Angina of the Stomach

What is Abdominal Angina?

Mesenteric Ischaemia

Also known as Mesenteric Ischaemia or intestinal angina, abdominal angina is a chronic condition where the patient suffers from pain in the abdomen. The main reason for the condition is reduced blood flow to the small or large intestine. Abdominal angina may occur after having a meal as an increased supply of oxygen is needed to support digestion. The symptom is very similar to that of the ‘angina’ symptom in angina pectoris which is caused by the obstruction of coronary arteries and that’s  solely the reason for it having ‘angina’- meaning pain -  in its name.⁴

The main cause of this condition is the narrowing of blood vessels due to the accumulation of plaque leading to a deficient blood supply. This process is called atherosclerosis.

Signs and Symptoms

• Chest pain or pain in the central abdominal region within 10 to 15 minutes after consuming a meal.
• Cramping is felt in the abdomen, especially in the midepigastric region.
• Nausea and vomiting.
• Anxiety.
• Diarrhea.
• When the abdomen is physically examined through palpation, the abdomen is scaphoid and soft.
• Significant weight loss may occur as the patient would consume less to avoid pain. They tend to develop an aversion to food.
• The aortoiliac occlusive disease which is the symptom of peripheral vascular disease may be present.¹

Causes and Risk Factors

The cause of abdominal angina is the insufficient blood flow in the vascular arteries which are unable to meet the increased demands needed to support digestion, this causes pain in the abdomen or chest. The primary cause of abdominal angina is celiac artery stenosis with insufficient collateralization. Abdominal angina has also been linked to aneurysms of the superior mesenteric artery, vasculitides, fibromuscular hyperplasia, and tumor encroachment on the celiac artery.² The blockage of the superior mesenteric artery is the most common cause of abdominal discomfort. Smoking and hyperlipidemia (high cholesterol) are two risk factors for atherosclerosis in the superior mesenteric artery. People assigned female at birth are more likely than people assigned male at birth to have this condition. Abdominal angina is a common symptom in those over the age of 60.³

Diagnosis

Laboratory testing is ineffective in making a diagnosis of abdominal angina. The diagnosis of mesenteric ischemia cannot be made using ultrasounds since it is insensitive. Although no laboratory test can be used, the diagnosis is primarily made by observing the patient's clinical history.⁵  An angiography of the celiac artery is the gold standard since it shows that the arteries aren't getting enough blood. The conventional diagnostic procedure is mesenteric angiography. Secondly, colonoscopy identifies specific areas of mucosa that have been damaged by localised bleeding and ulceration.  There are additional tests based on the patient’s clinical presentation such as complete blood cell count, erythrocyte sedimentation rate, and stool and blood cultures for infectious enteritis which may indicate the condition.² The procedure of Computed tomography (CT) angiography, which is as sensitive as an angiogram, has become the test of choice. If an occult mass or abscess is suspected, a CT scan of the abdomen with oral and intravenous contrast material is recommended. Because these patients have atherosclerotic disease, a thorough examination for heart and peripheral vascular disease is recommended. If the patient is being prepared for surgery, arterial blood gas and pulmonary function tests should be conducted in case of heavy smokers. Ultrasonographic and Doppler flow examinations, as well as magnetic resonance angiography (MRA) of the celiac and mesenteric channels, can help clarify the diagnosis and aid in the formulation of a treatment strategy.⁴

Management and Treatment

The type of treatment for abdominal angina is determined by the cause, the affected area, and the extent of tissue damage.

• Antibiotics are used to manage or prevent infections that have occurred from abdominal angina if the cause is colonic ischemia.
• If heart failure, hyperlipidemia, dysrhythmia, or hypertension is the cause of abdominal angina, drugs are prescribed and the patient is advised on diet and exercise.
• It is suggested that the patient eats small, frequent meals to relieve the strain on the digestive system.
• Depending on the extent of artery occlusion and tissue damage, surgery may be required. If necrosis is present, the tissue must be surgically removed. The afflicted artery is bypassed to restore perfusion in cases of severe occlusion or obstruction.
• Surgery will be required in case of persistent mesenteric artery ischemia.
• Endovascular mesenteric revascularization can be performed if the patient is unable to tolerate an open surgical procedure.
• Rather than bypassing the afflicted vessel, stents are frequently used to relieve the obstruction.¹
• Surgery is not required if ischemia has occurred as a result of mesenteric venous thrombosis. Anticoagulants (blood-thinning medication) are given to the patient for 3 to 6 months to prevent the creation of new clots. Surgery is only performed if the mesenteric tissues have been damaged.
• To enlarge narrowed blood arteries, catheterization/angioplasty can be used. Open procedures are also performed, yet this is uncommon.
• Some individuals may benefit from percutaneous transluminal angioplasty (PTA).
• The patient is instructed on how to eat properly, i.e., eat healthy foods, to restore lost weight. A healthy diet also helps to keep cholesterol levels in check.⁴
• If the patient is a smoker, it is strongly advised that he or she quits.

Prevention

The condition can be prevented from occurring by obtaining a healthy diet and quitting smoking in case of smokers.

Complications

The most common complication is weight loss. On the other hand, ischemic bowel, hemorrhage, infection, intestinal infarction, prolonged ileus, and graft infection are all possible complications.

Outcome

A 30% morbidity rate has been documented even after administering treatment to affected individuals. Hematoma, pseudoaneurysm, thrombosis, and intestinal infarction, are the most common consequences following surgery or an endovascular procedure. It is critical to inform the patient about the importance of giving up smoking. When the patient is released from the hospital, he or she should be instructed to eat multiple little meals in a day rather than one large meal. This procedure necessitates a reduction in blood flow in the mesenteric arteries. If the surgery does not go well, the symptoms will show up right away. A number of people who have had failed surgeries end up with large bowel resection and a small gut. Therefore, patients need to be monitored to ensure that there is no recurrence even after treatment.

When to See a Doctor

It is important to see a doctor when the individual is suffering from recurrent stomach pain after having meals. Since the presentation of abdominal angina can be non-specific, if the diagnosis is delayed, the disorder carries high morbidity and mortality. 

Summary

Postprandial pain arises when blood supply to the colon is insufficient to meet visceral demands in mesenteric vascular occlusive disease. Ischemia of the intestine occurs when there is a disparity between the oxygen supplied to and consumed by the GI tract.⁴ The smaller size of the mesenteric arteries causes a reduction in blood flow. The most common cause of abdominal angina is atherosclerosis. Cigarette smokers have an increased chance of having this disease. Abdominal angina is a very uncommon condition with a significant death rate. People assigned female at birth and the elderly are more likely to develop it. The problem with diagnosis is that the symptoms are frequently ambiguous, and no follow-up is done. Since there is no proper medical treatment available, physicians must closely monitor the symptoms of the patients. The patients will be asked to adopt a healthy diet and quit smoking.