http://repub.eur.nl/res/aut/18529/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/22678/ 2011-03-11T00:00:00Z 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. http://repub.eur.nl/res/pub/25966/ 2011-02-01T00:00:00Z Background: The diagnosis of chronic GI ischemia (CGI) remains a clinical challenge. Currently, there is no single simple test with high sensitivity available. Visible light spectroscopy (VLS) is a new technique that noninvasively measures mucosal oxygen saturation during endoscopy. Objective: To determine the diagnostic accuracy of VLS for the detection of ischemia in a large cohort of patients. Design: Prospective study, with adherence to the Standards for Reporting of Diagnostic Accuracy. Setting: Tertiary referral center. Patients: Consecutive patients referred for evaluation of possible CGI. Interventions: Patients underwent VLS along with the standard workup consisting of evaluation of symptoms, GI tonometry, and abdominal CT or magnetic resonance angiography. Main Outcome Measurements: VLS measurements and the diagnosis of CGI as established with the standard workup. Results: In 16 months, 121 patients were included: 80 in a training data set and 41 patients in a validation data set. CGI was diagnosed in 89 patients (74%). VLS cutoff values were determined based on the diagnosis of CGI and applied in the validation data set, and the results were compared with the criterion standard, resulting in a sensitivity and specificity of VLS of 90% and 60%, respectively. Repeated VLS measurements showed improvement in 80% of CGI patients after successful treatment. Limitations: Single-center study; only 43% of patients had repeated VLS measurements after treatment. Conclusions: VLS during upper endoscopy is a promising easy-to-perform and minimally invasive technique to detect mucosal hypoxemia in patients clinically suspected of having CGI, showing excellent correlation with the established ischemia workup. http://repub.eur.nl/res/pub/26019/ 2010-10-01T00:00:00Z Aims: Diagnosing chronic upper gastrointestinal ischaemia (CUGI) remains a challenge in clinical practice. Histological examination of biopsy material currently plays no role in the diagnosis of transient CUGI, as little is known about gastrointestinal histology in these patients. The aim of this study was to investigate upper gastrointestinal histology in patients with well-defined CUGI.Methods and results: Consecutive patients suspected of CUGI were included prospectively and underwent a diagnostic work-up existing of upper endoscopy, gastrointestinal tonometry and computed tomography (CT) or magnetic resonance (MR) angiography. Results were discussed in a multidisciplinary team and a consensus diagnosis was made. Endoscopic biopsy samples were taken from the descending duodenum, gastric antrum and corpus, and scored using the Sydney, Vienna, Chiu, Marsh and Operative Link for Gastritis Assessment (OLGA) classifications. Gastropathy was scored present or absent. Seventy-nine patients were analysed in 8 months. CUGI was diagnosed in 41 patients (52%): 36 males, mean age 60 (17-86) years. Prevalence of gastropathy was significantly higher in patients with ischaemia (P = 0.025). No other differences were found between patients with and without ischaemia.Conclusions: Histological examination of biopsy samples plays no definitive role in diagnosing CUGI, but the presence of histological signs of reactive gastropathy can be used to support the clinical diagnosis of ischaemia. http://repub.eur.nl/res/pub/20124/ 2010-07-01T00:00:00Z http://repub.eur.nl/res/pub/20608/ 2010-01-01T00:00:00Z Background: Diagnosing chronic gastrointestinal ischemia (CGI) is a challenging problem in clinical practice. Serum markers for CGI would be of great diagnostic value as a non-invasive test method. Aims: This study investigated serum markers in patients with well-defined ischemia. Furthermore, intestinal mucosal injury was also evaluated in CGI patients. Methods: Consecutive patients suspected of CGI were prospectively enrolled and underwent a diagnostic work-up consisting of gastrointestinal tonometry and either CT or MR angiography. Blood samples for analysis of intestinal fatty acid-binding protein (I-FABP), D-dimer, lactate dehydrogenase (LDH), leucocyte counts, C-reactive protein (CRP), and L-lactate were drawn before and after a standard meal. Intestinal mucosal injury was assessed with glutamine, citrulline and arginine in blood samples and compared to a sugar absorption test (SAT). Test reproducibility was validated in healthy subjects. Results: Forty patients and nine healthy subjects were included. Ischemia was diagnosed in 32 patients (80%). I-FABP, leucocyte counts, LDH, CRP, glutamine, citrulline, arginine and SAT levels did not differ between patients with and without ischemia. L-lactate concentration showed a significant elevation in ischemia patients as compared to non-ischemia patients. In ischemia patients, D-dimer levels showed a significant elevation postprandially as compared to D-dimer levels at baseline. However, these ischemia patients did not show intestinal mucosal injury. Conclusions: I-FABP, leucocyte counts, LDH and CRP levels are not clinically useful for the diagnosis of CGI. However, postprandial rises in L-lactate and D-dimer serum levels can serve as non-invasive indicators of CGI. http://repub.eur.nl/res/pub/18483/ 2009-02-01T00:00:00Z 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.