. At 6-month followup, the patient remained free of abdominal pain. [hindawi.com]
Foster School of Medicine, El Paso, TX CASE REPORT A60 year old Hispanic female presented with generalized crampy abdominal pain of 24 hours duration. [practicalgastro.com]
A rare cause of acute abdominal pain with ascites. Dtsch Med Wochenschr. 1998;123:1166–71. [PubMed] [westjem.com]
Thus, it is an important diagnosis to consider in patients with acute onset of abdominal pain on ACEi therapy. [casereports.bmj.com]
- Vomiting
She mentioned that it occurred after drinking her daily green smoothie, after which she immediately developed severe abdominal cramping, nausea, vomiting, and watery diarrhea. [journals.lww.com]
Pain was associated with nausea, intractable vomiting, dyspnoea and dizziness. Ten-point review of systems was negative except for the above reported symptoms. Vitals on admission were stable. [casereports.bmj.com]
Patients often present with non-specific findings of abdominal pain, nausea, and vomiting. [radiopaedia.org]
We report a case of a 34-year-old woman who presented with abdominal cramping, vomiting and diarrhea due to an acute exacerbation of HAE. [westjem.com]
Visceral edema in the digestive system can manifest as nausea, vomiting, abdominal pain, diarrhea, and constipation, depending on the location that is involved. [ncbi.nlm.nih.gov]
- Diarrhea
She mentioned that it occurred after drinking her daily green smoothie, after which she immediately developed severe abdominal cramping, nausea, vomiting, and watery diarrhea. [journals.lww.com]
Pain was acute in onset and associated with nausea, nonbilious emesis, and several bouts of watery, nonbloody diarrhea. She denied fever, chills, dysuria or sick contacts. [practicalgastro.com]
We report a case of a 34-year-old woman who presented with abdominal cramping, vomiting and diarrhea due to an acute exacerbation of HAE. [westjem.com]
She has had a similar episode in the past; the most recent being three months prior, which was also associated with an itchy rash and abdominal pain and diarrhea. [ncbi.nlm.nih.gov]
Common symptoms include abdominal pain, vomiting, diarrhea, and ascites [3–5]. [hindawi.com]
Skin
- Angioedema
This is even more poignant in the cases of urticaria-associated angioedema. [ncbi.nlm.nih.gov]
The clinical findings and treatment of intestinal angioedema are summarized in Tables 1 and and 2. Table 1. Clinical Features of intestinal Hereditary Angioedema and ACE-inhibitor associated angioedema. Table 2. [westjem.com]
INTRODUCTION There are two main categories of angioedema: the mast-cell mediated and the bradykinin mediated angioedema.1 Bradykinin mediated angioedema, unlike the mast-cell mediated angioedema is usually without symptoms of pruritus and urticaria and [practicalgastro.com]
CT of angioedema of the small bowel. AJR Am J Roetgenol. 2001;176:649–52. Cited Here 4. Palmquist S, Mathews B. Isolated intestinal type angioedema due to ACE‐inhibitor therapy. Clin Case Rep. 2017;5(5):707–10. Cited Here 5. [journals.lww.com]
- Pruritus
INTRODUCTION There are two main categories of angioedema: the mast-cell mediated and the bradykinin mediated angioedema.1 Bradykinin mediated angioedema, unlike the mast-cell mediated angioedema is usually without symptoms of pruritus and urticaria and [practicalgastro.com]
She was previously asymptomatic and, at admission, did not have any other symptoms, including nausea, vomiting, diarrhea or any other gastrointestinal symptom, breathing difficulty, cough, rash or pruritus. [elsevier.es]
In addition, pruritus is the most prominent complaint in urticaria, but it is less troublesome or absent in angioedema. Furthermore, pain or tenderness is uncommon in urticaria but frequent or even severe in angioedema. [emedicine.medscape.com]
Workup
She underwent extensive workup for her abdominal pain and rash, and all was unrevealing except for high Immunoglobulin E (Ig E). Multiple imaging came back negative for any pathology. [ncbi.nlm.nih.gov]
Such uncommon presentations are easily misdiagnosed, bearing serious consequences for the patient and the hospital system through unnecessary extensive workups. [practicalgastro.com]
Hepatitis B and C virus workup Rheumatoid factor Cryoglobulin levels Imaging studies Imaging studies Most angioedema patients do not need any imaging studies. [emedicine.medscape.com]
Workup is usually nondiagnostic including leukocytosis and nonspecific bowel wall thickening on CT scan. Therapy consists of withdrawal of the medication. This is a diagnosis of exclusion, and physicians must have a high index of suspicion. [hindawi.com]
Laboratory
- Leukocytosis
Laboratory tests showed raised APR levels (CRP and leukocytosis). New comment Comments No comments for this article References 1.- Romeu Vilar D. [reed.es]
Laboratory tests were relevant for mild leukocytosis with high neutrophil count (12.910leukocyte/μL, 79.2% of neutrophil). [elsevier.es]
Workup is usually nondiagnostic including leukocytosis and nonspecific bowel wall thickening on CT scan. Therapy consists of withdrawal of the medication. This is a diagnosis of exclusion, and physicians must have a high index of suspicion. [hindawi.com]
Article PubMed Google Scholar Ohsawa I, Nagamachi S, Suzuki H, Honda D, Sato N, Ohi H, Horikoshi S, Tomino Y: Leukocytosis and high hematocrit levels during abdominal attacks of hereditary angioedema. [bmcgastroenterol.biomedcentral.com]
In conclusion, ACEI-induced small-bowel angioedema is primarily seen in women and causes severe abdominal pain, mild leukocytosis, and CT findings that may potentially be mistaken for small-bowel ischemia or other diagnoses. [ajronline.org]
Treatment
In one study, it was shown that angioedema was more common in patients with CIU/CSU unresponsive to treatment as compared with patients responsive to treatment (59% vs. 29%) [11]. [ncbi.nlm.nih.gov]
It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. [angioedemanews.com]
The treatments recommended depend on the type of angioedema you have. [nhs.uk]
Scoring took place at baseline and at 4 hours post-treatment. Efficacy assessments Treatment outcome score (TOS) Treatment outcome score (TOS) is a composite measure of symptom response to treatment. [bmcgastroenterol.biomedcentral.com]
Prompt detection and treatment of this rare disease can significantly improve patient outcome by minimizing morbidity from misdiagnosis or unnecessary operative interventions. [westjem.com]
Prognosis
CT bowel changes long segment concentric thickening of the bowel submucosa jejunum more often affected mural stratification straightening of bowel loops no obstruction mild mesenteric edema ascites no lymphadenopathy Treatment and prognosis In cases of [radiopaedia.org]
Prognosis The prognosis for patients with angioedema depends on the etiology and varies as follows: Angioedema with identifiable causes – If the trigger(s) can be identified and avoided, angioedema can be prevented Angioedema without identifiable causes [emedicine.medscape.com]
Etiology
However, angioedema from both etiologies presents similarly and share a common mechanism. [westjem.com]
Interestingly, fresh frozen plasma has also shown efficacy in aborting acute attacks.6 In conclusion, physicians must remain mindful of this entity in patients presenting with acute abdominal pain, vomiting, or diarrhea of unknown etiology. [journals.lww.com]
[…] diarrhea secondary to extravasation of fluid into the intraluminal space.13 Discussion Abdominal pain is one of the most common conditions in clinical practice and yet a challenging complaint to accurately diagnose due to the vast number of possible etiologies [practicalgastro.com]
In addition, supportive care should be provided, regardless of the etiology. [emedicine.medscape.com]
Abdominal pain is a common presenting complaint in clinical practice, yet poses a diagnostic dilemma given the vast number of etiologies. [ncbi.nlm.nih.gov]
Epidemiology
Epidemiology of angioedema without wheals in an allergy and immunology center. Medicina (B Aires) 2015; 75: 273-6. 3. Chan NJ, Soliman AM. Angiotensin converting enzyme inhibitor-related angioedema: onset, presentation, and management. [medicinabuenosaires.com]
Epidemiologic and clinical features of anaphylaxis in Korea. Ann Allergy Asthma Immunol. 2008 Jan. 100(1):31-6. [Medline]. Kalmár L, Hegedüs T, Farkas H, Nagy M, Tordai A. [emedicine.medscape.com]
Epidemiology The overall incidence of ACE-induced angioedema is reported to be about 0.1% to 0.2% and is 5 times more common in African Americans than among white patients [ 36 ]. [ncbi.nlm.nih.gov]
Pathophysiology
Pathophysiology Angioedema is a result of the fast onset of an increase in local vascular permeability in subcutaneous or submucosal tissue. [emedicine.medscape.com]
The pathophysiology behind it is a consequence of increased vascular permeability caused by the release of vasoactive mediators. [ncbi.nlm.nih.gov]
ACE inhibitor-induced angioedema of the intestine: case report, incidence, pathophysiology, diagnosis and management. Can J Gastroenterol, 15 (2001), pp. 827-832 [5] T. Campbell, B. Peckler, R.D. Hackstadt, A. Payor. [elsevier.es]
A review of the literature and pathophysiology,” Annals of Internal Medicine, vol. 117, no. 3, pp. 234–242, 1992. View at: Google Scholar R. A. Sabroe and A. [hindawi.com]
Prevention
Results of a double-blinded clinical trial in nine patients, reported in The New England Journal of Medicine in 1976, evaluated Danocrine’s efficacy in preventing acute hereditary angioedema attacks. [angioedemanews.com]
[…] antihistamines or occasionally steroid medication to reduce the swelling drug-induced angioedema will usually resolve if you change to a different medication – your doctor will advise you about this hereditary angioedema can't be cured, but medications can help prevent [nhs.uk]
Although most cases typically resolve within 1–3 days, early recognition may prevent unnecessary imaging as well as possible exploratory surgery.4 DISCLOSURES Author contributions: A. Hassan and S. Weissman wrote and edited the manuscript. S. [journals.lww.com]
Because the likelihood of side effects is greater, other drugs are usually reserved for when antihistamines fail to prevent angioedema, and are generally given under specialist supervision. [allergy.org.au]
Making the diagnosis can prevent patients from exposure to costly and invasive procedures. 2. [hindawi.com]