An 85 year old male had an aortic stent implanted about 14 months ago following an MI (heart attack). Since then he has suffered from constipation and daily disabling bouts of nausea (feeling sick but not actually being sick). He takes the usual cardiac drugs (clopidogrel [stopped after 11 months] aspirin, bisoprolol, ramipril and simvastatin). Removing these one at a time had no effect, since when he has had endoscopy, sigmoidoscopy, blood tests and CAT scans, all of which were normal. I am not a doctor but a friend and I think it is likely that he has chronic mesenteric ischaemia (CMI) because:

1. He has the principal risk factor - a history of cardiovascular disease;

2. He has two of the symptoms but "fear of eating because of the subsequent pain" causes weight loss, so the other three are really only one symptom - abdominal pain, which he doesn't have,

• Abdominal pain after meals

• Weight loss

• Fear of eating or change in eating habits due to post-meal pain

• Nausea and/or vomiting

• Constipation or diarrhoea.

Why might a cardiac by-pass or stent insertion make the symptoms of CMI worse?

If atherosclerosis affects both cardiac and mesenteric arteries then blood pressure will rise to try and maintain blood flow through both. If the obstruction to flow in the cardiac artery is reduced by a stent or by-pass then blood flow to the heart will increase but at the cost of reducing flow to the mesenteric artery and exacerbating the enteric symptoms.

It would be reasonable to suppose that, just as angina often starts with tiredness and breathlessness with pain coming later, CMI might start with nausea and constipation but doctors normally see patients at fairly late stage when damage to the bowel wall has already occurred and pain is established..