Endoscopic Visualization of Angiotensin-converting Enzyme Inhibitor-induced Small Bowel Angioedema as a Cause of Relapsing Abdominal Pain using Double-balloon Enteroscopy

A 40-year-old woman presented with 3 episodes of abdominal pain. Abdominal ultrasound demonstrated edema of the small bowel. Double-balloon enteroscopy (DBE) showed diffuse swelling of the small intestine, petechial bleeding in the jejunum, and focal inflammation of the ileum. Pain and small bowel edema resolved spontaneously within 48 h during each episode. Review of the patient’s history revealed that she had been started on enalapril for arterial hypertension two weeks before her first episode. Angiotensin-converting enzyme (ACE) inhibitor-associated angioedema of the small bowel was suspected and enalapril was discontinued. The patient remained symptom-free after discontinuing the ACE inhibitor. Review of the literature reveals only 11 similar cases with this case being the first to apply DBE to visualize macroscopic alterations to the small intestine. Angioedema of the intestine is a diagnostic pitfall frequently leading to prolonged diagnostic procedures and is a potential cause for abdominal pain in patients taking ACE inhibitors.