Splanchnic Artery Stenosis and Abdominal Complaints: Clinical History Is of Limited Value in Detection of Gastrointestinal Ischemia

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

Prevalence of sensitization reported and objectively assessed food hypersensitivity amongst six-year-old children: a population-based study.

There is a paucity of information on food hypersensitivity (FHS) in young children and there are even fewer population-based studies in this area. The aim of the study was to determine the prevalence of parentally reported FHS, and objectively diagnosed FHS amongst six-year-old children and to establish the rates of sensitization to key allergens. This population-based cohort study recruited 798 6-year-olds resident on the Isle of Wight (UK). Sensitization rates, reported rates of FHS and objectively assessed FHS was established using food challenges. A total of 94 (11.8%) 6 yr olds reported a problem with a food or food ingredient. The rate of sensitization to the pre-defined panel of food allergens was 25/700 (3.6%). Based on open food challenge and/or suggestive history and skin tests, the prevalence of FHS was 2.5% (95% CI 1.5-3.8). Based on double-blind challenges, a clinical diagnosis or suggestive history and positive skin tests, the prevalence was 1.6% (95% CI 0.9-2.7). The rates of perception of FHS are higher than the prevalence of sensitization to main food allergens and the prevalence of FHS based on food challenges. Milk, peanut and wheat were the key food allergens amongst those with positive challenges

The influence of respiration on criteria for transabdominal duplex examination of the splanchnic arteries in patients with suspected chronic splanchnic ischemia

<p>Background: Duplex ultrasound imaging of the mesenteric vessels is often used as a first diagnostic tool to evaluate the mesenteric circulation in patients with unexplained chronic abdominal symptoms. Several studies on duplex criteria have been published; however, most studies are small and included not exclusively patients with symptoms suggestive of chronic mesenteric syndrome (CMS). This study evaluated the contribution of respiration-monitored duplex ultrasound imaging in the diagnosis of stenosis or occlusion of the mesenteric arteries in patients suspected of CMS and thereby improves the definition of the criteria for stenosis.</p><p>Methods: Between 1999 and 2007, 779 consecutive patients presented to our tertiary referral center for evaluation and treatment of CMS. Mesenteric artery duplex ultrasound imaging and angiography of the abdominal aorta and its branches were performed in 324 patients. Angiography was considered the gold standard for verifying the presence or absence of arterial pathology.</p><p>Results from duplex imaging and angiography were compared to determine the optimal duplex criteria for stenosis. In addition, the contribution of expiration and inspiration on duplex imaging and angiography were established. Results: Significantly higher peak systolic and end-diastolic velocities were found in the celiac artery (CA) and superior mesenteric artery (SMA) during expiration than during inspiration. Receiver operating characteristic curve analyses found respiration-dependent cutoff values for CA and SMA stenosis. The values corresponding with the highest accuracy (minimal false-negative and false-positive results) were determined. Peak systolic velocities cutoff points during expiration and inspiration were 280 and 272 cm/s, respectively, for the CA and 268 and 205 cm/s for the SMA. The end-diastolic velocity cutoff points during expiration and inspiration were 57 and 84 cm/s, respectively, for the CA and 101 and 52 cm/s for the SMA. Sensitivity for different duplex parameters in detecting mesenteric stenosis was 66% to 78% and specificity was 77% to 86%.</p><p>Conclusions: This study proposes new criteria related to respiration for duplex ultrasound imaging of the mesenteric arteries in patients with symptoms suggestive of CMS. It emphasizes the importance of taking into account the effect of respiration on duplex parameters. The lower sensitivity and specificity in our study compared with other studies puts into perspective the position of duplex imaging in the work-up of patients with suspected CMS. Duplex results should be used as a guide, with a low threshold giving a higher negative predictive value and, consequently, a lower positive predictive value.</p>

Endovascular therapy for chronic mesenteric ischemia

ObjectivesWe sought to describe the outcomes of a consecutive series of patients with chronic mesenteric ischemia (CMI) who were treated with percutaneous stent revascularization.BackgroundHistorically, the treatment for CMI has been surgical revascularization. However, surgery carries a significant procedural complication rate and mortality.MethodsFifty-nine consecutive patients with CMI underwent stent placement in 79 stenotic (>70%) mesenteric arteries. All patients had clinical follow-up and 90% had anatomical follow-up with angiography (computed tomography or conventional) or ultrasound at ≥6 months after the procedure.ResultsProcedural success was obtained in 96% (76 of 79 arteries) and symptom relief occurred in 88% (50 patients). At a mean follow-up of 38 ± 15 months (range, 6 to 112 months), 79% of the patients remained alive, and 17% (n = 10) experienced a recurrence of symptoms. Angiography or ultrasound obtained at 14± 5 months after the procedure demonstrated a restenosis rate of 29% (n = 20). All patients with recurrent symptoms had angiographic in-stent restenosis and were successfully revascularized percutaneously.ConclusionsPercutaneous stent placement for the treatment of CMI can be performed with a high procedural success and a low complication rate. The long-term freedom from symptoms and vascular patency are comparable with surgical results. The inherent lower procedural morbidity and mortality makes the endovascular approach the preferred revascularization technique for these patients