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Chronic mesenteric ischemia: Diagnosis & management. Ann Med Surg (Lond) 2022; 80:104138. [PMID: 36045857 PMCID: PMC9422046 DOI: 10.1016/j.amsu.2022.104138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background Objectives Discussion
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Terlouw LG, van Dijk LJ, van Noord D, Voogd T, Bakker BJ, Nikkessen S, Bruno MJ, Moelker A. MRI-based pre- and postprandial flow in the mesenteric vasculature of patients with suspected chronic mesenteric ischemia. Eur J Radiol 2022; 151:110316. [DOI: 10.1016/j.ejrad.2022.110316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/03/2022]
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Surgical and endovascular revascularization of chronic mesenteric ischemia. Langenbecks Arch Surg 2022; 407:2085-2094. [PMID: 35182180 PMCID: PMC9399053 DOI: 10.1007/s00423-022-02462-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2022] [Indexed: 11/05/2022]
Abstract
Purpose Chronic mesenteric ischemia (CMI) is a rare but life-threatening disease. This study reviewed outcomes in patients treated surgically for CMI by open treatment (OT) and endovascular treatment (ET), analyzing risk factors for endovascular failure. Methods Clinical data for 36 patients treated for CMI from 2007 to 2017 were retrospectively analyzed. The study’s primary endpoint was symptom-free survival. The secondary endpoint was the primary technical success for endovascular and open surgical treatments. Risk factors for endovascular failure were identified by using univariate analysis. Results Patients were analyzed as treated: 21 patients (58.3%) in the ET and 15 (41.6%) in the OT group. Overall, 20 patients (56%) presented with abdominal angina, 9 (25%) with rest pain, and 7 (19%) without symptoms. An ET was initially attempted in 31 patients (86.1%). The conversion rate from ET to OT was 32.3%, which resulted in a primary technical success of 67.6% in ET and 100% in OT. Six patients from the ET group (19.3%) required surgical revision due to restenosis. One-year (OT 91.6% vs. ET 96.8%; n.s.) and three-year primary patency (OT 91.6% vs. ET 80.6%; n.s.) as well as 3-year symptom-free survival did not differ between the groups (OT 62.5% vs. ET 69.4%; n.s). Overall, in-hospital mortality was 2.8% (n = 1), which was not statistically different between the groups (OT 6% vs. ET 0%; n.s.). High-grade stenosis of the superior mesenteric artery tended to be associated with higher technical failure (P = 0.06). Conclusions ET showed a comparable perioperative outcome with higher technical failure. OT was distinguished by excellent early and late technical success.
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Abstract
Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.
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Affiliation(s)
- Monjur Ahmed
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA 19107, United States
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Jo S, Orosz E, Patel AV. An Unusual Cause of Duodenitis. Gastroenterology 2021; 160:e11-e14. [PMID: 32828815 DOI: 10.1053/j.gastro.2020.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/02/2022]
Affiliation(s)
| | - Evan Orosz
- Division of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anish Vinit Patel
- Division of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
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Goodall R, Langridge B, Onida S, Ellis M, Lane T, Davies AH. Median arcuate ligament syndrome. J Vasc Surg 2020; 71:2170-2176. [DOI: 10.1016/j.jvs.2019.11.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/03/2019] [Indexed: 12/11/2022]
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Terlouw LG, Moelker A, Abrahamsen J, Acosta S, Bakker OJ, Baumgartner I, Boyer L, Corcos O, van Dijk LJD, Duran M, Geelkerken RH, Illuminati G, Jackson RW, Kärkkäinen JM, Kolkman JJ, Lönn L, Mazzei MA, Nuzzo A, Pecoraro F, Raupach J, Verhagen HJM, Zech CJ, van Noord D, Bruno MJ. European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J 2020; 8:371-395. [PMID: 32297566 PMCID: PMC7226699 DOI: 10.1177/2050640620916681] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/08/2020] [Indexed: 12/24/2022] Open
Abstract
Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.
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Affiliation(s)
- Luke G Terlouw
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
- Department of Radiology, Erasmus MC University Medical Center,
Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center,
Rotterdam, the Netherlands
| | - Jan Abrahamsen
- Department of Clinical Physiology, Viborg Regional Hospital,
Viborg, Denmark
| | - Stefan Acosta
- Department of Clinical Sciences Malmö, Lund University, Lund,
Sweden
- Department of Cardio‐Thoracic and Vascular Surgery, Skane
University Hospital, Malmö, Sweden
| | - Olaf J Bakker
- Department of Vascular Surgery, Sint Antonius hospital,
Nieuwegein, the Netherlands
- Department of Vascular Surgery, University Hospital Leipzig,
Leipzig, Germany
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital,
Bern University Hospital, University of Bern, Bern, Switzerland
| | - Louis Boyer
- Department of Diagnostic and Interventional Radiology, Montpied
University Hospital, Clermont‐Ferrand, France
| | - Olivier Corcos
- Department of Gastroenterology, Intestinal Stroke Center,
Hopital Beaujon APHP, Clichy, France
| | - Louisa JD van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
| | - Mansur Duran
- Department of Vascular and Endovascular Surgery, Marienhospital
Gelsenkirchen, Gelsenkirchen, Germany
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente,
Enschede, the Netherlands
- Multi-modality Medical Imaging (M3I) group, Faculty of Science
and Technology, Technical Medical Centre, University of Twente, Enschede, the
Netherlands
| | - Giulio Illuminati
- Department of Surgical Sciences, University of Rome La
Sapienza, Rome, Italy
| | - Ralph W Jackson
- Department of Interventional Radiology, Newcastle upon Tyne
Hospitals NHS Foundation Trust, UK
| | - Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, Kuopio, Finland
- Department of Vascular Surgery, Mayo Clinic, Rochester, MN,
USA
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum
Twente, Enschede, the Netherlands
- Department of Gastroenterology and Hepatology, University
Medical Center Groningen, Groningen, the Netherlands
| | - Lars Lönn
- Department of Radiology, University of Copenhagen, Copenhagen,
Denmark
| | - Maria A Mazzei
- Department of Medical, Surgical and Neuro Sciences, Diagnostic
Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena,
Italy
| | - Alexandre Nuzzo
- Department of Gastroenterology, Hopital Beaujon APHP, Clichy,
France
| | - Felice Pecoraro
- Department of Surgical Oncological and Oral Sciences,
University of Palermo, Vascular Surgery Unit, AOUP ‘P. Giaccone’ Palermo,
Palermo, Italy
| | - Jan Raupach
- Department of Radiology, University Hospital Hradec Kralove,
Hradec Kralove, Czech Republic
| | - Hence JM Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical
Center, Rotterdam, the Netherlands
| | - Christoph J Zech
- Radiology and Nuclear Medicine, University of Basel, Basel,
Switzerland
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Franciscus
Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
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Akasheva DU, Zhigareva EI, Kuznetsova IV, Rudenko BA, Drapkina OM. Chronic mesenteric ischemia: a case report and review of the literature. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2020. [DOI: 10.15829/1728-8800-2020-1-2379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- D. U. Akasheva
- National Medical Research Center for Preventive Medicine
| | | | | | - B. A. Rudenko
- National Medical Research Center for Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Preventive Medicine
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Beita AKV, Whayne TF. The Superior Mesenteric Artery: From Syndrome in the Young to Vascular Atherosclerosis in the Old. Cardiovasc Hematol Agents Med Chem 2019; 17:74-81. [PMID: 31538906 DOI: 10.2174/1871525717666190920100518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 11/22/2022]
Abstract
This review is directed at increasing awareness of two diverse rare upper gastrointestinal problems that occur at opposite ends of the age spectrum and are difficult to diagnose and treat. The Superior Mesenteric Artery Syndrome (SMAS) likely involves a young patient, especially female, and is especially associated with rapid weight loss, resulting in relative strangulation of the duodenum by a narrowing of the angle between the Superior Mesenteric Artery (SMA) and the aorta. On the other hand, atherosclerosis of the SMA is associated most likely with postprandial upper intestinal ischemia and abdominal pain occurs in the elderly at high risk for cardiovascular (CV) disease. Medical management of the SMAS in the young involves good alimentation and weight gain to overall increase the intestinal fat pad. Medical management of SMA atherosclerotic ischemia in the elderly is directed at marked lipid lowering with atherosclerotic plaque stabilization or even regression. If needed, surgery for SMAS can be attempted laparoscopically with duodenojejunoscopy which is the most popular procedure but there are also more conservative possibilities that avoid division of the duodenum. In addition, sometimes direct vision is needed to successfully operate on SMAS. If surgery is needed for SMA atherosclerotic ischemia, it is usually attempted endoscopically with angioplasty and stent placement. Most important, in the case of these two rare clinical entities, is that the clinician have a suspicion of their presence when indicated so that the young or old patient can be spared unnecessary suffering and return to good health in a timely fashion.
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Affiliation(s)
| | - Thomas F Whayne
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, United States
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van Dijk LJD, Harki J, van Noord D, Verhagen HJM, Kolkman JJ, Geelkerken RH, Bruno MJ, Moelker A. Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI): study protocol for a randomized controlled trial. Trials 2019; 20:519. [PMID: 31429792 PMCID: PMC6700968 DOI: 10.1186/s13063-019-3609-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 07/23/2019] [Indexed: 12/21/2022] Open
Abstract
Background Chronic mesenteric ischemia (CMI) is the result of insufficient blood supply to the gastrointestinal tract and is caused by atherosclerotic stenosis of one or more mesenteric arteries in > 90% of cases. Revascularization therapy is indicated in patients with a diagnosis of atherosclerotic CMI to relieve symptoms and to prevent acute-on-chronic mesenteric ischemia, which is associated with high morbidity and mortality. Endovascular therapy has rapidly evolved and has replaced surgery as the first choice of treatment in CMI. Bare-metal stents (BMS) are standard care currently, although retrospective studies suggested significantly higher patency rates for covered stents (CS). The Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI) trial is designed to prospectively assess the patency of CS versus BMS in patients with atherosclerotic CMI. Methods/design The CoBaGI trial is a randomized controlled, parallel-group, patient- and investigator-blinded, superiority, multicenter trial conducted in six centers of the Dutch Mesenteric Ischemia Study group (DMIS). Eighty-four patients with a consensus diagnosis of atherosclerotic CMI are 1:1 randomized to either a balloon-expandable BMS (Palmaz Blue with rapid-exchange delivery system, Cordis Corporation, Bridgewater, NJ, USA) or a balloon-expandable CS (Advanta V12 over-the-wire, Atrium Maquet Getinge Group, Hudson, NH, USA). The primary endpoint is the primary stent-patency rate at 24 months assessed with CT angiography. Secondary endpoints are primary stent patency at 6 and 12 months and secondary patency rates, freedom from restenosis, freedom from symptom recurrence, freedom from re-intervention, quality of life according the EQ-5D-5 L and SF-36 and cost-effectiveness at 6, 12 and 24 months. Discussion The CoBaGI trial is designed to assess the patency rates of CS versus BMS in patients treated for CMI caused by atherosclerotic mesenteric stenosis. Furthermore, the CoBaGI trial should provide insights in the quality of life of these patients before and after stenting and its cost-effectiveness. The CoBaGI trial is the first randomized controlled trial performed in CMI caused by atherosclerotic mesenteric artery stenosis. Trial registration ClinicalTrials.gov, ID: NCT02428582. Registered on 29 April 2015. Electronic supplementary material The online version of this article (10.1186/s13063-019-3609-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louisa J D van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Radiology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Jihan Harki
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands.,TechMed Centre, Faculty Science and Technology, University Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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van Dijk LJ, van Noord D, Geelkerken RH, Harki J, Berendsen SA, de Vries AC, Moelker A, Vergouwe Y, Verhagen HJ, Kolkman JJ, Bruno MJ. Validation of a score chart to predict the risk of chronic mesenteric ischemia and development of an updated score chart. United European Gastroenterol J 2019; 7:1261-1270. [PMID: 31700639 PMCID: PMC6826523 DOI: 10.1177/2050640619856765] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 05/16/2019] [Indexed: 12/23/2022] Open
Abstract
Background and objective The objective of this article is to externally validate and update a recently published score chart for chronic mesenteric ischemia (CMI). Methods A multicenter prospective cohort analysis was conducted of 666 CMI-suspected patients referred to two Dutch specialized CMI centers. Multidisciplinary consultation resulted in expert-based consensus diagnosis after which CMI consensus patients were treated. A definitive diagnosis of CMI was established if successful treatment resulted in durable symptom relief. The absolute CMI risk was calculated and discriminative ability of the original chart was assessed by the c-statistic in the validation cohort. Thereafter the original score chart was updated based on the performance in the combined original and validation cohort with inclusion of celiac artery (CA) stenosis cause. Results In 8% of low-risk patients, 39% of intermediate-risk patients and 94% of high-risk patients of the validation cohort, CMI was diagnosed. Discriminative ability of the original model was acceptable (c-statistic 0.79). The total score of the updated chart ranged from 0 to 28 points (low risk 19% absolute CMI risk, intermediate risk 45%, and high risk 92%). The discriminative ability of the updated chart was slightly better (c-statistic 0.80). Conclusion The CMI prediction model performs and discriminates well in the validation cohort. The updated score chart has excellent discriminative ability and is useful in clinical decision making.
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Affiliation(s)
- Louisa Jd van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Surgery, Medisch Spectrum Twente and Multimodality Medical Imaging group, TechMed Centre, Faculty Science and Technology, University Twente, Enschede, the Netherlands
| | - Jihan Harki
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sophie A Berendsen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Yvonne Vergouwe
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Evaluation of endoscopic visible light spectroscopy: comparison with microvascular oxygen tension measurements in a porcine model. J Transl Med 2019; 17:65. [PMID: 30819196 PMCID: PMC6396526 DOI: 10.1186/s12967-019-1802-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/17/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Visible light spectroscopy (VLS) is a technique used to measure the mucosal oxygen saturation during upper gastrointestinal endoscopy to evaluate mucosal ischemia, however in vivo validation is lacking. We aimed to compare VLS measurements with a validated quantitative microvascular oxygen tension (μPO2) measurement technique. METHODS Simultaneous VLS measurements and μPO2 measurements were performed on the small intestine of five pigs. First, simultaneous measurements were performed at different FiO2 values (18%-100%). Thereafter, the influence of bile was assessed by comparing VLS measurements in the presence of bile and without bile. Finally, simultaneous VLS and μPO2 measurements were performed from the moment a lethal dose potassium chloride intravenously was injected. RESULTS In contrast to μPO2 values that increased with increasing FiO2, VLS values decreased. Both measurements correlated poorly with R2 = 0.39, intercept 18.5, slope 0.41 and a bias of - 16%. Furthermore, the presence of bile influenced VLS values significantly (median (IQR)) before bile application 57.5% (54.8-59.0%) versus median with bile mixture of the stomach 73.5% (66.8-85.8), p = < 2.2 * 10-16; median with bile mixture of small bowel 47.6% (41.8-50.8) versus median after bile removal 57.0% (54.7-58.6%), p = < 2.2 * 10-16). Finally, the VLS mucosal oxygen saturation values did not decrease towards a value of 0 in the first 25 min of asystole in contrast to the μPO2 values. CONCLUSIONS These results suggest that VLS measures the mixed venous oxygen saturation rather than mucosal capillary hemoglobin oxygen saturation. Further research is needed to establish if the mixed venous compartment is optimal to assess gastrointestinal ischemia.
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van Dijk LJD, Harki J, van Noord D, de Vries AC, Moelker A, Verhagen HJM, Kuipers EJ, Bruno MJ. Detection of mesenteric ischemia by means of endoscopic visible light spectroscopy after luminal feeding. Gastrointest Endosc 2019; 89:94-102. [PMID: 30055157 DOI: 10.1016/j.gie.2018.07.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic visible light spectroscopy (VLS) enables measurement of mucosal oxygen saturation during upper GI endoscopy and is used in the diagnostic work-up of chronic mesenteric ischemia (CMI). Currently, VLS is performed when the patient has fasted. We aimed to determine whether food challenge improves the diagnostic performance of VLS measurements for the diagnosis of CMI. METHODS This was a single-center prospective study of healthy controls and consecutive patients suspected of having CMI and referred to a Dutch specialized CMI center for standardized diagnostic CMI work-up. Immediately after conventional fasting, VLS measurements were taken, luminal feeding was administered, and VLS measurements were repeated 45 minutes later. Patients were classified as CMI if a multidisciplinary expert-based consensus diagnosis of CMI was established and successful revascularization therapy resulted in symptom relief. Patients were classified as no-CMI when consensus diagnosis was not reached or when symptom relief did not occur after technically successful treatment. RESULTS We included 60 patients with suspected CMI and 16 healthy controls. Duodenal oxygen saturation was significantly higher postprandially compared with the fasting state: healthy controls: median (interquartile range) pre 54% (49%-56%), post 56% (53%-58%), P = .02), no-CMI patients (pre 55% (51%-57%), post 57% (53%-59%), P > .01); CMI patients: pre 51% (48%-53%), post 54% (50%-58%), P = .01. Mucosal oxygen saturation did not significantly increase postprandially in the duodenal bulb or antrum of the stomach. Absolute postprandial oxygen measurements and the absolute or relative difference between preprandial versus postprandial oxygen measurements did not provide additional discriminative ability for the diagnosis of CMI. CONCLUSIONS Postprandial VLS measurements have no added benefit for the diagnosis of CMI.
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Affiliation(s)
- Louisa J D van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jihan Harki
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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14
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van Dijk LJ, van Noord D, de Vries AC, Kolkman JJ, Geelkerken RH, Verhagen HJ, Moelker A, Bruno MJ. Clinical management of chronic mesenteric ischemia. United European Gastroenterol J 2018; 7:179-188. [PMID: 31080602 PMCID: PMC6498801 DOI: 10.1177/2050640618817698] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/15/2018] [Indexed: 12/26/2022] Open
Abstract
This
This Dutch Mesenteric Ischemia Study group consists of: Ron Balm, Academic Medical Center, Amsterdam Gert Jan de Borst, University Medical Center Utrecht, Utrecht Juliette T Blauw, Medisch Spectrum Twente, Enschede Marco J Bruno, Erasmus MC University Medical Center, Rotterdam Olaf J Bakker, St Antonius Hospital, Nieuwegein Louisa JD van Dijk, Erasmus MC University Medical Center, Rotterdam Hessel CJL Buscher, Gelre Hospitals, Apeldoorn Bram Fioole, Maasstad Hospital, Rotterdam Robert H Geelkerken, Medisch Spectrum Twente, Enschede Jaap F Hamming, Leiden University Medical Center, Leiden Jihan Harki, Erasmus MC University Medical Center, Rotterdam Daniel AF van den Heuvel, St Antonius Hospital, Nieuwegein Eline S van Hattum, University Medical Center Utrecht, Utrecht Jan Willem Hinnen, Jeroen Bosch Hospital, ‘s-Hertogenbosch Jeroen J Kolkman, Medisch Spectrum Twente, Enschede Maarten J van der Laan, University Medical Center Groningen, Groningen Kaatje Lenaerts, Maastricht University Medical Center, Maastricht Adriaan Moelker, Erasmus MC University Medical Center, Rotterdam Desirée van Noord, Franciscus Gasthuis & Vlietland, Rotterdam Maikel P Peppelenbosch, Erasmus MC University Medical Center, Rotterdam André S van Petersen, Bernhoven Hospital, Uden Pepijn Rijnja, Medisch Spectrum Twente, Enschede Peter J van der Schaar, St Antonius Hospital, Nieuwegein Luke G Terlouw, Erasmus MC University Medical Center, Rotterdam Hence JM Verhagen, Erasmus MC University Medical Center, Rotterdam Jean Paul PM de Vries, University Medical Center Groningen, Groningen Dammis Vroegindeweij, Maasstad Hospital, Rotterdam review provides an overview on the clinical management of chronic mesenteric ischemia (CMI). CMI is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. However, patients may present with, atypically, symptoms such as abdominal discomfort, nausea, vomiting, diarrhea or constipation. Early consideration and diagnosis of CMI is important to timely treat, to improve quality of life and to prevent acute-on-chronic mesenteric ischemia. The diagnosis of CMI is based on the triad of clinical symptoms, radiological evaluation of the mesenteric vasculature and if available, functional assessment of mucosal ischemia. Multidisciplinary consensus on the diagnosis of CMI is of paramount importance to adequately select patients for treatment. Patients with a consensus diagnosis of single-vessel or multi-vessel atherosclerotic CMI are preferably treated with endovascular revascularization.
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Affiliation(s)
- Louisa Jd van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands.,Technical Medical Center, Faculty Science and Technology, University Twente, Enschede, the Netherlands
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Harki J, Suker M, Tovar-Doncel MS, van Dijk LJ, van Noord D, van Eijck CH, Bruno MJ, Kuipers EJ, Ince C. Patients with chronic mesenteric ischemia have an altered sublingual microcirculation. Clin Exp Gastroenterol 2018; 11:405-414. [PMID: 30425547 PMCID: PMC6200368 DOI: 10.2147/ceg.s159160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Little is known about the microcirculatory alterations in patients with chronic mesenteric ischemia (CMI). We hypothesized that patients with CMI have an impaired microcirculatory function and show an oral microcirculatory response after caloric challenge compared to healthy controls. Methods All patients and controls received the standard workup for CMI. Sublingual micro-circulation was evaluated before (T0) and 20 minutes after (T1) feeding. The total vessel density (TVD; mm/mm2), perfused vessel density (PVD; mm/mm2), proportion of perfused vessels (PPV; %) and microvascular flow index (MFI; AU) were assessed. Results We included 12 patients (63.2 years [IQR 48.8–70.4 years], 67% males) and 12 controls (32.7 years [IQR 27.7–38.1 years], 42% males). At baseline, patients with CMI had a decreased PPV of the sublingual small vessels (median 84.8% vs 95.7%, P=0.006), PPV of all vessels (PPV median 85.4% vs 95.3%, P=0.007) and microvascular flow index of all vessels (MFIa; median 3.00 vs 2.80, P=0.039) compared to healthy controls. After caloric challenge, PVD increased significantly in both small vessels (perfused vessel density of the small vessels [PVDs]) and all vessels (perfused vessel density of all vessels [PVDa]; PVDs [T0]) median 16.3 [IQR 13.3–22.1] vs [T1] median 19.9 [IQR 14.2–26.2], P=0.008; PVDa [T0] median 19.1 [IQR 16.2–23.6] vs [T1] median 22.2 [IQR 16.5–28.9], P=0.02; proportion of perfused vessels of the small vessels (PPVs; [T0] median 84.8% [IQR 75.3–90.4] vs [T1] median 91.0% [IQR 80.1–93.8], P=0.010). In contrast, no significant changes in microcirculatory parameters were observed after caloric challenge in healthy controls. Conclusion Patients with CMI have an impaired sublingual microcirculation at baseline and show a significant response in the sublingual microcirculation after caloric challenge, whereas healthy controls have a normal microcirculation at baseline and show no reactive response upon a caloric challenge as seen in CMI patients. Sublingual microcirculation visualization may offer a rapid noninvasive method to identify patients at risk for having CMI.
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Affiliation(s)
- Jihan Harki
- Department of Gastroenterology and Hepatology,
| | - Mustafa Suker
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | | | - Casper Hj van Eijck
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, .,Department of Internal Medicine
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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van Dijk LJ, Moons LM, van Noord D, Moelker A, Verhagen HJ, Bruno MJ, Rouwet EV. Persistent symptom relief after revascularization in patients with single-artery chronic mesenteric ischemia. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2017.12.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Björck M, Koelemay M, Acosta S, Bastos Goncalves F, Kölbel T, Kolkman JJ, Lees T, Lefevre JH, Menyhei G, Oderich G, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Sanddal Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Geelkerken B, Gloviczki P, Huber T, Naylor R. Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 53:460-510. [PMID: 28359440 DOI: 10.1016/j.ejvs.2017.01.010] [Citation(s) in RCA: 351] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Diagnostic Accuracy of the Combination of Clinical Symptoms and CT or MR Angiography in Patients With Chronic Gastrointestinal Ischemia. J Clin Gastroenterol 2017; 51:e39-e47. [PMID: 27466167 DOI: 10.1097/mcg.0000000000000605] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND No golden diagnostic standard is available to diagnose chronic gastrointestinal ischemia (CGI). GOALS We aimed to establish an accurate prediction model for CGI, based on clinical symptoms and radiologic evaluation of the amount of stenosis in the celiac artery (CA) and superior mesenteric artery (SMA) by means of computed tomography-angiography or magnetic resonance (MR)-angiography. STUDY We prospectively included 436 consecutive patients with clinical suspicion of CGI in a tertiary referral center. Predictors for CGI were obtained by comparing clinical parameters to the diagnosis of CGI. Multivariable logistic regression was used to combine the strongest predictors in a model. A score chart based on the prediction model was provided to calculate the risk of CGI. RESULTS CGI was present in 171/436 (39%) patients (67 y; range, 54 to 74 y; 27% male). Strongest predictors for CGI were female gender [odds ratio (OR)=1.44; 95% confidence interval (CI), 0.85-2.43], weight loss (OR=1.63, 95% CI, 0.98-2.72), concomitant cardiovascular disease (OR=1.70, 95% CI, 1.04-2.78), duration of symptoms (OR=0.88, 95% CI, 0.79-0.99), and stenosis of CA and SMA (50% to 70% stenosis CA: OR=1.33, 95% CI, 0.56-3.19; >70% stenosis CA: OR=5.79, 95% CI, 3.42-9.81; 50% to 70% stenosis SMA: OR=3.21, 95% CI, 0.81-12.74; >70% stenosis SMA: OR=4.39, 95% CI, 2.30-8.41). A model based on clinical symptoms alone showed limited discriminative ability for diagnosing CGI (c-statistic 0.62). Adding radiologic imaging of the mesenteric arteries improved the discriminative ability (c-statistic 0.79). CONCLUSIONS Clinical symptoms alone are insufficient to predict the risk of CGI. Radiologic evaluation of the mesenteric arteries is essential. This tool may be useful for clinicians to assess the risk of CGI and to decide whether further diagnostic work-up for CGI is needed.
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van Noord D, Kolkman JJ. Functional testing in the diagnosis of chronic mesenteric ischemia. Best Pract Res Clin Gastroenterol 2017; 31:59-68. [PMID: 28395789 DOI: 10.1016/j.bpg.2016.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/03/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Chronic mesenteric ischemia (CMI) results from insufficient oxygen delivery or utilization to meet metabolic demand. Two main mechanisms may lead to mesenteric ischemia: occlusion in the arteries or veins of the gastrointestinal tract, or reduced blood flow from shock states or increased intra-abdominal pressure, so-called non-occlusive mesenteric ischemia. Severe stenoses in the three main mesenteric vessels as demonstrated with CT-angiography or MR-angiography are sufficient to proof mesenteric ischemia, for example in patients who present with weight loss, postprandial pain and diarrhea. Still in many clinical situations mesenteric ischemia is only one of many possible explanations. Especially in patients with a single vessel stenosis in the celiac artery or superior mesenteric artery with postprandial pain, mesenteric ischemia remains a diagnosis of probability or assumption without functional proof of actual ischemia. This review is aimed to provide an overview of all past, present and future ways to functionally proof CMI.
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Affiliation(s)
- Desirée van Noord
- Erasmus MC University Medical Center Rotterdam, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands; Franciscus Gasthuis & Vlietland, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands.
| | - Jeroen J Kolkman
- Medisch Spectrum Twente, Department of Gastroenterology and Hepatology, Enschede, The Netherlands; Universitair Medisch Centrum Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands.
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Harki J, Plompen EPC, van Noord D, Hoekstra J, Kuipers EJ, Janssen HLA, Tjwa ETTL. GI ischemia in patients with portal vein thrombosis: a prospective cohort study. Gastrointest Endosc 2016; 83:627-36. [PMID: 26324386 DOI: 10.1016/j.gie.2015.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 07/05/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS GI ischemia is a concerning adverse event of portal vein thrombosis (PVT). Minimally invasive techniques, such as visible light spectroscopy (VLS), have greatly improved the ability to diagnose GI ischemia. The aim of this study was to assess the clinical presentation and characteristics of GI ischemia in patients with PVT. METHODS Patients with noncirrhotic, nonmalignant PVT were included in this prospective cohort study. Clinical symptoms of GI ischemia were assessed by a structured questionnaire, VLS, and radiologic evaluation of the mesenteric vasculature. VLS measurements were compared with those in patients with cirrhosis and with a reference population. RESULTS We included 15 patients with chronic PVT and 1 patient with acute PVT (median age 46.1 years [interquartile range [IQR], 30.9-53.7]; 44% male). Decreased mucosal oxygenation in at least 1 location of the GI tract was found in 12 patients (75%). Compared with the reference population (median 60.0 [IQR, 56.2-61.7]), VLS measurements were mostly decreased in the descending duodenum in patients with PVT (median 55.5 [IQR, 52.3-58.8]; P = .02) and patients with cirrhosis (median 52.0 [IQR, 46.5-54.0], P = .003). Symptoms typical for GI ischemia, such as postprandial pain and exercise-induced pain, were reported in 10 patients (63%) with PVT. In patients with extension of thrombosis into the superior mesenteric vein and splenic vein and/or presence of hypercoagulability, decreased VLS measurements were observed compared with historical control subjects. CONCLUSIONS In patients with chronic PVT, GI ischemia is frequent. VLS enables objective and quantitative determination of GI mucosal ischemia. Onset of abdominal symptoms such as postprandial pain should prompt the physician to re-evaluate extent, cause, and treatment of PVT.
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Affiliation(s)
- Jihan Harki
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Elisabeth P C Plompen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Désirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jildou Hoekstra
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Sana A, Moons LMG, Hansen BE, Dewint P, van Noord D, Mensink PBF, Kuipers EJ. Use of visible light spectroscopy to diagnose chronic gastrointestinal ischemia and predict response to treatment. Clin Gastroenterol Hepatol 2015; 13:122-30.e1. [PMID: 25019697 DOI: 10.1016/j.cgh.2014.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 06/22/2014] [Accepted: 07/03/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic gastrointestinal ischemia (CGI) is more common than previously thought. Visible light spectroscopy (VLS) allows for noninvasive measurements of mucosal capillary hemoglobin oxygen saturation during endoscopy. We evaluated the response of patients with occlusive CGI to treatment after evaluation by radiologic imaging of the vasculature and VLS. We also identified factors associated with response to treatment in these patients. METHODS In a prospective study, we collected data from 212 patients referred for evaluation of suspected CGI from November 2008 through January 2011. Patients underwent an extensive evaluation that included visualization of gastrointestinal arteries and assessments of mucosal perfusion by means of VLS. Treatment response was evaluated in patients with occlusive CGI. Factors associated with response to therapy were assessed by using multivariate logistic regression analysis. RESULTS Occlusive CGI was diagnosed in 107 patients (50%); 96 were offered treatment (90%). After median follow-up period of 13 months, data on treatment response were available from 89 patients (93%); 62 patients had a sustained response (70%). Weight loss before treatment (odds ratio [OR], 1.93), presence of an abdominal bruit (OR, 2.36), and corpus mucosal saturation level <56% (OR, 4.84) were the strongest predictors of a positive response to treatment. CONCLUSIONS Treatment of CGI, diagnosed by a multimodal approach, provides a substantial long-term rate of response (70% in 13 months). Weight loss, abdominal bruit, and low corpus mucosal saturation identify patients most likely to respond to treatment. Multiple techniques should therefore be used to assess patients with CGI, including VLS measurements, to detect mucosal hypoxia.
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Affiliation(s)
- Aria Sana
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Center for Medical Decision Sciences, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pieter Dewint
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Désirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter B F Mensink
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Combining radiological imaging and gastrointestinal tonometry: a minimal invasive and useful approach for the workup of chronic gastrointestinal ischemia. Eur J Gastroenterol Hepatol 2013; 25:719-25. [PMID: 23395993 DOI: 10.1097/meg.0b013e32835ddc45] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The established approach for patients suspected of chronic gastrointestinal ischemia (CGI) includes assessment of medical history, vascular imaging, such as by digital subtraction angiography, and, more recently, computed tomography angiography (CTA) or magnetic resonance angiography. Mucosal perfusion assessment techniques have recently been shown to be of additional diagnostic value, including visible light spectroscopy and gastric exercise tonometry. Gastric exercise tonometry, however, is cumbersome and impossible to perform in a considerable proportion of patients. An alternative approach is provided by 24 h gastrointestinal tonometry (TM). We challenged the use of TM in combination with CTA as an alternative approach to evaluate patients suspected of CGI. METHODS Patients referred for suspected CGI were prospectively evaluated using CTA and TM, and discussed in a multidisciplinary team, where a consensus diagnosis was made. CGI patients were offered therapy. Persistent symptom relief after adequate therapy during follow-up was used as the 'gold standard' and was defined as a definitive diagnosis of CGI. RESULTS In 31 months, 186 patients were included (men 69, mean age 63 years). A consensus diagnosis of CGI was made in 128 (69%) patients: 94 with occlusive and 34 with nonocclusive CGI. After a median follow-up of 21 months after a therapeutical intervention, 91% of the CGI patients were free from symptoms. CONCLUSION In patients clinically suspected of CGI, the combination of CTA and TM provides a minimally invasive, reliable diagnostic approach, which seems to be very useful in clinical practice and to have an outcome similar to the established diagnostic workup.
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Sana A, van Noord D, Mensink PB, Kooij S, van Dijk K, Bravenboer B, Lieverse AG, Sijbrands EJ, Langendonk JG, Kuipers EJ. Patients with chronic gastrointestinal ischemia have a higher cardiovascular disease risk and mortality. Atherosclerosis 2012; 224:235-41. [DOI: 10.1016/j.atherosclerosis.2012.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 06/28/2012] [Accepted: 07/06/2012] [Indexed: 10/28/2022]
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ter Steege RWF, Sloterdijk HS, Geelkerken RH, Huisman AB, van der Palen J, Kolkman JJ. Splanchnic artery stenosis and abdominal complaints: clinical history is of limited value in detection of gastrointestinal ischemia. World J Surg 2012; 36:793-9. [PMID: 22354487 PMCID: PMC3299959 DOI: 10.1007/s00268-012-1485-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Splanchnic artery stenosis is common and mostly asymptomatic and may lead to gastrointestinal ischemia (chronic splanchnic syndrome, CSS). This study was designed to assess risk factors for CSS in the medical history of patients with splanchnic artery stenosis and whether these risk factors can be used to identify patients with high and low risk of CSS. Methods All patients referred for suspected CSS underwent a standardized workup, including a medical history with questionnaire, duplex ultrasound, gastrointestinal tonometry, and angiography. Definitive diagnosis and treatment advice was made in a multidisciplinary team. Patients with confirmed CSS were compared with no-CSS patients. Results A total of 270 patients (102 M, 168 F; mean age, 53 years) with splanchnic artery stenosis were analyzed, of whom 109 (40%) had CSS and 161 no CSS. CSS-patients more often reported postprandial pain (87% vs. 72%, p = 0.007), weight loss (85% vs. 70%, p = 0.006), adapted eating pattern (90% vs. 79%, p = 0.005) and diarrhea (35% vs. 22%, p = 0.023). If none of these risk factors were present, the probability of CSS was 13%; if all were present, the probability was 60%. Adapted eating pattern (odds ratio (OR) 3.1; 95% confidence interval (CI) 1.08–8.88) and diarrhea (OR 2.6; 95% CI 1.31–5.3) were statistically significant in multivariate analysis. Conclusions In patients with splanchnic artery stenosis, the clinical history is of limited value for detection of CSS. A diagnostic test to detect ischemia is indispensable for proper selection of patients with splanchnic artery stenosis who might benefit from treatment.
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Affiliation(s)
- R W F ter Steege
- Department of Gastroenterology, University Medical Centre Groningen, Hanzeplein 1, Postbox 30001, 9700 RB, Groningen, The Netherlands.
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