Simultaneous mucosal and small bowel angioedema due to captopril

Isolated intestinal type angioedema due to ACE-inhibitor therapy

A 42-year-old woman presents with abdominal pain after taking her first dose of lisinopril. Visceral angioedema was diagnosed based on clinical suspicion and abdominal computed tomography (CT). Awareness of this rare side effect of a common medication is key to avoid delays in diagnosis and unnecessary procedures.

Angiotensin converting enzyme inhibitor-induced gastrointestinal angioedema: a case series and literature review

GOALS

The objective of this study was to better understand the presenting signs and symptoms of angiotensin converting enzyme (ACE) inhibitor-induced gastrointestinal angioedema, review the medical literature related to this condition, and bring this diagnosis to the attention of clinicians.

BACKGROUND

Angioedema occurs in 0.1% to 0.7% of patients treated with ACE inhibitors and ACE inhibitors account for 20% to 30% of all angioedema cases presenting to emergency departments. However, only recently have ACE inhibitors been recognized as a cause of angioedema of the gastrointestinal tract. Patients with this disease present with one or more episodes of abdominal pain associated with nausea, vomiting, and/or diarrhea.

STUDY

We present four cases of ACE inhibitor-induced gastrointestinal angioedema seen at a single institution and review the literature of other case reports.

RESULTS

Review of the medical literature identified 27 case reports of ACE inhibitor-induced angioedema of the gastrointestinal tract. Multiple ACE inhibitors were implicated in these case reports suggesting that this disease is a class effect of ACE inhibitors. In cases where the race of the patient was stated, 50% were identified as being African American. Ascities was described as a radiographic finding in 16 of 27 cases. There were no reported cases of paracentesis or ascitic fluid analysis described in any of the identified case reports.

CONCLUSIONS

This series highlights ascites as a key feature that distinguishes ACE inhibitor-induced gastrointestinal angioedema from infectious enteritis. This series also confirms the increased incidence of this condition among African American women, an unpredictable interval between medication initiation and the development of symptoms, and the heightened probability of symptom recurrence if ACE inhibitors are not discontinued. ACE inhibitor-induced gastrointestinal angioedema is a rare cause of acute abdominal complaints, but is likely underdiagnosed and should be considered in the differential diagnosis of all individuals taking ACE inhibitors with such symptoms. Early recognition of ACE inhibitor-induced gastrointestinal angioedema may avoid recurrent episodes or costly, invasive evaluations.

ACE Inhibitor-Induced Angioedema of the Bowel

Angiotensin converting enzyme inhibitor ACEI-induced angioedema of the intestine is a rare occurrence and often unrecognized complication of ACEI. We present a case of a 45-year-old Hispanic female with angioedema of the small bowel progressing to facial and oral pharyngeal angioedema. Patients are typically middle-aged females on ACEI therapy who present to the emergency department with abdominal pain, nausea, vomiting, and diarrhea. This is a diagnosis of exclusion, and physicians must have a high index of suspicion to make the diagnosis. Symptoms typically resolve within 24–48 hours after ACE inhibitor withdrawal. Recognizing these signs and symptoms, and discontinuing the medication, can save a patient from unnecessary, costly, and invasive procedures.

Calcium channel blocker-associated small bowel angioedema

INTRODUCTION

Isolated angioedema of the small intestine is a rare entity. The cases described have been related with angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or C1 esterase inhibitor deficiency. We present a case of small intestine angioedema caused by calcium channel blockers (CCBs) and a review of the literature.

CASE REPORT

Over the course of approximately 2 years, a 56-year-old African American woman presented to our hospital with 8 similar episodes of diffuse, intermittent abdominal pain, nausea, vomiting, and diarrhea. The diagnostic workup was extensive and included normal stool studies, anticardiolipin antibodies, antinuclear antibodies, antineutrophil cytoplasmic antibodies, cryoglobulin studies, complement levels, urinary 5-hydroxyindoleacetic acid, and serum markers for inflammatory bowel diseases. A computed tomographic angiogram was normal. Abdominal computed tomographic scans showed prominent mural thickening of different intestinal segments, always involving the ileum. An esophagogastroduodenoscopy showed patchy edematous, violaceous folds in the second portion of the duodenum. Colonoscopy revealed a markedly edematous and erythematous distal ileum. The recurrences subsided after CCBs were discontinued in this patient and reoccurred when they were incidentally restarted.

CONCLUSIONS

Our case demonstrates that CCBs can cause isolated intestinal angioedema with distinctive endoscopic findings. The discontinuation of the involved medication is the key for both diagnosis and treatment.

Endoscopic visualization of angiotensin-converting enzyme inhibitor-induced small bowel angioedema as a cause of relapsing abdominal pain using double-balloon enteroscopy

A 40-year-old woman presented with 3 episodes of abdominal pain. Abdominal ultrasound demonstrated edema of the small bowel. Double-balloon enteroscopy (DBE) showed diffuse swelling of the small intestine, petechial bleeding in the jejunum, and focal inflammation of the ileum. Pain and small bowel edema resolved spontaneously within 48 h during each episode. Review of the patient's history revealed that she had been started on enalapril for arterial hypertension two weeks before her first episode. Angiotensin-converting enzyme (ACE) inhibitor-associated angioedema of the small bowel was suspected and enalapril was discontinued. The patient remained symptom-free after discontinuing the ACE inhibitor. Review of the literature reveals only 11 similar cases with this case being the first to apply DBE to visualize macroscopic alterations to the small intestine. Angioedema of the intestine is a diagnostic pitfall frequently leading to prolonged diagnostic procedures and is a potential cause for abdominal pain in patients taking ACE inhibitors.

Repeated Subileus due to Angioedema During Renin-Angiotensin System Blockade

A 77-year-old man with membranous nephropathy was treated with triple blockade of the renin-angiotensin-aldosterone system and developed subileus six times in 5 months. The resection of his sigmoid colon uncovered angioedema. It should be noted that angiotensin-converting enzyme or angiotensin receptor blocker can cause angioedema of the intestine and induce subileus.

Human meprin alpha and beta homo-oligomers: cleavage of basement membrane proteins and sensitivity to metalloprotease inhibitors

Meprin is a zinc endopeptidase of the astacin family, which is expressed as a membrane-bound or secreted protein in mammalian epithelial cells, in intestinal leucocytes and in certain cancer cells. There are two types of meprin subunits, alpha and beta, which form disulphide-bonded homo- and hetero-oligomers. Here we report on the cleavage of matrix proteins by hmeprin (human meprin) alpha and beta homo-oligomers, and on the interactions of these enzymes with inhibitors. Despite their completely different cleavage specificities, both hmeprin alpha and beta are able to hydrolyse basement membrane components such as collagen IV, nidogen-1 and fibronectin. However, they are inactive against intact collagen I. Hence the matrix-cleaving activity of hmeprin resembles that of gelatinases rather than collagenases. Hmeprin is inhibited by hydroxamic acid derivatives such as batimastat, galardin and Pro-Leu-Gly-hydroxamate, by TAPI-0 (tumour necrosis factor alpha protease inhibitor-0) and TAPI-2, and by thiol-based compounds such as captopril. Therapeutic targets for these inhibitors are MMPs (matrix metalloproteases), TACE (tumour necrosis factor alpha-converting enzyme) and angiotensin-converting enzyme respectively. The most effective inhibitor of hmeprin alpha in the present study was the naturally occurring hydroxamate actinonin ( K(i)=20 nM). The marked variance in the cleavage specificities of hmeprin alpha and beta is reflected by their interaction with the TACE inhibitor Ro 32-7315, whose affinity for the beta subunit (IC50=1.6 mM) is weaker by three orders of magnitude than that for the alpha subunit ( K(i)=1.6 microM). MMP inhibitors such as the pyrimidine-2,4,6-trione derivative Ro 28-2653 that are more specific for gelatinases do not bind to hmeprin, presumably due to the subtle differences in the mode of zinc binding and active-site structure between the astacins and the MMPs.

Gastrointestinal side effects of drugs

Drugs can have adverse effects on any part of the gastrointestinal (GI) tract from mouth to colon. It is essential that a detailed and accurate drug history is taken in patients presenting with GI complaints. Many drug-induced effects will regress or heal on cessation of treatment. NSAIDs are usually associated with gastric and duodenal ulcers but are also recognised to cause lichen planus in the mouth, oesophageal inflammation and strictures, and small bowel and colonic ulcers and strictures. A newer class of anti-inflammatory drugs, the cyclooxygenase-2 (COX-2)-selective inhibitors, have been developed and have a more favourable GI safety profile than standard NSAIDs. Acute diarrhoea, relapse of inflammatory bowel disease (IBD), microscopic colitis and acute pancreatitis are also induced by ingestion of standard NSAIDs. The calcium antagonists, phenytoin and cyclosporin, induce gum hyperplasia, particularly in patients with poor oral hygiene. Alendronate, a bisphosphonate, has been associated with development of oesophageal ulcers, and specific recommendations are now given to reduce this complication. Of the many different forms of colitis associated with drug ingestion, the most frequent is pseudomembranous colitis. This is a complication of antibiotics and is caused by the toxin produced by Clostridium difficile. Many drugs have been associated with the development of acute pancreatitis, although a definite cause and effect relationship has been shown for only a few drugs. These include didanosine, furosomide, corticosteroids, azathioprine and sodium valproate.

Angiotensin-converting enzyme inhibitor angioedema of the intestine: a case report and review of the literature

Visceral angioedema is a rare complication of angiotensin-converting enzyme (ACE) inhibitor use. To date, 15 cases have been reported in the literature. Common presentation is that of a middle-aged woman with abdominal pain, emesis, and diarrhea who has recently begun taking an ACE inhibitor. Signs include leukocytosis, ascites, and edematous small bowel seen on computed tomography. Diagnosis is elusive, and frequently invasive procedures, including surgery, are pursued. These can be avoided if the astute physician recognizes the association and withdraws the offending medication. We present the typical diagnostic dilemma faced in the evaluation of a patient with ACE inhibitor angioedema of the intestine, and review the current available literature.

Angioneurotic edema

Angioneurotic edema is nonpitting edema involving the face, lips, tongue, larynx, and other locations. It may occur with use of angiotensin- converting enzyme inhibitors, vasopeptidase inhibitors, and, less frequently, angiotensin receptor blockers. Most episodes occur within the first 6 months of therapy. Predisposing factors for converting enzyme inhibitor angioedema include previous idiopathic angioedema, African American race, and transplant-related immunocompromise. Treatment is directed to preventing airway compromise. (c)2001 Le Jacq Communications, Inc.