A 39 year old Army recruit and a long distance runner was referred to the vascular clinic with a two year history of abdominal colic after vigorous exercise (typically running for greater than 40 minutes). It was described as cramp like with a heavy feeling in his guts. The pain resolved with rest but was associated with increased flatulence, nausea, and fatigue. The pain was not demonstrated when he ate a heavy meal; there was no history of diarrhoea or weight loss.

Three years before the patient had undergone coronary artery bypass grafting for angina, New York Heart Association class II. There was a positive history of familial hypercholesterolaemia and ischaemic heart disease. His serum cholesterol was initially 11.1 mg/l at presentation but was brought down by medical and dietary measures. He was a non-smoker. On examination the patient looked extremely healthy; blood examination revealed a mildly raised cholesterol concentration (6.2 mg/l). An ultrasound examination for urinary and biliary tract was normal. A barium meal study did not reveal any abnormality in the upper gastrointestinal tract. A duplex scan of the arterial tree with particular emphasis on the coeliac and mesenteric vessels did not reveal any abnormality. This was followed by contrast computed tomography (fig 1) and mesenteric angiogram (fig2).

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Figure 1

Computed tomogram of the abdominal aorta and coeliac axis demonstrating a tight stenosis at the origin of the coeliac artery with post-stenotic dilatation. The superior mesenteric artery is seen to be of normal calibre.

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Figure 2

Aortogram showing aortic atheroma with a tight stenosis at the origin of the coeliac artery and post-stenotic dilatation. The superior mesenteric artery is of normal calibre.