Delayed postprandial pain

Specialty: Gastrointestinal.

• Late post-meal abdominal pain
• chronic intestinal ischemia
• postprandial intestinal angina

Why it occurs

• Chronic mesenteric ischemia (intestinal angina secondary to atherosclerotic stenosis of at least two of the three large splanchnic arterial trunks: celiac trunk, superior mesenteric artery or inferior mesenteric artery)
• Active duodenal ulcer (typically the pain appears 2-4 hours after ingestion due to the passage of acidic chyme from the stomach to the duodenum devoid of cushioning foods)
• Gallder emptying dysfunction syndrome or tardive biliary dyskinesia
• Chronic pancreatitis in intermediate-advanced stages with pain exacerbated by late pancreatic stimulation.

Initial workup

CT angiography of the abdomen (evaluation of the arterial ostia of the celiac trunk and the mesenteric arteries looking for calcifications and significant stenosis >70%) | Doppler ultrasound of mesenteric vessels (measurement of maximum systolic velocities in the fasting and postprandial state in the celiac trunk and superior mesenteric artery) | Upper gastrointestinal endoscopy (EDA, to specifically rule out active duodenal ulcer or refractory gastric ulcer) | General analysis to evaluate malnutrition (albumin, prealbumin, cholesterol, blood count, iron and vitamin profile).

Standard management

• Sublingual nitroglycerin or transdermal patches — used prophylactically 15-30 minutes before main meals to induce vasodilation of the splanchnic vasculature and attenuate intestinal angina
• Proton pump inhibitors if duodenal ulcer is confirmed — pantoprazole 40 mg/day or esomeprazole 40 mg/day for 4-8 weeks
• Antiplatelet agents and high-dose statins for the management of underlying systemic atherosclerotic disease — acetylsalicylic acid 100 mg/day and atorvastatin 40-80 mg/day
• Percutaneous revascularization treatment (angioplasty and mesenteric stenting) or surgery in proven mesenteric ischemia.