Endgames Picture Quiz

An elderly woman with postprandial abdominal pain

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4509 (Published 10 July 2014) Cite this as: BMJ 2014;349:g4509
  1. Anantharaman Ramasamy, core trainee in medicine1,
  2. Romeshan Sunthareswaran, consultant surgeon2,
  3. Dinuke Warakaulle, consultant radiologist3,
  4. Simon Dubrey, consultant cardiologist1
  1. 1Department of Cardiology, Hillingdon Hospital, Uxbridge UB8 3NN, UK
  2. 2Department of Surgery, Stoke Mandeville Hospital, Aylesbury, UK
  3. 3Department of Radiology, Stoke Mandeville Hospital, Aylesbury, UK
  1. Correspondence to: S Dubrey simon.dubrey{at}thh.nhs.uk

An 84 year old woman presented with a five month history of central, recurrent, severe epigastric pain, which occurred about 20 minutes after eating. This was associated with nausea, occasional diarrhoea, and vomiting. She had experienced early satiety and weight loss over the last few months. Her medical history included myocardial infarction two years earlier. She also had a 40 pack year history of smoking. On examination, she was cachectic, but physical examination and digital rectal examination were otherwise unremarkable. Blood tests—including full blood count, liver functions tests, amylase, and renal function—were normal. Chest and abdominal radiographs, abdominal ultrasound, and computed tomography of the abdomen were unremarkable. Computed tomography angiography was performed (fig 1).


  • 1. What does the computed tomography angiogram show?

  • 2. What is the most likely diagnosis in this patient?

  • 3. What are the differential diagnoses?

  • 4. What are the management options for this patient?


1. What does the computed tomography angiogram show?

Short answer

Stenotic disease of the proximal segments of the coeliac axis and superior mesenteric artery.

Long answer

The computed tomography …

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