|Year : 2013 | Volume
| Issue : 1 | Page : 110-112
Exertional abdominal pain as a symptom of secondary pulmonary hypertension in mitral stenosis
J Najafian, N Toghianifar, A Khosravi
Department of cardiology, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Acceptance||21-Apr-2011|
|Date of Web Publication||2-Feb-2013|
Department of cardiology, Isfahan Cardiovascular Research Center, Isfahan University of Medical Sciences, Jomhouri Sq., Khorram St., Sadigheh Tahereh Research Center, Isfahan, P. O. Box: 81465-1148
Source of Support: None, Conflict of Interest: None
| Abstract|| |
We report a rare presentation of mitral stenosis (MS). MS is a common valvular disease, the first manifestation of which is usually easy fatigability and exertional dyspnea. As the disease progresses in severity, other signs and symptoms appear, such as orthopnea, hemoptysis, and peripheral edema. This is the first report of a case of mitral stenosis presenting with exertional abdominal pain as the first manifestation. This case report describes the clinical characteristics of a 55-year-old woman with mitral stenosis and severe pulmonary hypertension, whose first symptom was exertional abdominal pain.
Keywords: Abdominal pain, mitral stenosis, pulmonary hypertension
|How to cite this article:|
Najafian J, Toghianifar N, Khosravi A. Exertional abdominal pain as a symptom of secondary pulmonary hypertension in mitral stenosis. Niger J Clin Pract 2013;16:110-2
|How to cite this URL:|
Najafian J, Toghianifar N, Khosravi A. Exertional abdominal pain as a symptom of secondary pulmonary hypertension in mitral stenosis. Niger J Clin Pract [serial online] 2013 [cited 2020 Aug 14];16:110-2. Available from: http://www.njcponline.com/text.asp?2013/16/1/110/106779
| Introduction|| |
Mitral stenosis (MS) is a valvular heart disease with various etiologies. The predominant cause of MS in developing countries is rheumatic heart disease. Reduced cardiac output and pulmonary hypertension are the main pathophysiologic mechanisms explaining the signs and symptoms of MS.  Pulmonary hypertension in patients with MS results mainly from passive backward transmission of the elevated left atrial pressure. Pulmonary arteriolar constriction and organic obliterative changes in the pulmonary vascular bed are other contributory mechanisms and are considered to be complications of longstanding and severe MS.  There are several reports of atypical presentation of MS. [3-7] All of these atypical presentations were related to peripheral arterial emboli or pulmonary hypertension. Our search of Medline and PubMed did not reveal any report of exertional abdominal pain as the first manifestation of MS.
Written informed consent was obtained from the patient for publication of this report.
| Case Report|| |
A 55-year-old woman was referred to Isfahan Alzahra Hospital by a general practitioner from a rural region of Chaharmahal state in the central part of Iran. The patient was asymptomatic at rest but complained of abdominal pain on mild exertion. This exertional abdominal pain had started 1 month earlier and had increased in frequency recently. The patient was hospitalized in the surgical emergency ward.
On the initial evaluation, the patient's general condition appeared to be good. She had no history of heart disease. Physical examination findings included: accentuated first and second heart sounds, jugular venous pressure (JVP) 5 cm above the sternal angle, a soft holosystolic murmur at the 5 th intercostal space in the midclavicular line but no diastolic murmur. Abdominal examination was normal (no tenderness, no ascites, normal bowel sounds, and no bruit). A 12-lead electrocardiogram showed sinus rhythm, with normal axes and no significant ST and T wave changes. The P wave in V 1 was biphasic, with a dominantly negative component, indicating left atrial enlargement [Figure 1]. Laboratory investigations, including complete blood count, blood urea nitrogen, serum creatinine, serum alanine aminotransferase, serum aspartate aminotransferase, serum alkaline phosphatase, serum sodium and potassium, and urinalysis, were all within normal limits. To rule out mesenteric ischemia, Doppler sonography of the aorta and mesenteric artery was performed, but no obstruction was detected in these vessels.
|Figure 1 : Electrocardiogram of the patient. Biphasic T wave in V1 indicates left atrial enlargement|
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As the patient's condition was stable she was transferred to the internal medicine ward. Echocardiography was done, which revealed a sclerotic mitral valve with moderate stenosis and severe pulmonary hypertension. The left atrium, right ventricle, and right atrium were enlarged. The tricuspid gradient was 50 mmHg, and a moderate tricuspid regurgitation was present [Figure 2]. Heparin, warfarin, propranalol, and furosemide were started. After 2 days the patient's abdominal symptoms improved but her exertional dyspnea persisted. She was discharged on a medical regimen which included warfarin (5 mg daily), propranalol (20 mg bid), and hydrochlorthiazide (50 mg daily). Two months later, the patient was still symptomatic, with exertional dyspnea but no abdominal pain. She was therefore referred for mitral valvuloplasty. Ballon valvuloplasty was performed. At the end of the procedure, the tricuspid gradient reduced to 30 mmHg. At the follow-up visit 30 days after valvuloplasty, the patient was completely asymptomatic.
|Figure 2 : Echocardiogram. B-mode and doppler study reveal mod≠erate MS and moderate pulmonary hypertension|
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| Discussion|| |
The most common symptom of pulmonary hypertension is exertional dyspnea. Other common symptoms are fatigue and angina pectoris (which may represent right ventricular ischemia), syncope, near syncope, and peripheral edema.  This is the first report of exertional abdominal pain being the first manifestation of MS.
This patient had both mitral stenosis and pulmonary hypertension. As revealed by echocardiography, the pulmonary hypertension was out of proportion to the severity of her MS; so other factors such as pulmonary emboli or reactive arteriolar change in the pulmonary circulation must have contributed to the severity of her pulmonary hypertension. In spite of having moderate MS, the patient was asymptomatic until 1 month before, when the exertional abdominal pain had started. It is probable that small pulmonary emboli might have increased the pulmonary artery pressure to a critical level. Elevation of pulmonary arterial pressure beyond this critical level could potentially induce either right heart ischemia and chest pain or liver congestion and abdominal pain. Thus, during physical exertion, venous return would increase and pulmonary pressure would rise past this critical point and lead to abdominal pain. This is a simple explanation for this patient's symptomatology. Several other more complicated mechanisms may also have been involved.
| Conclusion|| |
Although very rare, exertional abdominal pain may be a symptom of secondary pulmonary hypertension.
| Acknowledgments|| |
The authors wish to thank Dr. Alireza Mohamadi, Farsan Rural Health Center, for the good care provided to the patient and for referring her for evaluation.
| References|| |
|1.||Sagie A, Freitas N, Padial LR, Leavitt M, Morris E, Weyman AE, et al. Doppler echocardiographic assessment of long-term progression of mitral stenosis in 103 patients: Valve area and right heart disease. J Am Coll Cardiol 1996;28:472-9. |
|2.||Otto CM, Bonow RO. Valvular heart disease in libby Braunwald's heart disease: A textbook of cardiovascular medicine. 8th ed. Philadelphia: Saunders; 2007. p. 1647-51. |
|3.||Albalbissi KA, Burress JW, Garcia ID, Iskandar SB. Severe mitral stenosis with atypical presentation: Hemorrhagic pleural effusion: A case report and literature review. Tenn Med 2009;102:47-50. |
|4.||Kumar S, Jain AP, Jain S. Rheumatic mitral stenosis with epistaxis as an initial symptom. Singapore Med J 2009;50:e74-5. |
|5.||Kandel G, Aberman A. Pain, ascites in a woman with mitral stenosis. Hosp Pract (Hosp Ed) 1982;17:43-4. |
|6.||Brenner WI, Boal BH, Reed GE. Chylothorax as a manifestation of rheumatic mitral stenosis: Its postoperative management with a diet of medium-chain triglycerides. Chest 1978;73:672-3. |
|7.||Ahmed W, Bashir U, Akhtar N, Shah MA. Rheumatic mitral stenosis presenting as acute abdominal aortic occlusion and foot drop. J Coll Physicians Surg Pak 2005;15:39-40. |
[Figure 1], [Figure 2]