A112 ANGIOEDEMA,A RARE YET AN IMPORTANT CAUSE OF ABDOMINAL PAIN. A CASE STUDY AND LITERATURE REVIEW

Background

Abdominal pain is a common gastroenterological symptom with an extensive deferential diagnoses. Angioedema is an important cause to remember after the more common causes have been excluded.It is caused by a deficiency in the inhibitor of the first component of classical complement pathway and is divided into hereditary or acquired.Acquired angioedema is associated with autoimmune or lymphoproliferative neoplasms.The clinical features of both include recurrent,self-limiting and circumscribed edema affecting the subcutaneous tissue of the upper respiratory airways and gastrointestinal tract.

Aims

We describe an interesting case of acquired angioedema presenting with recurrent abdominal pain. We also systematically review the current literature on this rare entity.

Methods

A search of electronic databases was performed inclusive to September 2019, for all studies and reviews of patients with acquired angioedema manifested as recurrent attacks of abdominal pain.

Results:

Case Report: 65 year old lady ho has an at least 2 year long history of abdominal pain and bloating associated on some occasions with nausea and vomiting.She presented to our emergency department in August,2018 with a day history of severe generalized abdominal pain and was found to have circumferential thickening,edema with mucosal hyperenhancement involving the distal segment of the small bowel.Splenomegaly was noted on that study.A double balloon enteroscopy was planned,but ultimately cancelled as her ileitis had resolved.The patient was discharged home as her pain resolved with conservative management which included intravenous fluid, pain medications and antiemetics.She then represented to the hospital on September 16, 2019 severe abdominal pain and throat tightness associated with shortness of breath. Again,noted was an extremely short segment of ileum with mucosal edema and hyperenhancement which resolved on a repeat CT scan done during that admission on September 18th, 2019.In light of the patient’s symptoms,CT scan findings,progressive anemia, thrombocytopenia and splenomegaly. It was thought that her abdominal pain is related to secondary to angioedema driven by a lymphoproliferative process as evident by the splenomegaly and worsening cytopenia. A bone marrow was done which revealed clonal B, so the diagnosis of lymphoma was made. The patient’s C1 esterase was 0.2 with reduced functional activity.CH50 less 10 perecent. A diagnosis of acquired angioedema was made and the patient was started on BERINERT 3000 IU SQ every three days with 1500 IU for break through with significant improvement in the frequency and severity of abdominal pain episodes.

Conclusions

Acquired angioedema is to be considered as a cause of recurrent abdominal pain in a patient with a lymphoproliferative malignancy after common causes and etiologies have been ruled out.

Funding Agencies

None

The international WAO/EAACI guideline for the management of hereditary angioedema-The 2017 revision and update

Hereditary Angioedema (HAE) is a rare and disabling disease. Early diagnosis and appropriate therapy are essential. This update and revision of the global guideline for HAE provides up-to-date consensus recommendations for the management of HAE. In the development of this update and revision of the guideline, an international expert panel reviewed the existing evidence and developed 20 recommendations that were discussed, finalized and consented during the guideline consensus conference in June 2016 in Vienna. The final version of this update and revision of the guideline incorporates the contributions of a board of expert reviewers and the endorsing societies. The goal of this guideline update and revision is to provide clinicians and their patients with guidance that will assist them in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2). The key clinical questions covered by these recommendations are: (1) How should HAE-1/2 be defined and classified?, (2) How should HAE-1/2 be diagnosed?, (3) Should HAE-1/2 patients receive prophylactic and/or on-demand treatment and what treatment options should be used?, (4) Should HAE-1/2 management be different for special HAE-1/2 patient groups such as pregnant/lactating women or children?, and (5) Should HAE-1/2 management incorporate self-administration of therapies and patient support measures?

Enterococcis: pathogens of the 90s

The genus Enterococcus consists of at least 12 species, two of which account for over 95% of the clinically important strains, E faecalis (85%-90%) and E faecium (5%-10%). Despite their ubiquity and frequent isolation, they have not been thought to cause serious disease because they lack common virulence factors. Now, however, enterococci are regarded as true pathogens and are the second leading cause of nosocomial infections. This change results from their increasing antimicrobial resistance and the extensive use of antimicrobial drugs (for example-cephalosporins) that are not active against them. Serious infections should usually be treated with a beta-lactam and an aminoglycoside, but glycopeptides have been increasingly used during the last decade. Two novel resistance patterns of particular concern recently are high level aminoglycoside resistance (HLAR) and vancomycin resistance. The prevalence of HLAR is between 15% and 55%, and glycopeptide resistance has become widespread in various geographical areas. This poses a serious problem, as such resistance may spread to other Gram-positive organisms and is often associated with resistance to other antimicrobial drugs. This may theoretically result in groups of organisms for which there will be no effective antimicrobial treatment.