Abdominal pain with bowel wall edema

Q: A 68-year-old male whose blood pressure medicines have recently been changed presented to the Emergency Room with severe colicky abdominal pain associated with nausea and vomiting. CT of the abdomen showed bowel wall edema. Acute care surgery was consulted for possible "ex-lap", but the only advice offered was to discontinue his home BP medicine. Which anti-hypertensive is highly suspected? - Select one

A) ACE inhibitor

B) Beta-Blocker

C) Calcium Channel Blocker 

D) Diuretic (Furosemide)

E) Vasodilator (hydralazine)

Answer: A

The objective of this question is to emphasize that well-known angioedema associated with ACE-I is not limited to the face, lips, mouth, throat, larynx, uvula, but also the extremities, genitalia, and bowel wall are also common. Appearance of bowel wall edema on abdominal computed tomography (CT) or ultrasound, including in POCUS, when combined with history and symptoms, can avoid undue further workup or even unneeded "exploratory laparotomy". Elderly patients are more prone to bowel wall angioedema.

#surgical-critical-care

#GI

#pharmacology

References:

1. Dobbels P, Van Overbeke L, Vanbeckevoort D, Hiele M. Acute abdomen due to intestinal angioedema induced by ACE inhibitors: not so rare? Acta Gastroenterol Belg 2009; 72:455.

2. Chase MP, Fiarman GS, Scholz FJ, MacDermott RP. Angioedema of the small bowel due to an angiotensin-converting enzyme inhibitor. J Clin Gastroenterol 2000; 31:254.

3. Arakawa M, Murata Y, Rikimaru Y, Sasaki Y. Drug-induced isolated visceral angioneurotic edema. Intern Med 2005; 44:975.