ACE Inhibitor-Induced Angioedema of the Small Bowel

Abstract

Angiotensin-converting enzyme (ACE) inhibitors are routinely prescribed for patients with hypertension, coronary artery disease (CAD), heart failure with systolic dysfunction, diabetes and chronic kidney disease (CKD). This category of medications is also the leading cause of drug-induced angioedema, occurring in 0.1% to 0.7% of patients. A 49-year-old female presented for evaluation of worsening abdominal pain with nausea, vomiting, and severe bloating, worsening over the next 12 months. Her past medical history included hypertension, depression, hiatal hernia, and an abdominal hysterectomy 20 years prior. Her only medication was Lisinopril 20 mg daily which she had been on for two years. Work up included an EGD and colonoscopy which showed no abnormalities, laboratory workup were all normal except for mildly elevated CRP of 21 and lipase of 73, and the only abnormality seen on imaging came from the CT which showed borderline thickening of distal small bowel loops. She continued to experience symptoms for a total of 15 months, at which point her ACE-inhibitor was stopped. Her symptoms resolved shortly afterwards and did not return, suggesting angioedema caused by her ACE inhibitor. This was likely seen on her initial abdominal CT as the cause for the borderline wall thickening of the small bowel loops. This case demonstrates the angioedema may be exclusive to the GI tract with no overt evidence of swelling elsewhere. We recommend consideration of ACE inhibitor-induced angioedema in any patient using ACE inhibitors presenting with non-specific abdominal complaints without evidence of other causes. Practice recommendations would include reviewing medications while considering ACE inhibitor induced angioedema, checking bradykinin levels which may be elevated with ACE inhibitor use, and a trial off of the ACE inhibitor to see if symptoms resolve. We also recommend discussion of angioedema, including GI symptoms, with patients prior to starting ACE inhibitors.Figure 1Figure 2