Angiotensin-converting enzyme inhibitor-induced bowel angioedema: clinical features, diagnostic challenges, and recovery predictors from survival analysis: a systematic review of current reported cases

Thanathip Suenghataiphorna, Narisara Tribuddharatb, Pojsakorn Danpanichkulc, Narathorn Kulthamrongsrid, Piyawat Kantagowite

Griffin Hospital, Cerby, CT, USA; St. Elizabeth, Boston, MA, USA; Texas Tech University Health Science Center, Lubbock, TX, USA; University of Hawaii, Honolulu, HI, USA; Chulalongkorn University, Bangkok, Thailand

aDepartment of Internal Medicine, Griffin Hospital, Derby, CT, USA (Thanathip Suenghataiphorn); bSt. Elizabeth, Boston, MA, USA (Narisara Tribuddharat); cDepartment of Internal Medicine, Texas Tech University Health Science Center, Lubbock, TX, USA (Pojsakorn Danpanichkul); dUniversity of Hawaii, Honolulu, HI, USA (Narathorn Kulthamrongsri); eFaculty of Medicine, Chulalongkorn University, Bangkok, Thailand (Piyawat Kantagowit)

Correspondence to: Thanathip Suenghataiphorn, Department of Internal Medicine, Griffin Hospital, Derby, CT; 130 Division St, Derby, CT, 06418, USA, e-mail: Thanathip.sue@gmail.com
Received 20 January 2025; accepted 9 April 2025; published online 28 April 2025
DOI: https://doi.org/10.20524/aog.2025.0967
© 2025 Hellenic Society of Gastroenterology

Abstract

Background Angiotensin-converting enzyme inhibitor-induced bowel angioedema (ACEi-IAE) is a rare and frequently under-recognized condition. Its nonspecific gastrointestinal symptoms could lead to missed diagnoses, unnecessary procedures and inappropriate treatments. Given the scarcity of studies, we conducted a systematic review to summarize the clinical characteristics of ACEi-IAE, the diagnostic approach and factors predicting delayed recovery.

Methods Electronic databases, including MEDLINE, OVID and EMBASE, were used to identified eligible studies from inception to November 2024. Eligible cases were required to have a clear diagnosis of ACEi-IAE. Kaplan-Meier and multivariate Cox regression analyses were used to identify factors associated with delayed recovery time.

Results Our systematic review included 81 eligible studies, comprising 117 ACEi-IAE cases with a mean age of 50 years, of which 83% were female. Patients were mainly African Americans (50%) taking lisinopril (71%). All patients (100%) presented with abdominal pain and other non-specific features. The median recovery time was 48 h after discontinuing ACEi. Patients who had been taking lisinopril for a longer than average period (25.9 months) had a statistically significantly lower hazard ratio for recovery (adjusted hazard ratio [aHR] 0.39, 95% confidence interval [CI] 0.19-0.81; P=0.012), as did patients who had radiographic evidence of jejunal edema (aHR 0.29, 95%CI 0.11-0.74; P=0.010). Diagnostic criteria were proposed and summarized based on the findings.

Conclusions Clinicians should be aware of ACEi-induced bowel angioedema, particularly in ACEi users with non-specific abdominal pain. Implementation of our proposed diagnostic criteria is recommended to prevent unnecessary investigation and inappropriate treatment.

Keywords Angiotensin-converting enzyme inhibitors, bowel angioedema, epidemiology

Ann Gastroenterol 2025; 38 (3): 276-283

Introduction

Angiotensin-converting enzyme inhibitors (ACEi) are commonly prescribed medications for cardiovascular diseases, used by at least 40 million people globally [1], and comprise at least one third of the anti-hypertensive drugs in the USA [2]. While generally well-tolerated, ACEi can cause angioedema, a serious side effect characterized by swelling of the deep layers of skin and mucosal tissue due to increased vascular permeability. The incidence of ACEi-induced angioedema is estimated to be between 0.1% and 0.7%, although the true incidence may be higher as a result of underdiagnosis [3]. The most well-known presentation is angioedema of the face and oropharynx, contributing to 20-40% of angioedema presentations in the emergency room.

However, ACEi can also induce angioedema of the intestines, a less common and often overlooked complication. ACEi-induced intestinal angioedema poses a diagnostic challenge, as it presents with non-specific symptoms, such as abdominal pain, nausea, vomiting and diarrhea, often mimicking other gastrointestinal conditions [4]. This often results in delayed diagnosis, misdiagnosis, unnecessary invasive procedures and inappropriate treatments [5].

The scarcity of information regarding the factors associated with ACEi bowel-induced angioedema (ACEi-IAE) and the duration of recovery creates a complication for the diagnosis and treatment of this patient group. Therefore, we conducted a systematic case review to investigate all reported cases of ACEi-IAE and factors that may impact the duration of recovery, in order to better understand the clinical presentation, diagnostic challenges and management of the condition.

Materials and methods

Search strategy and eligibility

Two investigators (TS and NT) independently conducted searches in PubMed, OVID and EMBASE databases, without language restrictions, from inception through November 2024, using the search strategy specified in Supplementary Table 1. The investigators (TS and NT) independently assessed the eligibility of the retrieved records. Any conflicts were resolved through further discussions involving a third investigator (PD). The protocol was designed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) checklist (Supplementary Table 2) [6]. The protocol was preregistered (PROSPERO: 618287). Eligible studies had to be published as case reports or case series in which ACEi-induced bowel angioedema was diagnosed. All reported patients must have been currently receiving an ACE inhibitor, whose removal led to resolution of the symptoms. No restrictions on age, country of origin, or language (provided that an English translation was available) was applied. Conference abstracts and peer-reviewed articles were incorporated into the study, provided that the case diagnosis was indicated.

Data extraction

To ensure consistency and rigor, we implemented a standardized data collection protocol across all included studies. This protocol facilitated the systematic extraction of key variables pertinent to our research objectives. Extracted data encompassed demographic information, including the first author’s surname, the country where the study was conducted, and the year of publication. Patient characteristics were meticulously recorded, capturing details such as age, sex, and self-reported race. Regarding the ACEi administration, we documented the specific type of ACEi prescribed, the administered dosage, and the duration of ACEi usage. Clinical manifestations of angioedema were captured, including the nature and severity of symptoms, radiographic findings—at least 1 of the following types of information was reported: segmental thickening, mesenteric edema (with areas of involvement if provided), target signs, infiltrate of a small bowel region, mucosal thickening or luminal narrowing—and the anatomical location of the angioedema. Finally, data regarding the resolution of angioedema, specifically the recovery time (defined as duration of hospital stay from the day of diagnosis until discharge), was collected to assess the clinical course of the adverse event. This detailed extraction process allowed for a comprehensive analysis of ACEi-induced angioedema.

Statistical analysis

Continuous variables were presented as mean ± standard deviation, while categorical variables were presented as percentages. Recovery time was evaluated as a primary survival outcome using Kaplan-Meier analysis for the initial evaluation. Cox regression univariate and multivariate analyses were used to assess predictors of the duration of recovery time, reported in terms of a hazard ratio (HR) with 95% confidence (P<0.05). A stepwise Cox regression method was used to identify variables that independently had a significant association with the recovery time. All data analyses were conducted using StataMP 17.0 software (StataCorp, College Station, Texas).

Results

Our search strategy identified 549 records. After removing 89 duplicates, we reviewed those studies by title and abstract and rejected a further 375 studies that did not meet the eligibility criteria related to study design or participants. Subsequently, we thoroughly reviewed 85 articles and excluded 4 for reporting different medication types [7-10]. Ultimately, 81 studies met the eligibility criteria for our systematic review, totaling 117 cases [4,5,11-91]. Fig. 1 illustrates our search methodology and selection process, and Supplementary Table 3 details each of the selected case reports.

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Figure 1 Study selection and PRISMA flow diagram

Table 1 shows the baseline characteristics of all documented case reports. The average participant age was 50 years old, and 83% were female. The majority of the case reports came from the USA (72%), followed by Belgium (8%). Of the patients whose race was reported, 50% were African Americans, while 40% were White. Lisinopril was the most common medication that contributed to ACEi-induced bowel angioedema (71%). The average duration of medication intake was 24 months, and ACEi-induced bowel angioedema could occur from 12 h to 10 years after exposure. Abdominal pain was present in every reported case, while 75% had nausea, 67% had vomiting and 45% had diarrhea. Small bowel radiographic edema constituted the largest category (34%) of bowel edemas seen on computed topography, followed by jejunum (24%) and ileum (17%).

Table 1 Results of data synthesis

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Survival analysis

In all of the reported cases that recovered, the median recovery time was 48 h after discontinuing the medication. A Kaplan-Meier analysis of the recovery period is shown in Fig. 2. Patients with a longer-than-average duration (25.9 months) of lisinopril intake had a significantly lower crude hazard ratio (cHR 0.35, 95%CI 0.19-0.66; P=0.001) and adjusted hazard ratio (aHR 0.39, 95%CI 0.19-0.81; P=0.012) for recovery. In addition, patients who had radiographic evidence of jejunal edema had a statistically significantly lower cHR (cHR 0.49, 95%CI 0.25-0.93; P=0.03) and aHR (aHR 0.29, 95%CI 0.11-0.74; P=0.010) for recovery. No other variables achieved statistical significance; thus, only the 2 aforementioned variables were used in the multiple Cox regression model. Univariate and multivariate Cox regression analyses are depicted in detail in Table 2. The survival curves generated by the final Cox regression model for a longer duration of lisinopril in Fig. 3.

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Figure 2 Kaplan-Meier analysis of the recovery period

CI, confidence interval

Table 2 Univariate and multivariate Cox regression analysis of predictors for time to recovery

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Figure 3 Cox regression model: duration of lisinopril intake

Discussion

To date, this is the first systematic review of patients with ACEi-induced bowel angioedema. This meta-analysis comprised 81 studies and 117 patients. We report multiple novel findings from this study. Firstly, patients are predominantly middle-aged females, possibly indicating a disproportionate effect in this subpopulation. Secondly, lisinopril is the medication that most frequently causes ACEi-induced bowel angioedema, highlighting a possible concern about one of the most common medications prescribed worldwide. Finally, patients who took lisinopril for longer periods, and those who had evidence of jejunal edema, were at greater risk of a delayed recovery.

The first reported general angioedema was reported in 1876 [92], but ACEi medications were not discovered until 100 years later, in 1975, and were first introduced to the general public in 1981 [93]. By then, reports of angioedema associated with ACEi had been published in 1977 and 1980 [94], and angioedema has been associated with ACEi ever since. However, the first ACEi-induced bowel angioedema surfaced in 1994, signifying a newly discovered unwanted effect that may possibly lead to a missed diagnosis in patients who regularly take ACEi. Interestingly, most patients in our analysis were middle-aged females, whereas earlier publications reported that ACEi-angioedema was more likely to be found in males [95]. This may stem from the differences in organ systems presentation, in which males are likely to present with skin and subcutaneous tissue findings, but women are likely to present with gastrointestinal symptoms [96].

We found that all patients presented with abdominal pain, while lisinopril was the major medication associated with ACEi-angioedema. More than 80% of new ACEi users received lisinopril [97], making it the most common medication reported to cause issues. Other gastrointestinal symptoms included nausea, vomiting and diarrhea. The radiographic evidence of small bowel edema seen in many cases was probably due to fluid sequestration in the abdomen, as seen in patients who later developed shock [64] and evidenced by double-balloon endoscopy [85]. Previous studies reported that 57% of patients had unnecessary surgery or biopsies [46], which could have been prevented if a detailed medication history had been obtained. Furthermore, given the short period of time for information collection, patients are likely to be discharged from both emergency rooms and outpatients’ departments [21,65], but they may later return and require admission. Some of these patients may suffer for up to 4 years before obtaining the correct diagnosis [60]. Table 3 shows the proposed diagnostic criteria [16] and factors that should be considered to indicate ACEi-induced bowel angioedema. A detailed history of medication usage in this subpopulation group may help in determining the diagnosis.

Table 3 Proposed diagnostic criteria and factors for ACEi-induced bowel angioedema

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Even though all patients recovered, many patients reported severe pain as the condition progressed, requiring multiple pain medications [61,62,65]. We found that the recovery time was impacted by 2 factors: a higher dosage and a jejunal location of the edema. The gastrointestinal tract is innervated by multiple nerve systems, but given the limited information about differences between small intestine sections, further investigation will be necessary. One possible theory is that recovery capabilities in each of the gastrointestinal tract segment differs, as seen in the disproportionate impact of aging, whereas the distal gastrointestinal tract is more affected [98]. A longer recovery time is debilitating for the patients, as prolonged symptoms have a negative impact on their quality of life and may lead to further unnecessary investigations. Although there is no dose-dependent relationship with traditional angioedema [99], it is possible that bradykinin may exert its effect on the gut differently from other organ systems [100]. A longer recovery time could also increase morbidity and mortality, as the prolonged length of stay could increase the number of hospital-acquired infections and conditions for these patients.

Our study had several limitations. First, the relatively small sample size may limit the ability of statistical methods to fully capture patient variability. Second, our survival analysis was an estimate based on the available data, that can lead to possible underreported of various socioeconomic status. Finally, we cannot definitively conclude that the factors identified are the most significant, as certain variables—such as treatment modalities, complications, underlying conditions and laboratory results—were excluded from the analysis because of the limited sample size and data availability. Further robust large-scale studies are necessary to validate our findings and assess their impact on patient outcomes.

Clinicians should suspect ACEi bowel angioedema in ACEi users presenting with non-specific abdominal pain. Prolonged lisinopril use and jejunal edema may be associated with delayed recovery after drug discontinuation. The proposed diagnostic criteria may help prevent missed and delayed diagnoses, thus avoiding unnecessary investigations and inappropriate treatments. Further research into the factors affecting the development and recovery period is crucial for understanding the underlying mechanisms and developing preventive strategies for this rare but debilitating condition.

Summary Box

What is already known:

  • Angiotensin-converting enzyme inhibitors (ACEi) can cause angioedema, from generalized to intestinal angioedema

  • The clinical features and factors impacting ACEi-induced intestinal angioedema recovery time are currently unknown

  • ACEi-induced intestinal angioedema poses a diagnostic challenge and may lead to inappropriate treatments

What the new findings are:

  • Patients who took lisinopril for a longer than average time had longer recovery times, as did those with jejunal edema

  • Patients are overwhelmingly middle-aged, female and African American

  • All patients with ACEi-induced bowel angioedema fully recovered, but they had various debilitating episodes before a final diagnosis was obtained

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Notes

Conflict of Interest: None