Diagnosis and management of splanchnic ischemia.

Department of Gastroenterology, Medisch Spectrum Twente, 7500 KA Enschede, The Netherlands.
World Journal of Gastroenterology (Impact Factor: 2.37). 01/2009; 14(48):7309-20.
Source: PubMed


Splanchnic or gastrointestinal ischemia is rare and randomized studies are absent. This review focuses on new developments in clinical presentation, diagnostic approaches, and treatments. Splanchnic ischemia can be caused by occlusions of arteries or veins and by physiological vasoconstriction during low-flow states. The prevalence of significant splanchnic arterial stenoses is high, but it remains mostly asymptomatic due to abundant collateral circulation. This is known as chronic splanchnic disease (CSD). Chronic splanchnic syndrome (CSS) occurs when ischemic symptoms develop. Ischemic symptoms are characterized by postprandial pain, fear of eating and weight loss. CSS is diagnosed by a test for actual ischemia. Recently, gastro-intestinal tonometry has been validated as a diagnostic test to detect splanchnic ischemia and to guide treatment. In single-vessel CSD, the complication rate is very low, but some patients have ischemic complaints, and can be treated successfully. In multi-vessel stenoses, the complication rate is considerable, while most have CSS and treatment should be strongly considered. CT and MR-based angiographic reconstruction techniques have emerged as alternatives for digital subtraction angiography for imaging of splanchnic vessels. Duplex ultrasound is still the first choice for screening purposes. The strengths and weaknesses of each modality will be discussed. CSS may be treated by minimally invasive endoscopic treatment of the celiac axis compression syndrome, endovascular antegrade stenting, or laparotomy-assisted retrograde endovascular recanalization and stenting. The treatment plan is highly individualized and is mainly based on precise vessel anatomy, body weight, co-morbidity and severity of ischemia.

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Available from: Jeroen J Kolkman, Oct 02, 2015
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    • "Both air tonometry and visible light spectroscopy are methods to detect mucosal ischemia in the gastrointestinal tract. The technical principles of both techniques have been extensively described elsewhere [2, 21]. Noord et al. showed that both tests have almost similar accuracy [21]. "
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    ABSTRACT: 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. 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. 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. 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.
    World Journal of Surgery 02/2012; 36(4):793-9. DOI:10.1007/s00268-012-1485-4 · 2.64 Impact Factor
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    • "The absence of specific signs upon physical examination can make the diagnosis of AMI very challenging and the clinical consequences of missed AMI can be catastrophic. A rapid diagnosis is the most important factor for prognosis, and urgent investigation of vessel patency should thus be done by abdominal CT or IADSA [2,3,5-7,9]. During the work-up, the patient should be closely monitored and stabilized [2]. "
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    ABSTRACT: Ischemic bowel disease comprises both mesenteric ischemia and colonic ischemia. Mesenteric ischemia can be divided into acute and chronic ischemia. These are two separate entities, each with their specific clinical presentation and diagnostic and therapeutic modalities. However, diagnosis may be difficult due to the vague symptomatology and subtle signs. We report the case of a 68-year-old Caucasian woman who presented with abdominal discomfort, anorexia, melena and fever. A physical examination revealed left lower quadrant tenderness and an irregular pulse. Computed tomography of her abdomen as well as computed tomography enterography, enteroscopy, angiography and small bowel enteroclysis demonstrated an ischemic jejunal segment caused by occlusion of a branch of the superior mesenteric artery. The ischemic segment was resected and an end-to-end anastomosis was performed. The diagnosis of segmental small bowel ischemia was confirmed by histopathological study. Mesenteric ischemia is a pathology well-known by surgeons, gastroenterologists and radiologists. Acute and chronic mesenteric ischemia are two separate entities with their own specific clinical presentation, radiological signs and therapeutic modalities. We present the case of a patient with symptoms and signs of chronic mesenteric ischemia despite an acute etiology. To the best of our knowledge, this is the first report presenting a case of acute mesenteric ischemia with segmental superior mesenteric artery occlusion.
    Journal of Medical Case Reports 02/2012; 6:48. DOI:10.1186/1752-1947-6-48
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    ABSTRACT: L’ischémie mésentérique est définie comme la conséquence anatomique et clinique d’une diminution importante et/ou prolongée du débit sanguin splanchnomésentérique. On distingue l’ischémie mésentérique aiguë de l’ischémie chronique, l’ischémie occlusive de l’ischémie non occlusive, l’ischémie artérielle de l’ischémie veineuse. Les causes des ischémies artérielles occlusives sont essentiellement les emboles à partir d’une cardiopathie ou d’une valvulopathie et les thromboses sur artères pathologiques. Les ischémies artérielles non occlusives sont en général la conséquence d’un bas débit cardiaque ou d’une hypovolémie prolongée, mais aussi de certains traitements (ergot, digitaliques) ou drogues (cocaïne). Mesenteric ischemia is defined by the anatomical and clinical consequences of a prolonged decrease of splanchnomesenteric perfusion. Mesenteric ischemia is classified not only by following its acute or chronic course, but also by an occlusive or non-occlusive mechanism, and by arterial or veinous vascular involvement. Etiologies of arterial ischemia are emboli from valvulopathy or cardiopathy and thrombosis from pathological arteries. Non occlusive arterial mesenteric ischemia occurs in low-flow states or in patients with vasoconstrictive medications or drugs (cocaine). Mots clésIschémie aiguë-Ischémie chronique-Ischémie occlusive-Ischémie non occlusive-Ischémie artérielle-Ischémie veineuse-Facteur pronostique KeywordsAcute ischemia-Chronic-Occlusive-Non occlusive-Arterial-Veinous-Prognosis factor
    Côlon & Rectum 02/2010; 4(1):4-13. DOI:10.1007/s11725-010-0206-4
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