Brief Explanation

Chronic mesenteric ischemia (CMI) is a rare condition that causes abdominal symptoms. The diagnosis of CMI is challenging, and the time from presentation to diagnosis ranges from 20 to 25 months;1, 2 during this time, the patient may develop acute mesenteric ischemia (AMI).3, 4 Common ischemic changes seen on endoscopy include erythema, edema, petechial hemorrhage, superficial ulcerations, deep ulcerations, luminal narrowing, and stenosis.5 However, these findings are seldom discriminative against other diseases. Herein, we report a case in which we captured real-time endoscopic images suggestive of CMI. The patient was a 70-year-old woman with postprandial abdominal pain and weight loss for approximately 6 months who was admitted to our hospital for further management. She took aspirin for angina pectoris and atherosclerosis obliterans for over 10 years. Upper gastrointestinal endoscopy and video capsule endoscopy revealed multiple ulcers in the stomach, duodenum, jejunum, and ileum. Colonoscopy revealed the transverse colon mucosa as pale (Fig. 1a); however, progression into erythematous mucosa started after 20 s (Fig. 1b). Within an additional 40 s, most of the mucosa had become erythematous (Fig. 1c; Video S1). Computed tomography angiography performed 2 days after colonoscopy revealed celiac artery (CA) stenosis (Fig. 2a) and superior mesenteric artery (SMA) obstruction (Fig. 2b). Based on imaging findings and clinical symptoms, she was diagnosed with CMI and underwent stenting of the CA and SMA. Her abdominal symptoms subsided immediately after the procedure and have not reappeared to date. In the present case, the multiple gastrointestinal ulcers were considered to be due to ischemia–reperfusion injury, and the development of collateral blood flow could have prevented her from developing AMI. The captured changes in the mucosa over time encompassing a transient ischemia–reperfusion injury suggestive of CMI, may be useful for its early diagnosis and therapeutic intervention in the future.

Endoscopic images during observation of the transverse colon. (a) The transverse colon mucosa at the beginning of observation. (b) The transverse colon mucosa after 20 s. (c) The transverse colon mucosa after 40 s.

Computed tomography angiography imaging performed 2 days after colonoscopy. (a) The celiac artery was stenotic at its origin. (b) The superior mesenteric artery was occluded.

Authors declare no conflict of interest for this article.

Acknowledgments

We would like to thank Daisuke Hirayama for acquiring the data, and Shinji Yoshii for the helpful discussion. We also would like to thank Editage (www.editage.com) for English language editing.

Informed consent

Informed consent was obtained from the patient for publication of her information and imaging.