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Assessment and treatment of splanchnic ischemia

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PanVascular Medicine

Abstract

Gastrointestinal ischemia is a relatively rare disorder and is probably underappreciated in the daily practice. Although stenotic lesions of the splanchnic vessels are common, most stenoses remain asymptomatic, but some cause symptoms, and catastrophic complications can develop. GI ischemia can also result despite normal microvasculature, referred to as nonocclusive mesenteric ischemia (NOMI). This condition is frequently encountered, not only in critically ill patients and during major surgery but also in athletes and patients with all forms of circulatory (pre-)shock. The diagnosis of gastrointestinal ischemia is notoriously difficult, and most centers experience long patient and doctor’s delay before making the diagnosis. This probably relates to delayed treatment and high mortality rates in acute splanchnic ischemia. In recent years, successful treatment has been reported with low complication rate (Mensink et al. 2006a; Bigirwamungu-Bargeman et al. 2009; van Petersen et al. 2009, 2010). The emergence of less invasive treatment options, including endovascular treatment and endoscopic/laparoscopic surgery of the celiac axis compression syndrome, has shifted the cost-benefit ratio. As treatment becomes more accessible, the need to make a correct diagnosis increases. The main challenge is to find a simple, widely available diagnostic test. In suspected acute GI ischemia, small studies identified the serum marker I-FABP (intestinal fatty acid-binding protein) and urgent CT scan as valuable diagnostic test. In chronic GI ischemia, measurement of increased luminal PCO2 (tonometry) and reduced mucosa oxygen concentration (visual light spectroscopy) have been validated with acceptable accuracy. Also the insight in epidemiology, clinical presentation, course, and outcome of treatment has been established more firmly (Sana et al. 2010; Van Noord et al. 2011, 2013; Kolkman et al. 2008; Bigirwamungu-Bargeman et al. 2009; Mensink et al. 2009; ter Steege et al. 2012; Kerkhof et al. 2013). In this chapter, the main topics will be covered including the celiac axis compression syndrome (Mensink et al. 2006b; van Petersen et al. 2009), the difference between single- and multivessel involvement, the female preponderance and atherosclerotic risk profile (Mensink et al. 2006a; Van Noord et al. 2011; Veenstra et al. 2012), and the low prevalence of symptomatic versus asymptomatic stenosis (Kerkhof et al. 2013).

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Abbreviations

ASS:

Acute splanchnic syndrome (syn: acute mesenteric ischemia)

CA:

Celiac artery (syn: celiac trunc)

CACS:

Celiac artery compression syndrome (syn: median arcuate ligament syndrome)

CMI:

Chronic mesenteric ischemia (syn: chronic splanchnic syndrome)

CSD:

Chronic splanchnic disease

CSS:

Chronic splanchnic syndrome (syn: chronic mesenteric ischemia)

DSA:

Digital subtraction angiography

EDV:

End-diastolic velocity (end-diastolic flow velocity in cm/sec)

GET:

Gastric exercise tonometry

ICAC:

Incidental celiac artery compression

IMA:

Inferior mesenteric artery

NOMI:

Non-occlusive mesenteric ischemia

SMA:

Superior mesenteric artery

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Authors and Affiliations

  1. Department of Gastroenterology, Medisch Spectrum Twente Enschede and University Medical Center Groningen, Ariënsplein 1, 7511 XJ, Enschede, The Netherlands

    Jeroen J. Kolkman M.D. Ph.D.

  2. Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands

    Dr. Robert H. Geelkerken M.D. Ph.D.

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  1. Jeroen J. Kolkman M.D. Ph.D.
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Correspondence to Jeroen J. Kolkman M.D. Ph.D. .

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  1. Akademisches Lehrkrankenhaus MLU, Bitterfeld-Wolfen, Germany

    Peter Lanzer

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Kolkman, J.J., Geelkerken, R.H. (2014). Assessment and treatment of splanchnic ischemia. In: Lanzer, P. (eds) PanVascular Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-37393-0_143-1

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