Digestive Diseases and Sciences, Vol. 49, Nos. 11/12 (November/December 2004), pp. 1990–1995 ( C  2004) CASE REPORT Three Cases of Chronic Mesenteric Ischemia Presenting as Abdominal Pain and Helicobacter pylori-Negative Gastric Ulcer MARINA SOMIN, MD,* SVETLANA KOROTINSKI, MD,* MALKA ATTALI, MD,* ANATOL FRANZ, MD,† ERAN E. WEINMANN, MD,† and STEPHEN D. H. MALNICK, MA(Oxon), MSc, MB, BS(Lond)* KEY WORDS: mesenteric ischemia; Helicobacter pylori; gastric ulcer. Mesenteric ischemia is well described as a cause of chronic abdominal pain (1). The classic complaint is of postpran- dial abdominal pain. The pain steadily increases in sever- ity before reaching a plateau and resolves during the next 1 to 2 hr. The pain appears in the epigastrium and may radiate through to the back. The severity of the pain is greater after large meals or meals with a high fat content (2). These complaints are, of course, not specific and raise the possibility of peptic ulcer disease. Chronic Helicobacter pylori infection is the major cause of peptic ulcer disease, and use of nonsteroidal anti- inflammatory drugs (NSAIDs) accounts for the majority of the remainder (3). Non-NSAID, non-H. pylori gastric ulcers are constituting a greater proportion of diagnosed ulcers as the prevalence of H. pylori decreases (3). We re- port here three cases of chronic mesenteric ischemia where an H. pylori-negative gastric ulcer unassociated with the use of NSAIDs was detected in the initial evaluation. the patients’ complaints ultimately responded to revascular- ization therapy, with resolution of their non-NSAID, non- H. pylori gastric ulcers. CASE REPORTS Case 1. An 80-year-old man presented with right upper quad- rant abdominal pain and signs of peritoneal irritation. His med- ical history included type 2 diabetes mellitus, hypertension, and a myocardial infarction in 1994. He was treated with cap- topril, 12.5 mg tid, atenolol, 25 mg od, aspirin, 100 mg od, Manuscript received February 19, 2004; accepted July 8, 2004. From the *Department of Internal Medicine C and †Division of Vas- cular Surgery, Kaplan Medical Center, Rehovot 76100, Israel. Address for reprint requests: Dr. Stephen D. H. Malnick, Department of Internal Medicine C, Kaplan Medical Center, Rehovot 76100, Israel; stevash@trendline.co.il. and furosemide, 40 mg od. CT scan of the abdomen showed mild inflammation of the ileocecal wall with infiltration of the mesenteric fat. He responded well to conservative therapy but returned a month later with recurrent abdominal pain, mainly in the upper abdomen. Laboratory investigations revealed an ESR of 88 mm/hr. The remainder of the routine investigations, in- cluding CBC and renal and liver functions, was unremarkable. Esophagogastroduodenoscopy was performed, which revealed three ulcers on the angulus and greater curvature of the stomach, the largest of which was 1.5 cm in diameter. A rapid urease test for H. pylori, performed on a biopsy from the gastric antrum, was negative. The patient received omeprazole, 20 mg od; treatment with aspirin was discontinued. Initially there was an improve- ment in the abdominal pain but subsequently postprandial pain returned. Repeat CT scan of the abdomen at this time revealed only calcification of the abdominal aortic wall. The patient continued to suffer from abdominal pain and, in addition, developed diarrhea with weight loss. An upper Gl series revealed ulcerations and rigidity of the wall of the terminal ileum, the cecum, and the distal colon. On colonoscopy there was ulceration of the mucosa of the terminal ileum and biopsy showed inflammatory ulceration with differing stages of regeneration. A provisional diagnosis of inflammatory bowel disease was made and treatment was commenced with parenteral steroids and oral 5-ASA compounds but there was no response to therapy. Repeat gastroscopy showed the continued presence of two of the three gastric ulcers detected previously. A duplex scan of the abdominal arteries did not detect any flow in the superior mesenteric artery, and it was decided to perform abdominal angiography. This revealed occlusion (or complete occlusion) of both the superior mesenteric artery and the celiac trunk (Figure 1). Percutaneous angioplasty with insertion of a stent in the superior mesenteric artery was performed. There was a dramatic improvement in the patient’s symptoms—the abdominal pain improved and he gained 12 kg in weight. Repeat endoscopy showed resolution of the gastric ulcers. He remains free of pain during 3 years of follow-up. Case 2. A 76-year-old woman was referred with severe post- prandial abdominal pain. Her medical history included hyperlipi- demia and hypertension that were not treated medically. She had stopped eating a month prior to admission due to an exacerbation 1990 Digestive Diseases and Sciences, Vol. 49, Nos. 11/12 (November/December 2004) 0163-2116/04/1200-1990/0 C  2004 Springer Science+Business Media, Inc.