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 Suenghataiphorn; Narisara Tribuddharat; Pojsakorn Danpanichkul; Narathorn Kulthamrongsri; Piyawat Kantagowit

Authors Thanathip Suenghataiphorn, Narisara Tribuddharat, Pojsakorn Danpanichkul, Narathorn Kulthamrongsri, Piyawat Kantagowit.

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