Does anyone have experience of exercise induced right sided abdominal pain (not due to right heart failure - normal VP, IVC on echo) in severe MR due to MVP or other valvar disease. And now post op appears to have same syndrome with severe PHT. Is the PHT related to mesenteric ischaemia, causing the pain, and releasing vasoactive agents causing the PHT? All abdominal investigations negative (invasive mesenteric angio not yet done).
Abdominal angina is an abdominal pain after eating that occurs in individuals with ongoing poor blood supply to their small intestines known as chronic mesenteric ischemia. Also, there may be a relationship with valvular stenosis or artificial valve with the activation of VWF, which can result platelet aggregation and further thrombosis of already atherosclerotic mesenteric blood vessels.
Agree with Mr Irtiza. Also Congestion enetropathy may be a factor
Thank you both very much. The patient doesn't have atherosclerosis (normal coronary angio, normal abdo CT angio, low risk) but the idea of shear causing vWF activation is interesting but she has neither artificial valve (valve was repaired successfully) nor valvar stenosis. Of course pre-op she had mitral regurgitation. Neither does she have congestion. The mean RA pressure has never been raised clinically, just big a waves, no hepatic congestion on echo, normal IVC features on echo. I'm beginning to wonder if "congestion enteropathy" was often/sometimes/occasionally due to arterial supply problems rather than venous congestion. Any other comments?
If I have well understood, the patient has signs of pulmonary hypertension at echo. A normal inferior vena cava does not rule out at 100% a high central venous pressure at rest. Moreover, despite normal or near normal right atrial pressure at rest, patients with heart failure may have steep rise of right atrial pressure at exercise. Since you are performing broad investigations, why not to do a right heart catheterization, eventually with measures conducted also during exercise?
Also, I think it is better to exclude the unusual cases of abdominal pain like porphyria, FMF, vasculitis, connective tissue diseases & conversion disorder.
Venous pressure does not rise on exercise - last time we did it - by JVP at least. But can't rule it out now. She's having right heart cath with exercise later this week. But abdominal pain was first presentation 6 months before surgery, and still no evidence of congestion/big liver etc at any stage prior to surgery. But your comment is helpful Sergio, thank you!
Irtiza, the pain is entirely contemporaneous with the mitral regurgitation until surgery, and is now associated with pulmonary hypertension. It is very clearly exertional, and improves over time with rest, so is very unlikely to be most of the conditions you are suggesting (I realise in the absence of a full clinical assessment!). I can reassure you that it's not conversion disorder, I've seen the abdominal distension associated with the severe episodes, and the mitral facies and peripheral cyanosis is rather dramatic... But your comments are helpful as it's often hard to raise your gaze from the more likely to include things you've not thought of!
pulmonary hypertension and big a wave implicate mysenteric congestion .