Celiac territory ischemic syndrome in a patient on chronic hemodialysis

Mesenteric ischemia among chronic dialysis patients is usually of the nonocclusive type. Chronic occlusive mesenteric ischemia has been reported rarely in the dialysis population. The subset of"celiac-territory ischemic syndrome" has not been described in dialysis. The current report involves a 66-year-old female on chronic dialysis for 11 years. She experienced abdominal pain following sessions of hemodialysis, that later became more pronounced after eating. Abdominal angiography showed heavily calcified aorta, celiac trunk and superior mesenteric artery (SMA), with a 50% narrowing of the celiac and superior mesenteric arteries. During the following 9 months the symptoms worsened and weight loss set in. She was admitted with an episode of upper abdominal pain. Acalculous cholecystitis was found, along with multiple gastric and duodenal erosions including the second part, with an antral ulcer and multiple duodenal bulb ulcers. Repeated abdominal angiography showed progression of the stenotic lesions with significant narrowing of both the celiac trunk and the SMA. A stent was placed in the SMA. Following the procedure, the patient noted marked symptomatic improvement. On follow-up gastroduodenoscopy, all ischemic ulcers had healed completely. Serum albumin rose from a nadir of 31 to 40 g/l, and an extremely elevated c-reactive protein of 205,000 microg/l returned to normal (8,000 microg/l). The diagnosis of chronic occlusive mesenteric ischemia should be suspected among dialysis patients with post-prandial pain and weight loss in the face of calcified vessels. Predominant celiac territory ischemic syndrome presents as gastric and duodenal erosions and ulcers with or without acalculous cholecystitis.