Jihan Harki

Diagnostic Accuracy of the Combination of Clinical Symptoms and CT or MR Angiography in Patients With Chronic Gastrointestinal Ischemia

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.

GI ischemia in patients with portal vein thrombosis: A prospective cohort study

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.

Mo1967 Development of a Prediction Model to Assess the Risk of Chronic Gastrointestinal Ischemia in Referred Patients

Background and aim: Chronic gastrointestinal ischemia (CGI) is a challenging disease entity. Clinical symptoms may differ amongst patients. The aim of this study was to establish predictors for the diagnosis of CGI based on self-reported variables and to combine these in a prediction model. Patients and Methods: We analyzed data of a prospective cohort study. Between November 2006 and March 2013 self-reported symptoms were collected by a structured questionnaire of 431 consecutive patients referred to an academic hospital for evaluation of possible CGI. All patients received the standard work-up of CGI, consisting of radiological imaging of the gastrointestinal arteries, and functional testing for detection of mucosal ischemia by means of visible light spectroscopy (VLS) or tonometry. The results were discussed in a multidisciplinary expert panel leading to a consensus diagnosis, which was monitored during follow-up. Predictors for the diagnosis of CGI were obtained by comparing the self-reported symptoms in the questionnaire to the diagnosis of CGI. Multivariable logistic regression analysis was used to combine the strongest predictors in a prediction model. A simple score was developed based on the prediction model to distinguish low, intermediate and high risk patients for CGI. Results: Postprandial pain, exercise-induced pain or weight loss was present in 93% of patients. The majority of patients (n=288, 67%) was diagnosed with CGI and had persistent clinical response after treatment. Self-reported risk profiles showing strong association with CGI were female gender (OR 2.5, 95% CI 1.63.9), age > 60 years (OR 1.4 for 10 year increase, 95% CI 1.0-2.0), concomitant diabetes mellitus (OR 2.0, 95% CI 0.99-4.0), smoking (OR 1.5, 95% CI 0.98-2.3), and use of alcohol (OR1.3, 95% CI (0.96-1.7). Consequently, a c-statistic of 0.68 for the combination of predictors was obtained. Based on a 6-point scoring system patients were categorized as lower (predictive risk 51 79%) for CGI, indicating whether further diagnostic work-up is required (see Table 1). Conclusions: We present a scoring system for the presence of CGI on clinical features and risk profiles alone for patients suspected of CGI. This tool may be useful for clinicians to assess the risk of CGI and to decide whether further diagnostic work-up by means of radiological imaging of the gastrointestinal arteries and functional testing is indicated and worthwhile.