An 80-year-old woman presented with weight loss and diffuse abdominal pain that was
worse after meals. She had a history of diabetes, hypertension, chronic renal insufficiency
and chronic lymphatic leukemia. Palpation of the right lower abdominal quadrant was
painful. Laboratory investigations, abdominal ultrasound, and a barium enema of the
colon revealed no relevant abnormalities.
At gastroduodenoscopy an atypical area of inflammation was seen in the descending
part of the duodenum ([Fig. 1]). Histopathological examination showed nonspecific ulcerating inflammation ([Fig. 2]). A presumptive diagnosis of ischemic duodenitis was made, but no stenoses of the
large abdominal arteries were seen on duplex ultrasound examination. Omeprazole treatment
was started and her symptoms diminished.
Fig. 1 A large longitudinal ischemic ulcer was seen in the descending part of the duodenum.
Fig. 2 The duodenal biopsy showed ulceration with granulation tissue and re-epithelialization
(hematoxylin and eosin stain, original magnificaton × 100).
One year later she had a major cerebrovascular accident and died. An autopsy was performed.
On gross examination, areas of ulceration were seen in the medial part of the duodenum,
but there was no atherosclerosis in the major abdominal arteries. Remarkably, the
smaller vessels of the duodenum and kidneys showed severe atherosclerosis. Microscopically,
there was mucosal and submucosal ischemia with fibrosis in the abnormal parts of the
duodenum.
Ischemic duodenitis has been associated with severe atheromatous disease of the splanchnic
arteries [1]
[2]. As far as we know, this is the first report of ischemic duodenitis caused by severe
atherosclerosis of the duodenal arteries, but without involvement of the major abdominal
arteries. Cholesterol emboli could not be excluded, but the absence of atherosclerosis
in the major abdominal arteries makes this very unlikely [3]. There was no infiltration of lymphocytes, which suggests that there was probably
no causative relationship with the chronic lymphatic leukemia either. Rare causes
of ischemic gastrointestinal disease that can lead to similar endoscopic appearances,
such as vasculitis or amyloidosis, were also ruled out on the basis of the radiological
and histopathological findings [4]. A possible explanation in this case could be the gender differences in the pathophysiology
of atherosclerosis: sometimes a more diffuse pattern of atherosclerosis can be seen
in women, involving only the smaller arteries [5].
Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AD
