LETTERS TO THE EDITOR

 

Angiotensin-converting enzyme inhibitors-induced angioedema of the small bowel mimicking postoperative complication

 

 

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Key words: Angioedema. Small intestine. Drug-related side effects and adverse reactions. Postoperative complications.

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Dear Editor,

Only a few cases of angiotensin-converting enzyme inhibitors (ACEI)-induced angioedema of the small bowel (ASB) have been reported. We present a case of ACEI-induced ASB mimicking postoperative complications.

 

Case report

An 82-year-old white woman with primary adenocarcinoma of the anal canal underwent an uneventful laparoscopic abdominoperineal resection of the rectum and anal canal (pT2pN0cM0). Recently diagnosed with hypertension and treated with losartan 50 mg for four months. She denied drug or food allergies. Surgical history was positive for appendectomy. Losartan was restarted on postoperative day 4. On day 8, she presented mid-epigastric pain, emesis and diarrhea. She had a benign physical examination, except for tenderness in the epigastric area. The routine laboratory examination was normal. The computed tomography (CT) scan revealed marked thickening (8 mm) of the jejunum with relatively low-density submucosa (Fig. 1A and B). Because of intractable vomiting and consequently non-acceptance of oral and enteral feeding she required a nasogastric tube for bowel decompression and total parenteral nutrition for seven days. Additional investigations showed negative results (normal C1 esterase inhibitor concentration) and led to the hypothesis of ACEI-induced ASB and discontinuation of losartan. She showed clinical improvement within 72 hours and was discharged on day 15.

 

 

Discussion

ASB is an extremely rare complication of ACEI. Clinical manifestations usually appear within 72 hours after taking the medication, but there are reports of occurrence even ten years later. The most common symptoms are abdominal pain (100%), emesis (86%) and diarrhea (50%) (1). The diagnosis is usually considered after the identification of wall thickening of the small bowel, particularly the jejunum (2,3). In the absence of a test to confirm the diagnosis, the reversion of the manifestations following the discontinuation of medication for 48 hours is sufficient to establish the exact diagnosis as well as for the treatment (4).

 

Caroline Lorenzoni Almeida¹, Tiago Leal Ghezzi² and Oly Campos Corleta^3
1Radiology Service. Hospital de Clínicas de Porto Alegre. Porto Alegre, Brazil.
Divisions of ²Coloproctology and ³General Surgery.
Hospital de Clinicas de Porto Alegre. Porto Alegre, Brazil

 

References

1. Korniyenko A, Alviar CL, Cordova JP, et al. Visceral angioedema due to angiotensin-converting enzyme inhibitor therapy. CCJM 2011;78(5):297-304. DOI: 10.3949/ccjm.78a.10102.         [ Links ]

2. McGettigan MJ, Menias CO, Gao ZJ, et al. Imaging of drug-induced complications in the gastrointestinal system. RadioGraphics 2016;36(1):71-87. DOI: 10.1148/rg.2016150132.         [ Links ]

3. Vallurupalli K, Coakley KJ. MDCT features of angiotensin-converting enzyme inhibitor-induced visceral angioedema. AJR 2011;196;W405-11. DOI: 10.2214/AJR.10.4856.         [ Links ]

4. Bloom AS, Schranz C. Angiotensin-converting enzyme inhibitor-induced angioedema of the small bowel - A surgical abdomen mimic. J Emerg Med 2015;48(6):e127-9. DOI: 10.1016/j.jemermed.2015.01.016.         [ Links ]