Diagnosis of Chronic Gastrointestinal Ischemia

Three aortic branches provide the arterial blood supply to the gastrointestinal tract: the celiac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). The CA supplies stomach, liver, part of the pancreas and proximal part of the duodenum. The SMA supplies the distal part of the duodenum, the entire small bowel and the proximal colon. The IMA is relatively small and supplies the distal colon. The anatomy of these arteries varies largely and gastrointestinal artery stenotic disease is not uncommon. Occlusive gastrointestinal arterial disease often remains asymptomatic, due to the presence of abundant collateral circulation. Only patients with significant arterial stenosis in combination with insufficient collateral circulation develop clinical signs of mesenteric ischemia. In these cases, the diagnosis is often missed due to lack of sensitive diagnostic tests. The diagnostic approach in patients with possible chronic gastrointestinal ischemia (CGI) focuses on identification of gastrointestinal arterial stenosis and demonstration of mucosal ischemia. This thesis deals with the diagnosis of chronic gastrointestinal ischemia, which often remains a clinical challenge. This in part explains why CGI was for long considered to be a very rare disease, only presenting in patients with multiple stenotic abdominal arterial disease. The existence of single vessel abdominal arterial disease has long been debated. We therefore firstly reviewed the existence and characteristics of single vessel abdominal arterial disease

Mesenteric artery calcium scoring: a potential screening method for chronic mesenteric ischemia

Objective: A practical screening tool for chronic mesenteric ischemia (CMI) could facilitate early recognition and reduce undertreatment and diagnostic delay. This study explored the ability to discriminate CMI from non-CMI patients with a mesenteric artery calcium score (MACS). Methods: This retrospective study included CTAs of consecutive patients with suspected CMI in a tertiary referral center between April 2016 and October 2019. A custom-built software module, using the Agatston definition, was developed and used to calculate the MACS for the celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery. Scoring was performed by two blinded observers. Interobserver agreement was determined using 39 CTAs scored independently by both observers. CMI was defined as sustained symptom improvement after treatment. Non-CMI patients were patients not diagnosed with CMI after a diagnostic workup and patients not responding to treatment. Results: The MACS was obtained in 184 patients, 49 CMI and 135 non-CMI. Interobserver agreement was excellent (intraclass correlation coefficient 0.910). The MACS of all mesenteric arteries was significantly higher in CMI patients than in non-CMI patients. ROC analysis of the combined MACS of CA + SMA showed an acceptable AUC (0.767), high sensitivity (87.8%), and high NPV (92.1%), when using a ≥ 29.7 CA + SMA MACS cutoff. Comparison of two CTAs, obtained in the same patient at different points in time with different scan and reconstruction parameters, was performed in 29 patients and revealed significant differences in MACSs. Conclusion: MACS seems a promising screening method for CMI, but correction for scan and reconstruction parameters is warranted. Key Points: • A mesenteric artery calcium score obtained in celiac artery and superior mesenteric artery ha

Patients with chronic gastrointestinal ischemia have a higher cardiovascular disease risk and mortality

Objectives: We determined the prevalence of classical risk factors for atherosclerosis and mortality risk in patients with CGI. Methods: A case-control study was conducted. Patients referred with suspected CGI underwent a standard work-up including risk factors for atherosclerosis, radiological imaging of abdominal vessels and tonometry. Cases were patients with confirmed atherosclerotic CGI. Controls were healthy subjects previously not known with CGI. The mortality risk was calculated as standardized mortality ratio derived from observed mortality, and was estimated with ten-year risk of death using SCORE and PREDICT. Results: Between 2006 and 2009, 195 patients were evaluated for suspected CGI. After a median follow-up of 19 months, atherosclerotic CGI was diagnosed in 68 patients. Controls consisted of 132 subjects. Female gender, diabetes, hypercholesterolemia, a personal and family history of cardiovascular disease (CVD), and current smoking are highly associated with CGI. After adjustment, female gender (OR 2.14 95% CI 1.05-4.36), diabetes (OR 5.59, 95% CI 1.95-16.01), current smoking (OR 5.78, 95% CI 2.27-14.72), and history of CVD (OR 21.61, 95% CI 8.40-55.55) remained significant. CGI patients >55 years had a higher median ten-year risk of death (15% vs. 5%, P = 0.001) compared to controls. During follow-up of 116 person-years, standardized mortality rate was higher in CGI patients (3.55; 95% CI 1.70-6.52). Conclusions: Patients with atherosclerotic CGI have an increased estimated CVD risk, and severe excess mortality. S

Oxygen-dependent delayed fluorescence of protoporphyrin IX measured in the stomach and duodenum during upper gastrointestinal endoscopy

Protoporphyrin IX-triplet state lifetime technique (PpIX-TSLT) is a method used to measure oxygen (PO2) in human cells. The aim of this study was to assess the technical feasibility and safety of measuring oxygen-dependent delayed fluorescence of 5-aminolevulinic acid (ALA)-induced PpIX during upper gastrointestinal (GI) endoscopy. Endoscopic delayed fluorescence measurements were performed 4 hours after oral administration of ALA in healthy volunteers. The ALA dose administered was 0, 1, 5 or 20 mg/kg. Measurements were performed at three mucosal spots in the gastric antrum, duodenal bulb and descending duodenum with the catheter above the mucosa and while applying pressure to induce local ischemia and monitor mitochondrial respiration. During two endoscopies, measurements were performed both before and after intravenous administration of butylscopolamine. Delayed fluorescence measurements were successfully performed during all 10 upper GI endoscopies. ALA dose of 5 mg/kg showed adequate signal-to-noise ratio (SNR) values >20 without side effects. All pressure measurements showed significant prolongation of delayed fluorescence lifetime compared to measurements performed without pressure (P <.001). Measurements before and after administration of butylscopolamine did not differ significantly in the duodenal bulb and descending duodenum. Measurements of oxygen-dependent delayed fluorescence of ALA-induced PpIX in the GI tract during upper GI endoscopy are technically feasible and safe

Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI): Study protocol for a randomized controlled trial

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 highe

Single vessel abdominal arterial disease

The long-standing discussion concerning the mere existence of single vessel abdominal artery disease can be closed: chronic gastrointestinal ischaemia (CGI) due to single vessel abdominal artery stenosis exists, can be treated Successfully and in a safe manner. The most common causes of single vessel CGI are the coeliac artery compression syndrome (CACS) in younger patients, and atherosclerotic disease in elderly patients. The clinical symptoms of single vessel CGI patients are postprandial and exercise-related pain, weight loss, and an abdominal bruit. The current diagnostic approach in patients suspected of single vessel CGI is gastrointestinal tonometry combined with radiological visualisation of the abdominal arteries to define possible arterial stenosis. Especially in single vessel abdominal artery stenosis, gastrointestinal tonometry plays a pivotal role in establishing the diagnosis CGI. First-choice treatment of single vessel CGI remains surgical revascularisation, especially in CACS. In elderly or selected patients endovascular stent placement therapy is an acceptable option. (C) 2008 Elsevier Ltd. All rights reserved

Functional Testing in the Diagnosis of Chronic Mesenteric Ischemia

Chronic mesenteric ischemia (CMI) is a diagnostic challenge. There is no single, simple test with high sensitivity and specificity to diagnose or exclude this condition. In the previous years, functional tests such as tonometry and visible light spectroscopy (VLS) have been developed and incorporated in the standard work-up to optimize the diagnosis of CMI in patients with chronic abdominal symptoms. Both methods seem to be accurate for detection of mesenteric ischemia in combination with radiological imaging; however VLS during endoscopy is considerably more patient-friendly and less time consuming than tonometry. The current established approach for diagnosing CMI includes assessment of medical history and clinical symptoms, radiological imaging of the mesenteric arteries, and detection of mucosal ischemia by means of a functional test