For Referring Physicians
Newsletter

April 1999

What is that Belly Pain?

One of the most challenging problems facing a physician is the assessment of a patient with abdominal pain. When the pain is acute in onset, triage decisions have to be made regarding the need for hospitalization and possible surgical intervention. If, however, the pain is chronic or recurrent, a safe, cost-effective plan for workup should be implemented to distinguish among the many possible etiologies. It is not uncommon for many patients with chronic abdominal pain to undergo a myriad of diagnostic testing including blood tests, X-rays, GI-series, endoscopies, CT scans and nonvascular ultrasounds.

The pain or so-called intestinal angina associated with chronic small intestinal ischemia is not a rare finding in populations with a high prevalence of atherosclerotic diseases. The elderly and smokers are particularly at a higher risk. Chronic arterial insufficiency may precede an acute episode of infarction, especially in cases of progressive atherosclerotic narrowing. The patient complains of episodes of cramping or dull mid-abdominal pain that come on 15 to 30 minutes after a meal and can last up to 2 or 3 hours. This intestinal angina is greatest at times of maximum demand for blood supply to the bowel (e.g., after a large meal). Most patients will lose considerable amounts of weight because of the fear that eating will induce the pain. The cardinal symptoms of chronic mesenteric ischemia are post-prandial pain and weight loss.

Effective treatment of mesenteric ischemia exists in the form of angioplasty and bypass surgery. The efficacy of these procedures is limited unless the diagnosis is made before mesenteric infarction occurs. A simple, cost-effective, noninvasive screening test would be useful in facilitating early diagnosis. Mesenteric angiography is the gold standard for imaging the intestinal vasculature, but it is not suitable as a screening investigation. Over the past decade, color flow duplex Doppler ultrasound (CFD) has been proven to be a very accurate and reliable diagnostic tool in cases of suspected mesenteric ischemia.

Color-flow duplex Doppler ultrasound is a good noninvasive screening study for patients with suspected mesenteric ischemia and helps to select patients for angiography. It can provide an excellent anatomic display of the abdominal vasculature and allows easy placement of the Doppler sample volume for velocity measurements. Quantitative data acquired with CFD are accomplished with short scanning times. The diagnostic impact of this modality, however, is directly related to the experience of the investigator and should be attempted only in accredited laboratories.

If performed by an experienced sonographer, CFD can accurately identify high-grade stenoses of the superior mesenteric and celiac arteries. If the duplex findings are negative, we recommend evaluating for other sources of abdominal pain. If the findings are positive for 2 or 3-vessel stenosis, prompt angiography is indicated. It is important to remember that although duplex scanning can identify mesenteric artery stenosis, it cannot diagnose intestinal ischemia.

By establishing duplex scanning as a useful and accessible noninvasive screening tool, it is hoped that the time between onset of visceral ischemic symptoms and diagnosis of chronic visceral ischemia will be shortened significantly, potentially reducing the morbidity and mortality of the disease. With the aging population, we anticipate that the number of patients with chronic mesenteric ischemia will continue to increase.

For any additional information on this subject matter, please contact us at Apple Hill Surgical Associates - Vascular Division.

Thank you for your continued support!