Ischemic duodenitis without involvement of the large abdominal arteries.

weight loss and diffuse abdominal pain that was worse after meals. She had a his− tory of diabetes, hypertension, chronic re− nal insufficiency and chronic lymphatic leukemia. Palpation of the right lower ab− dominal quadrant was painful. Labora− tory investigations, abdominal ultra− sound, and a barium enema of the colon revealed no relevant abnormalities. At gastroduodenoscopy an atypical area of inflammation was seen in the descend− ing part of the duodenum (l" Fig. 1). Histopathological examination showed nonspecific ulcerating inflammation (l" Fig. 2). A presumptive diagnosis of ischemic duodenitis was made, but no stenoses of the large abdominal arteries were seen on duplex ultrasound exami− nation. Omeprazole treatment was start− ed and her symptoms diminished. One year later she had a major cerebro− vascular accident and died. An autopsy was performed. On gross examination, areas of ulceration were seen in the me− dial part of the duodenum, but there was no atherosclerosis in the major abdomi− nal arteries. Remarkably, the smaller ves− sels of the duodenum and kidneys showed severe atherosclerosis. Microsco− pically, there was mucosal and submuco− sal ischemia with fibrosis in the abnormal parts of the duodenum. Ischemic duodenitis has been associated with severe atheromatous disease of the splanchnic arteries [1,2]. As far as we know, this is the first report of ischemic duodenitis caused by severe athero− sclerosis of the duodenal arteries, but without involvement of the major ab− dominal arteries. Cholesterol emboli could not be excluded, but the absence of atherosclerosis in the major abdominal arteries makes this very unlikely [3]. There was no infiltration of lymphocytes, which suggests that there was probably no causative relationship with the chron− ic lymphatic leukemia either. Rare causes of ischemic gastrointestinal disease that can lead to similar endoscopic appearan− ces, such as vasculitis or amyloidosis, were also ruled out on the basis of the ra− diological and histopathological findings [4]. A possible explanation in this case could be the gender differences in the pa− thophysiology of atherosclerosis: some− times a more diffuse pattern of athero− sclerosis can be seen in women, involving only the smaller arteries [5].