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Mesenteric Ischemia Review in NEJM

This is a neat little review. 

While I am contemplating 345px-Ischemicbowel.PNGto actually starting a podcast that would review the GI literature in some detail on a monthly basis, i will prepare myself by posting a few reviews of the articles that sparked my interest/I feel are important for a gastroenterologist to be aware of.

I start with the March 10th Issue of NEJM, which has a nice summary article on Mesenteric Ischemia. Now if you are looking for a quick-guide to how to diagnose it or how to treat it – this is NOT the article for you. But if you want the details on exact specificity/sensitivity of different imaging modalities ( it happens to be 85% Sensitive-90% specific on Ultrasound, for example, and CTA is 95-100% Accurate) – then this is the article for you – you can download it and file it away for when you need the info. It is too bad that the authors did not want to make a table such as this (found and cited elsewhere):(which they cite as reference 26)

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But I understand that the aim here was to give a more “comprehensive” view on what mesenteric ischemia is for the general reader.  It has nice figures with examples of CTA with acute embolus to SMA, as well as chronic mesenteric ischemia with occlusion of SMA in setting of a celiac stent occlusion.

For the endoscopists amongst us, nothing is more true:”…endoscopic examination does not reach the majority of sections of the small bowel that are most frequently involved in mesenteric ischemia…” so dont scope of VCE these patients for no reason.

And now for clinical pearl:

Lawrence Brandt – a professor at Albert Einstein College of Medicine – one of the first persons to expose me to the wonderful world of gastroenterology loves to talk about non-occlusive mesenteric ischemia – NOMI  – Overall mortality is 50% – Mostly in patients with cardiac disease/complications/recent cardiac surgery. Papaverine hydrochloride through a catheter infusion can be considered. Not sure where else we can use Papaverine for a GI condition (let me know if you know).

To remember NOMI, Dr. Brandt usually brings up is a person in their 70s, with HTN, has an MI with hypotension, then stented, was put on beta blocker, and clopidogrel/aspirin, then develops severe abdominal pain. Exam is with mild tenderness, labs are unhelpful. INR is 2.1, everything else is ok. What’s the diagnosis? – NOMI!  Why? – vasoconstriction that is persistent,as a reaction to a previous insult, even if precipitating event is gone.

 

References as cited or linked.

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Functional Dyspepsia Review in NEJM 2015

imgresNEJM has a great article here – a summary of latest/greatest on Functional Dyspepsia. An often frustrating diagnosis.

Key Points: 1) Watch out for alarm symptoms, such as dysphagia that is progressive, melena, fam hx of esophageal cancer, iron deficiency anemia, weight loss, etc, but keep in mind that these are of very limited value. The sensitivity of alarm symptoms varied from 0% to 83% with considerable heterogeneity between studies. The specificity also varied significantly from 40% to 98%.

2) Classification may be useful, but probably isn’t – Postprandial distress syndrome versus Epigastric Pain syndrome.  Mainly here to highlight that some of these patients will have issues with gastric emptying.  86% of patients with gastroparesis will have dyspepsia.

3) Pathophysiology – no clear answer here, mostly magical thinking and theories. Probably a link between Brain-Stress-Epithelial Permeability- Eosinophils-Duodenum Sensitivity- etc. etc. etc.

4) Rate of response to placebo is ~40%.

5) The NNT for H.pylori eradication is 15. But only 5% of functional dyspepsia cases will be positive.

6) The NNT for acid suppression/PPI therapy is 10. But most trials with acid suppression happened before Rome III criteria were out, so maybe not.

7) Prokinetic agents are either dangerous, or do not work.

8) Complementary and Alternative Therapies are bogus.

9) Natural history is chronic and fluctuating.

10) Proposed Treatment Algorythm is acceptable.

Bottom Line: Article has great references. No new stuff, but good summary of what we know. File under teaching reference.