S. Christopoulos 1 , A. Szilagyi 1 , S.R. Kahn 1 ; 1 SMBD Jewish General Hospital, McGill University, Montreal, Quebec LEARNING OBJECTIVES: 1) To recognize the importance of a careful medication history and a thorough review of side effects; 2) To recognize ergotism as a cause of mesenteric ischemia. CASE INFORMATION: Over a two-year period, a 43-year-old woman presented to the emergency department on five separate occasions with complaints of severe abdominal pain. Extensive investigations including gastroscopy, colonoscopy, two CT scans and ultrasounds of the abdomen, small bowel follow-through contrast study, enteroclysis, as well as a complete gynecological work-up were all negative. Over this period of time, the patient's treating psychiatrist diagnosed her as having Somatic Pain Disorder. The patient was admitted to the medical service of our institution with severe malnutrition. Her past medical history included a longstanding history of migraine headaches treated with caffeine/ergotamine tartrate enemas, weekly or more often, since the age of 18. The patient described her abdominal pain as sharp, located primarily in the epigastric region, and radiating to the back. The episodes occurred one hour postprandially, and were associated with nausea and vomiting. She reported a 60 lb weight loss over a one-year period. Physical examination revealed cachexia. Serial abdominal examinations were unremarkable. Stool occult blood testing was negative. Tube feeding was initiated. A CT angiogram was requested, which revealed significant narrowing of both the celiac and superior mesenteric arteries with the presence of collaterals. A diagnosis of mesenteric ischemia was established. An angiogram was requested prior to intestinal bypass surgery, however the patient developed worsening abdominal pain, significant leucocytosis, a lactate level three times normal, and evidence of peritoneal irritation. She underwent urgent laparotomy, which revealed extensive ischemia of the small bowel and diffuse arterial disease of the abdominal aorta, the iliac, superior mesenteric, and celiac arteries. An aorto-superior mesenteric bypass was performed. The patient underwent a second look laparotomy within 24 hours and 30 cm of dusky small bowel were resected. The post-operative course was uneventful. Following the discontinuation of ergotamine use, the patient no longer experienced abdominal pain and gained a significant amount of weight. DISCUSSION: Despite new modalities to treat migraine headaches, ergotamine is still used chronically by some migraine sufferers. The most recognized complication of ergotism is arterial vasospasm of the upper and lower extremities. More rarely, vasospasm is recognized in the carotid, retinal, renal, and mesenteric arteries. In our patient, failure to suspect this unusual cause of mesenteric ischemia led to delayed diagnosis, severe weight loss, and advanced intestinal infarction. The importance of a careful drug history cannot be overemphasized.