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Using visible light spectrography in the diagnosis of patients with suspected chronic gastrointestinal ischemia can lead to more accurate diagnoses, more-effective treatment regimens, and, ultimately, longer-lasting positive results, according to a new study published in the January issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2014.07.012).
“Medical history and physical examination were poor predictors for the presence of CGI [chronic gastrointestinal ischemia] [but] addition of radiologic evaluation [and] functional testing by means of tonometry substantially improved the accuracy of diagnosis,” said study leader Dr. Aria Sana of Utrecht University in the Netherlands.
The authors added that “VLS [Visible light spectrography] has recently been introduced as a new minimally invasive technique to detect mucosal hypoxia by means of measurement of mucosal capillary hemoglobin oxygen saturation during endoscopy in patients clinically suspected of CGI.”
In a prospective study, Dr. Sana and her associates gathered data on 212 patients referred to their medical center between November 2008 through January 2011 for suspected CGI. Subjects underwent visualization of gastrointestinal arteries and assessments of mucosal perfusion via VLS; those found to have occlusive CGI were followed-up after a median 13 months’ time to assess their response to treatment.
Of the 212 subjects initially screened, 107 (50%) were found to have occlusive CGI. Of that population, 96 (90%) were offered treatment, of which 89 (93%) were available to provide follow-up data after the median time of 13 months.
Investigators found that 62 subjects (70% of the 89 who reported after the follow-up period) had sustained responses to treatment that they were prescribed as a result of VLS and visualization-based diagnoses. Furthermore, patients who displayed weight loss, abdominal bruit, and low corpus mucosal saturation were found most likely to respond to treatment, particularly the latter – corpus saturation level of less than 56% was “one of the strongest predictors of a positive treatment response” investigators found.
“The presence of [at least] two predictors or the absence of any predictor was of discriminative value with [greater than] 85% vs. [less than] 50% response rate, respectively, suggesting patients with a predicted response rate of < 50% should primarily be considered for conservative management,” Dr. Sana and her coinvestigators noted.
The authors disclosed no conflicts of any kind.
In this study from the Netherlands, the authors used visible light spectroscopy (VLS) to diagnose chronic gastrointestinal ischemia (CGI) and to predict its response to surgical or endoscopic treatment; a challenging task indeed. Diagnosis of CGI is difficult because the classic symptom complex of meal-precipitated abdominal pain leading to weight loss is nonspecific; asymptomatic splanchnic vascular obstruction is not uncommon in the general population with autopsy series showing significant stenosis of the celiac, superior mesenteric, and inferior mesenteric arteries of 50%, 30%, and 30%, respectively; radiologic imaging tests conventionally used to diagnose CGI evaluate only vascular anatomy and not physiologic parameters of ischemia, i.e., intracellular acidosis (which can be evaluated by balloon tonometry) nor mucosal hemoglobin oxygen saturation, which is determined by VLS.
The authors evaluated 212 patients referred for suspected CGI and in all performed radiologic imaging of the splanchnic vessels and assessment of mucosal perfusion by VLS. Obstructive CGI (OCGI)was diagnosed by a multidisciplinary team and required clinical agreement, significant stenosis of at least one splanchnic artery and mucosal ischemia as determined by VLS. OCGI was classified as single- or multivessel and patients were offered surgical or endovascular revascularization. Response to treatment was then evaluated in patients with OCGI. A total of 107 patients were diagnosed with OCGI and data on response to treatment was available in 89 with a median follow-up of 13 months. Sustained symptomatic response was seen in 62 (70%) and most strongly predicted by the presence of weight loss, an abdominal bruit, and a gastric corpus mucosal saturation level of < 56%. This is an important study because it stresses the value of a team approach to diagnosis and the use of a combination of techniques to evaluate vascular obstruction and its functional significance.
There were several shortcomings of the study, in my opinion, although these do not lessen the importance of the study’s message. Most important, the study was not blinded. Spontaneous resolution of symptoms was noted in 19 patients without OCGI and in an additional 9 patients treated with a variety of medical and surgical means. Celiac artery compression release relieved symptoms in 17 patients, although the ischemic nature of this entity is arguable. Repeat VLS was not performed in all patients. Finally, clinical follow-up was relatively short and long-term follow-up was mainly by questionnaire, leading to another source of bias. To perform fiber-optic catheter-based VLS oximetry during esophagogastroduodenoscopy in a consistent fashion is technically challenging but probably worthwhile to learn. The authors continue to shine light on this relatively dark and poorly illuminated subject matter; let it shine, let it shine, let it shine.
Dr. Lawrence J. Brandt, MACG, AGAF, FASGE, is a professor of medicine and surgery at the Albert Einstein College of Medicine, N.Y., and emeritus chief, division of gastroenterology, Montefiore Medical Center, Bronx, N.Y.
In this study from the Netherlands, the authors used visible light spectroscopy (VLS) to diagnose chronic gastrointestinal ischemia (CGI) and to predict its response to surgical or endoscopic treatment; a challenging task indeed. Diagnosis of CGI is difficult because the classic symptom complex of meal-precipitated abdominal pain leading to weight loss is nonspecific; asymptomatic splanchnic vascular obstruction is not uncommon in the general population with autopsy series showing significant stenosis of the celiac, superior mesenteric, and inferior mesenteric arteries of 50%, 30%, and 30%, respectively; radiologic imaging tests conventionally used to diagnose CGI evaluate only vascular anatomy and not physiologic parameters of ischemia, i.e., intracellular acidosis (which can be evaluated by balloon tonometry) nor mucosal hemoglobin oxygen saturation, which is determined by VLS.
The authors evaluated 212 patients referred for suspected CGI and in all performed radiologic imaging of the splanchnic vessels and assessment of mucosal perfusion by VLS. Obstructive CGI (OCGI)was diagnosed by a multidisciplinary team and required clinical agreement, significant stenosis of at least one splanchnic artery and mucosal ischemia as determined by VLS. OCGI was classified as single- or multivessel and patients were offered surgical or endovascular revascularization. Response to treatment was then evaluated in patients with OCGI. A total of 107 patients were diagnosed with OCGI and data on response to treatment was available in 89 with a median follow-up of 13 months. Sustained symptomatic response was seen in 62 (70%) and most strongly predicted by the presence of weight loss, an abdominal bruit, and a gastric corpus mucosal saturation level of < 56%. This is an important study because it stresses the value of a team approach to diagnosis and the use of a combination of techniques to evaluate vascular obstruction and its functional significance.
There were several shortcomings of the study, in my opinion, although these do not lessen the importance of the study’s message. Most important, the study was not blinded. Spontaneous resolution of symptoms was noted in 19 patients without OCGI and in an additional 9 patients treated with a variety of medical and surgical means. Celiac artery compression release relieved symptoms in 17 patients, although the ischemic nature of this entity is arguable. Repeat VLS was not performed in all patients. Finally, clinical follow-up was relatively short and long-term follow-up was mainly by questionnaire, leading to another source of bias. To perform fiber-optic catheter-based VLS oximetry during esophagogastroduodenoscopy in a consistent fashion is technically challenging but probably worthwhile to learn. The authors continue to shine light on this relatively dark and poorly illuminated subject matter; let it shine, let it shine, let it shine.
Dr. Lawrence J. Brandt, MACG, AGAF, FASGE, is a professor of medicine and surgery at the Albert Einstein College of Medicine, N.Y., and emeritus chief, division of gastroenterology, Montefiore Medical Center, Bronx, N.Y.
In this study from the Netherlands, the authors used visible light spectroscopy (VLS) to diagnose chronic gastrointestinal ischemia (CGI) and to predict its response to surgical or endoscopic treatment; a challenging task indeed. Diagnosis of CGI is difficult because the classic symptom complex of meal-precipitated abdominal pain leading to weight loss is nonspecific; asymptomatic splanchnic vascular obstruction is not uncommon in the general population with autopsy series showing significant stenosis of the celiac, superior mesenteric, and inferior mesenteric arteries of 50%, 30%, and 30%, respectively; radiologic imaging tests conventionally used to diagnose CGI evaluate only vascular anatomy and not physiologic parameters of ischemia, i.e., intracellular acidosis (which can be evaluated by balloon tonometry) nor mucosal hemoglobin oxygen saturation, which is determined by VLS.
The authors evaluated 212 patients referred for suspected CGI and in all performed radiologic imaging of the splanchnic vessels and assessment of mucosal perfusion by VLS. Obstructive CGI (OCGI)was diagnosed by a multidisciplinary team and required clinical agreement, significant stenosis of at least one splanchnic artery and mucosal ischemia as determined by VLS. OCGI was classified as single- or multivessel and patients were offered surgical or endovascular revascularization. Response to treatment was then evaluated in patients with OCGI. A total of 107 patients were diagnosed with OCGI and data on response to treatment was available in 89 with a median follow-up of 13 months. Sustained symptomatic response was seen in 62 (70%) and most strongly predicted by the presence of weight loss, an abdominal bruit, and a gastric corpus mucosal saturation level of < 56%. This is an important study because it stresses the value of a team approach to diagnosis and the use of a combination of techniques to evaluate vascular obstruction and its functional significance.
There were several shortcomings of the study, in my opinion, although these do not lessen the importance of the study’s message. Most important, the study was not blinded. Spontaneous resolution of symptoms was noted in 19 patients without OCGI and in an additional 9 patients treated with a variety of medical and surgical means. Celiac artery compression release relieved symptoms in 17 patients, although the ischemic nature of this entity is arguable. Repeat VLS was not performed in all patients. Finally, clinical follow-up was relatively short and long-term follow-up was mainly by questionnaire, leading to another source of bias. To perform fiber-optic catheter-based VLS oximetry during esophagogastroduodenoscopy in a consistent fashion is technically challenging but probably worthwhile to learn. The authors continue to shine light on this relatively dark and poorly illuminated subject matter; let it shine, let it shine, let it shine.
Dr. Lawrence J. Brandt, MACG, AGAF, FASGE, is a professor of medicine and surgery at the Albert Einstein College of Medicine, N.Y., and emeritus chief, division of gastroenterology, Montefiore Medical Center, Bronx, N.Y.
Using visible light spectrography in the diagnosis of patients with suspected chronic gastrointestinal ischemia can lead to more accurate diagnoses, more-effective treatment regimens, and, ultimately, longer-lasting positive results, according to a new study published in the January issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2014.07.012).
“Medical history and physical examination were poor predictors for the presence of CGI [chronic gastrointestinal ischemia] [but] addition of radiologic evaluation [and] functional testing by means of tonometry substantially improved the accuracy of diagnosis,” said study leader Dr. Aria Sana of Utrecht University in the Netherlands.
The authors added that “VLS [Visible light spectrography] has recently been introduced as a new minimally invasive technique to detect mucosal hypoxia by means of measurement of mucosal capillary hemoglobin oxygen saturation during endoscopy in patients clinically suspected of CGI.”
In a prospective study, Dr. Sana and her associates gathered data on 212 patients referred to their medical center between November 2008 through January 2011 for suspected CGI. Subjects underwent visualization of gastrointestinal arteries and assessments of mucosal perfusion via VLS; those found to have occlusive CGI were followed-up after a median 13 months’ time to assess their response to treatment.
Of the 212 subjects initially screened, 107 (50%) were found to have occlusive CGI. Of that population, 96 (90%) were offered treatment, of which 89 (93%) were available to provide follow-up data after the median time of 13 months.
Investigators found that 62 subjects (70% of the 89 who reported after the follow-up period) had sustained responses to treatment that they were prescribed as a result of VLS and visualization-based diagnoses. Furthermore, patients who displayed weight loss, abdominal bruit, and low corpus mucosal saturation were found most likely to respond to treatment, particularly the latter – corpus saturation level of less than 56% was “one of the strongest predictors of a positive treatment response” investigators found.
“The presence of [at least] two predictors or the absence of any predictor was of discriminative value with [greater than] 85% vs. [less than] 50% response rate, respectively, suggesting patients with a predicted response rate of < 50% should primarily be considered for conservative management,” Dr. Sana and her coinvestigators noted.
The authors disclosed no conflicts of any kind.
Using visible light spectrography in the diagnosis of patients with suspected chronic gastrointestinal ischemia can lead to more accurate diagnoses, more-effective treatment regimens, and, ultimately, longer-lasting positive results, according to a new study published in the January issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2014.07.012).
“Medical history and physical examination were poor predictors for the presence of CGI [chronic gastrointestinal ischemia] [but] addition of radiologic evaluation [and] functional testing by means of tonometry substantially improved the accuracy of diagnosis,” said study leader Dr. Aria Sana of Utrecht University in the Netherlands.
The authors added that “VLS [Visible light spectrography] has recently been introduced as a new minimally invasive technique to detect mucosal hypoxia by means of measurement of mucosal capillary hemoglobin oxygen saturation during endoscopy in patients clinically suspected of CGI.”
In a prospective study, Dr. Sana and her associates gathered data on 212 patients referred to their medical center between November 2008 through January 2011 for suspected CGI. Subjects underwent visualization of gastrointestinal arteries and assessments of mucosal perfusion via VLS; those found to have occlusive CGI were followed-up after a median 13 months’ time to assess their response to treatment.
Of the 212 subjects initially screened, 107 (50%) were found to have occlusive CGI. Of that population, 96 (90%) were offered treatment, of which 89 (93%) were available to provide follow-up data after the median time of 13 months.
Investigators found that 62 subjects (70% of the 89 who reported after the follow-up period) had sustained responses to treatment that they were prescribed as a result of VLS and visualization-based diagnoses. Furthermore, patients who displayed weight loss, abdominal bruit, and low corpus mucosal saturation were found most likely to respond to treatment, particularly the latter – corpus saturation level of less than 56% was “one of the strongest predictors of a positive treatment response” investigators found.
“The presence of [at least] two predictors or the absence of any predictor was of discriminative value with [greater than] 85% vs. [less than] 50% response rate, respectively, suggesting patients with a predicted response rate of < 50% should primarily be considered for conservative management,” Dr. Sana and her coinvestigators noted.
The authors disclosed no conflicts of any kind.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: Diagnosis of chronic gastrointestinal ischemia (CGI) via visible light spectrography (VLS) can lead to more effective treatment methods that yield longer-term results.
Major finding: Of patients diagnosed with CGI via VLS, 70% reported sustained responses to treatment after 13 months.
Data source: A prospective study.
Disclosures: The authors reported no conflicts.