A 75-year-old man presents with severe, sharp, stabbing abdominal pain every time he eats. The postprandial pain began 6 months ago and has gotten worse over the past 4 weeks. He is afraid to eat and has lost 25 lb in this time. PMH: • Coronary artery disease • Diabetes mellitus • Hypertension SH: 45-pack-year smoking history ROS: • Nausea • Occasional vomiting from the pain • Postprandial nausea Physical Exam: • Dry skin • No abdominal tenderness • Skin on lower extremities is shiny without hair
What is the most likely diagnosis?
a. Acute mesenteric ischemia
b. Ischemic colitis
c. Chronic mesenteric ischemia
d. Peptic ulcer disease
Answer c. Chronic intestinal ischemia Chronic intestinal ischemia usually results from long-standing atherosclerotic disease of two or more mesenteric vessels. Upon eating, the demand for oxygen is unmet because of atherosclerotic obstruction of blood flow. This causes excruciating pain and thus yields a patient who is scared to eat. As the underlying atherosclerotic disease worsens, the symptoms worsen. Acute mesenteric ischemia would present acutely and would be in a patient with atrial fibrillation, and ischemic colitis is a patient with bloody diarrhea after a low-flow state such as transient hypotension.