Cigarette Smoking: The Only Risk Factor of a Case with Chronic Mesenteric Ischemia

Chronic mesenteric ischemia (CMI) is a rare condition and ıt could be mis- diagnosed becouse lack of specific signs. Patients with chronic mesenteric ischemia (CMI) typically present with a history of the chronic intermittent abdominal pain, fear of eating and weight loss. The etiology of chronic mesenteric ischemia is multifactorial which includes atherosclerosis risk factors such as diabetes, hypertension, hyperlipidemia, smoking and obesity. Herein, we present a case whose only risk factor was smoking and presented with subacute abdominal pain. A 74-year-old woman was admitted to outpatient clinic with continuous abdominal pain, vomiting and diarrhea for 2 weeks. She had no other symptoms and chronic diseases. She is an active smoker for 58 pacs/year. Her physical examination revealed that diffuse abdominal pain without peritoneal signs. Laboratory results demonstrated an inflammatory condition however, abdominal ultrasound and endoscopic examination were in normal limits. Contrast enhanced abdominal CT revealed acute exacerbation of CMI. The patients treated with endovascular stent implantation and all symptoms were resolved. Chronic mesenteric ischemia could seen with atypical presentations, solely due to smoking without multiple risk factors in older patients. Therefore, it should be remembered that the diseases may be encountered in atypical presentations in older patients . Moreover, smoking habits should be questioned and patients should be reminded about smoking cessation.


ABSTRACT
Chronic mesenteric ischemia (CMI) is a rare condition and ıt could be misdiagnosed becouse lack of specific signs. Patients with chronic mesenteric ischemia (CMI) typically present with a history of the chronic intermittent abdominal pain, fear of eating and weight loss. The etiology of chronic mesenteric ischemia is multifactorial which includes atherosclerosis risk factors such as diabetes, hypertension, hyperlipidemia, smoking and obesity. Herein, we present a case whose only risk factor was smoking and presented with subacute abdominal pain. A 74-year-old woman was admitted to outpatient clinic with continuous abdominal pain, vomiting and diarrhea for 2 weeks. She had no other symptoms and chronic diseases. She is an active smoker for 58 pacs/year. Her physical examination revealed that diffuse abdominal pain without peritoneal signs. Laboratory results demonstrated an inflammatory condition however, abdominal ultrasound and endoscopic examination were in normal limits. Contrast enhanced abdominal CT revealed acute exacerbation of CMI. The patients treated with endovascular stent implantation and all symptoms were resolved. Chronic mesenteric ischemia could seen with atypical presentations, solely due to smoking without multiple risk factors in older patients. Therefore, it should be remembered that the diseases may be encountered in atypical presentations in older patients . Moreover, smoking habits should be questioned and patients should be reminded about smoking cessation.

INTRODUCTION
Chronic mesenteric ischemia (CMI) is a rare condition and defined by stenosis or occlusions of the celiac artery, superior or inferior mesenteric artery. The disease usually manifests in patients above 60 years of age and females are more likely to be affected than males. Symptomatic CMI only accounts for less than 5 % of intestinal ischemic events. It is typically revealed by intermittant abdominal pain and abdominal bruits which is aggravated with food intake with preserved appetite. The diagnosis of CMI is sometimes difficult because of a lack of specific signs or due to its sometime quiet presentation (1). Severe malnutrition can be important clinical sign that raise the suspicion of CMI. The condition is frequently diagnosed only at an advanced stage. An imaging study can confirm the presence of a stenosis or occlusion involving the mesenteric vessels. Usually patients had abundant mesenteric collateral circulation, while gradual and progressive stenosis of one or more major mesenteric vessels (2)(3). There are multiple etiologies however, the most common cause is atherosclerosis. Common risk factors for atherosclerosis such as diabetes mellitus, hypertension, hyperlipidemia, cigarette smoking, obesity, insulin resistance are also etiologic risk factors for CMI. Patients often have atherosclerotic disease history, such as peripheral vascular disease, coronary artery disease, and/or cerebrovascular disease. We want to present a new case of CMI with no etiologic risk factor except smoking.

CASE REPORT
A 74-year-old woman was admitted to outpatient clinic with continuous abdominal pain, vomiting and diarrhea for 2 weeks. She had no other symptoms and chronic diseases. She is an active smoker for 58 pacs/year. Her physical examination revealed that diffuse abdominal pain without peritoneal signs, melena or hematochezia. Blood analysis showed Hb 14,9 g/dL, hematocrit 48.2%, white blood cell count 25600/mm 3 , absolute neutrophil count (ANC) 20000/mm 3 , platelets 394000/mm 3 , and C-reactive protein 7,49 mg/dL (0 to 0.8). In biochemical analysis, liver function tests, renal function tests and electrolytes were within normal limits, amylase were 90 U/l (25 to 100). Abdominal ultrasound imagining showed that no pathological sign. Endoscopic examination was performed 3 weeks before her admission and revealed chronic gastritis. Contrast enhanced computerized tomography showed proximal 1 cm segment of celiac truncus and inferior mesenteric artery had severe stenosis, proximal 4 cm segment of superior mesenteric artery totally occluded and perfused by collaterals, right renal artery and bilateral iliac arteries has severe stenosis and perfused by collaterals ( Figure 1). She was diagnosed with acute exacerbation of CMI and hospitalized. The patient underwent visceral angiography with placement of stents in the celiac artery and seen collateral perfusions sufficient for mesenteric arteries. She was evaluated for hypertension diabetes mellitus, hyperlipidemia and no other risk factors were showed. After the stent implantation, she was free from abdominal pain and discharged from hospital.

CONCLUSIONS
Chronic mesenteric ischemia is a rare, but potentially life-threatening condition. Establishing a successful diagnosis is dependent upon suspicion and knowledge of mesenteric ischemia. Also atypical presentations like continuous acute abdominal pain must alert the doctors for mesenteric ischemic events. This case represents us that atypical presentation of illnesses and peripheral atherosclerosis in the statue of low risk factors could seen in elderly. Atherosclerosis is increasing in prevalence with age and common in geriatric population. Although there are many risk factors for atherosclerosis formation, current cigarette smoking is enough for common atherosclerosis in elderly (4).
Smoking cessation in all age groups is very important.