Resident UMKC-School of medicine Kansas, Missouri, United States
Introduction: Angiotensin-converting enzyme inhibitors (ACEIs) are known to cause drug-induced angioedema, though involvement of the gastrointestinal tract is rare. Bowel angioedema results from fluid leakage into the intestinal wall and can be challenging to diagnose, especially in patients with underlying conditions like Crohn’s disease, where overlapping symptoms may occur. Isolated bowel angioedema, although uncommon, poses diagnostic difficulties and requires careful evaluation, particularly when managing patients with complex abdominal diseases. Case Report: We present a 32-year-old Caucasian woman with well-controlled Crohn’s disease and hypertension, managed with Risankizumab and Lisinopril. She experienced a year of episodic abdominal pain, nausea, and vomiting, leading to repeated steroid tapers and a change in biologic therapy. She was hospitalized after a two-day period of worsening symptoms and presented hypotensive (85/55 mmHg) and tachycardic, though improved with IV fluids. Initial imaging revealed significant small bowel wall thickening and free fluid in the abdomen, raising suspicion for a Crohn’s flare. However, following the discontinuation of Lisinopril, the patient experienced rapid improvement within 24 hours. Repeat imaging confirmed resolution of bowel edema, and endoscopy and colonoscopy performed showed no abnormalities. She was diagnosed with ACEI-induced intestinal angioedema, which had been misinterpreted as Crohn’s disease. Discussion: Visceral angioedema due to ACEI is often recognized by systemic signs like facial or upper airway swelling, but when it presents with isolated bowel involvement, diagnosis can be challenging. This case highlights the importance of considering ACEI-induced bowel angioedema in patients with Crohn’s disease, as misdiagnosis may result in inappropriate treatment, such as escalation of biologic therapy. ACEI-induced bowel angioedema can occur at any time after initiating the medication and should be suspected in patients with unexplained gastrointestinal symptoms, especially if imaging shows bowel thickening. Recognizing this condition early is crucial to avoid unnecessary interventions. Conclusion: This case emphasizes the need for clinicians to be aware of ACEI-induced bowel angioedema as a rare but significant Crohn’s mimicker. Failure to recognize this condition can lead to unwanted treatments and complications. Timely diagnosis and discontinuation of the offending agent can result in rapid symptom resolution, preventing further unnecessary interventions and improving patient outcomes.
