Introduction In acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE), the gastrointestinal (GI) tract is a common site of angioedema attack. Abdominal involvement occurring by itself is difficult to diagnose as it may masquerade as other GI pathologies, including acute surgical abdomen. Case Description A 63 yr female diagnosed with stage IV marginal zone lymphoma was referred for management of acquired angioedema due to C1-INH deficiency (C1-INH-AAE). Patient had two episodes of angioedema requiring intubation, at which time C1 esterase inhibitor level was low. She had recurrent episodes of abdominal pain and distention for 6 months. Labs included C4: < 1.5 mg/dL, C1 esterase inhibitor: 5 mg/dL, and C1 function: 26%, C1q level < 3.6 mg/dL. It was unclear whether her abdominal complaints were secondary to angioedema versus progression of lymphoma. As exogenous replacement C1-inhibitor could potentially induce further autoantibodies against the rescue agent, and may be less effective, as needed bradykinin receptor antagonist was prescribed for attacks. CT scan during abdominal distension showed ascites and portal hypertension from splenic enlargement, rather than gastrointestinal angioedema as the cause of her pain. With chemotherapy, symptoms improved and angioedema did not recur. Discussion C1-INH-AAE is a rare disease and commonly associated with lymphoproliferative disorders, such as non-Hodgkin lymphoma. Bradykinin-driven angioedema involves the skin, GI tract; and most harrowingly the larynx. This case represents important aspects in the workup and management of C1-INH-AAE including symptom overlap between underlying malignancy and angioedema, the optimal treatment agent and recognition that the most definitive treatment of C1-INH-AAE is to treat underlying malignancy. In acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE), the gastrointestinal (GI) tract is a common site of angioedema attack. Abdominal involvement occurring by itself is difficult to diagnose as it may masquerade as other GI pathologies, including acute surgical abdomen. A 63 yr female diagnosed with stage IV marginal zone lymphoma was referred for management of acquired angioedema due to C1-INH deficiency (C1-INH-AAE). Patient had two episodes of angioedema requiring intubation, at which time C1 esterase inhibitor level was low. She had recurrent episodes of abdominal pain and distention for 6 months. Labs included C4: < 1.5 mg/dL, C1 esterase inhibitor: 5 mg/dL, and C1 function: 26%, C1q level < 3.6 mg/dL. It was unclear whether her abdominal complaints were secondary to angioedema versus progression of lymphoma. As exogenous replacement C1-inhibitor could potentially induce further autoantibodies against the rescue agent, and may be less effective, as needed bradykinin receptor antagonist was prescribed for attacks. CT scan during abdominal distension showed ascites and portal hypertension from splenic enlargement, rather than gastrointestinal angioedema as the cause of her pain. With chemotherapy, symptoms improved and angioedema did not recur. C1-INH-AAE is a rare disease and commonly associated with lymphoproliferative disorders, such as non-Hodgkin lymphoma. Bradykinin-driven angioedema involves the skin, GI tract; and most harrowingly the larynx. This case represents important aspects in the workup and management of C1-INH-AAE including symptom overlap between underlying malignancy and angioedema, the optimal treatment agent and recognition that the most definitive treatment of C1-INH-AAE is to treat underlying malignancy.