Mesenteric artery calcium scoring: a potential screening method for chronic mesenteric ischemia.

OBJECTIVE: A practical screening tool for chronic mesenteric ischemia (CMI) could facilitate early recognition and reduce undertreatment and diagnostic delay. This study explored the ability to discriminate CMI from non-CMI patients with a mesenteric artery calcium score (MACS). METHODS: This retrospective study included CTAs of consecutive patients with suspected CMI in a tertiary referral center between April 2016 and October 2019. A custom-built software module, using the Agatston definition, was developed and used to calculate the MACS for the celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery. Scoring was performed by two blinded observers. Interobserver agreement was determined using 39 CTAs scored independently by both observers. CMI was defined as sustained symptom improvement after treatment. Non-CMI patients were patients not diagnosed with CMI after a diagnostic workup and patients not responding to treatment. RESULTS: The MACS was obtained in 184 patients, 49 CMI and 135 non-CMI. Interobserver agreement was excellent (intraclass correlation coefficient 0.910). The MACS of all mesenteric arteries was significantly higher in CMI patients than in non-CMI patients. ROC analysis of the combined MACS of CA + SMA showed an acceptable AUC (0.767), high sensitivity (87.8%), and high NPV (92.1%), when using a ≥ 29.7 CA + SMA MACS cutoff. Comparison of two CTAs, obtained in the same patient at different points in time with different scan and reconstruction parameters, was performed in 29 patients and revealed significant differences in MACSs. CONCLUSION: MACS seems a promising screening method for CMI, but correction for scan and reconstruction parameters is warranted. KEY POINTS: • A mesenteric artery calcium score obtained in celiac artery and superior mesenteric artery has a high negative predictive value for chronic mesenteric ischemia and could serve as a screening tool. • Interobserver agreement of the mesenteric artery calcium score is excellent. • Scan and reconstruction parameters influence the mesenteric artery calcium score and warrant the development of a method to correct for these parameters.

No Superiority of Tacrolimus Suppositories vs Beclomethasone Suppositories in a Randomized Trial of Patients With Refractory Ulcerative Proctitis.

BACKGROUND & AIMS: Ulcerative proctitis (UP) refractory to 5-aminosalicylic acid (5-ASA) suppositories is a challenge to treat, often requiring step up to immunomodulator or biological therapy. Topical tacrolimus is effective and safe in patients with refractory UP. However, it is not clear how tacrolimus suppositories fit into in the treatment algorithm of UP. METHODS: We performed a randomized controlled, double-blind study at 8 hospitals in the Netherlands and Belgium from 2014 through 2017. Eighty-five patients with refractory UP (65% women) were randomly assigned to groups given once daily tacrolimus suppositories (2 mg; n = 43) or beclomethasone (3 mg; n = 42) for 4 weeks. The primary outcome was clinical response (decrease in Mayo score of 3 or more). Secondary outcomes included clinical remission, endoscopic response and remission, adverse events and quality of life. Outcomes were compared using Fisher's exact test and Mann-Whitney U test. RESULTS: Proportions of patients with clinical responses were 63% in the tacrolimus group and 59% in the beclomethasone group (P = .812); proportions of patients in clinical remission were 46% and 38%, respectively (P = .638). Proportions of patients with an endoscopic response were 68% and 60% in the tacrolimus group and in the beclomethasone group (P = .636); proportions in endoscopic remission rates were 30% and 13%, respectively (P = .092) Median increases in the inflammatory bowel disease questionnaire score were 18.0 in the tacrolimus group and 20.5 in the beclomethasone group (P = .395). Adverse event rates did not differ significantly between groups. CONCLUSIONS: In a 4-week randomized controlled trial, tacrolimus and beclomethasone suppositories induce comparable clinical and endoscopic responses in patients with UP refractory to 5-ASA. There were no significant differences in adverse events rates. Tacrolimus and beclomethasone suppositories are therefore each safe and effective treatment options for 5-ASA refractory disease. EUDRACT 2013-001259-11; Netherlands Trial Register NL4205/NTR4416.

Single-Center Retrospective Comparative Analysis of Transradial, Transbrachial, and Transfemoral Approach for Mesenteric Arterial Procedures.

PURPOSE: To assess feasibility and safety of transradial access (TRA) compared with transfemoral access (TFA) and transbrachial access (TBA) for mesenteric arterial endovascular procedures. MATERIALS AND METHODS: A retrospective cohort analysis was performed including all consecutive patients who underwent a mesenteric arterial procedure in a tertiary referral center between May 2012 and February 2018. Exclusion criteria were absence of data and lost to follow-up within 24 hours after the procedure. During the study period, 103 patients underwent 148 mesenteric arterial procedures (TBA, n = 52; TFA, n = 39; TRA, n = 57). Mean patient age was 64.3 years ± 13.3, and 91 patients (62%) were women. Primary outcomes were vascular access specified technical success rate and access site complication rate, as reported in hospital records. RESULTS: Technical success rate specified for the vascular access technique did not differ between the 3 approaches (TBA 96%, TFA 87%, TRA 91%; TRA vs TBA, P = .295; TBA vs TFA, P = .112; TRA vs TFA, P = .524), and overall access site complication rate was not different between the 3 approaches (TBA 42%, TFA 23%, TRA 35%; TRA vs TBA, P = .439; TBA vs TFA, P = .055; TRA vs TFA, P = .208). However, more major access site complications were reported for TBA than for TRA or TFA (TBA 17%, TFA 3%, TRA 2%; TRA vs TBA, P = .005; TBA vs TFA, P = .026; TRA vs TFA, P = .785). CONCLUSIONS: TRA is a safe and feasible approach for mesenteric arterial procedures comparable to TFA, but with a significantly lower major access site complication rate than TBA.

Endovascular Pressure Measurements to Assess the Functional Severity of Mesenteric Arterial Stenoses.

PURPOSE: To assess the ability of pressure measurements to discriminate clinically significant celiac artery (CA) or superior mesenteric artery (SMA) stenosis in patients with suspected chronic mesenteric ischemia (CMI). MATERIALS AND METHODS: Single-center, retrospective cohort study of 41 intra-arterial pressure measurements during mesenteric angiography with intended revascularization, performed in 37 patients (mean age 67.7 ± 10.8 years, 62% female) between April 2015 and May 2017. Simultaneous prestenotic and poststenotic pressure measurements had been obtained before and after intra-arterial administration of nitroglycerin. Revascularization was performed in 38 of 41 procedures. Definitive diagnosis of CMI was defined as patient-reported symptom relief or improvement after successful revascularization. RESULTS: Pressure gradients obtained after vasodilator administration were significantly higher in CAs and SMAs with ≥50% stenosis. Pressure ratios (pressure distal [Pd]/pressure aorta [Pa]) obtained after vasodilator administration were significantly higher in CAs with ≥50% stenosis. Subgroup analysis of 22 patients with a ≥50% stenosis of either CA or SMA showed significantly higher pressure gradients and Pd/Pa ratios after vasodilator administration in CMI patients (median pressure gradient: CMI [interquartile ratio] 36 [21-40] mm Hg versus no-CMI 20 [9-21] mm Hg, P = 0.041; Pd/Pa: CMI 0.703 [0.598-0.769] versus no-CMI 0.827 [0.818-0.906], P = .009). A ≤0.8 Pd/Pa cutoff value after administration of a vasodilator best identified a clinically relevant stenosis, with 86% sensitivity and 83% specificity. Complications related to the pressure measurements were not observed. CONCLUSIONS: Intra-arterial pressure measurements are feasible and safe. Low Pd/Pa ratios were associated with clinically relevant CA or SMA stenosis.

Evaluation of endoscopic visible light spectroscopy: comparison with microvascular oxygen tension measurements in a porcine model.

BACKGROUND: Visible light spectroscopy (VLS) is a technique used to measure the mucosal oxygen saturation during upper gastrointestinal endoscopy to evaluate mucosal ischemia, however in vivo validation is lacking. We aimed to compare VLS measurements with a validated quantitative microvascular oxygen tension (µPO2) measurement technique. METHODS: Simultaneous VLS measurements and µPO2 measurements were performed on the small intestine of five pigs. First, simultaneous measurements were performed at different FiO2 values (18%-100%). Thereafter, the influence of bile was assessed by comparing VLS measurements in the presence of bile and without bile. Finally, simultaneous VLS and µPO2 measurements were performed from the moment a lethal dose potassium chloride intravenously was injected. RESULTS: In contrast to µPO2 values that increased with increasing FiO2, VLS values decreased. Both measurements correlated poorly with R2 = 0.39, intercept 18.5, slope 0.41 and a bias of - 16%. Furthermore, the presence of bile influenced VLS values significantly (median (IQR)) before bile application 57.5% (54.8-59.0%) versus median with bile mixture of the stomach 73.5% (66.8-85.8), p = < 2.2 * 10-16; median with bile mixture of small bowel 47.6% (41.8-50.8) versus median after bile removal 57.0% (54.7-58.6%), p = < 2.2 * 10-16). Finally, the VLS mucosal oxygen saturation values did not decrease towards a value of 0 in the first 25 min of asystole in contrast to the µPO2 values. CONCLUSIONS: These results suggest that VLS measures the mixed venous oxygen saturation rather than mucosal capillary hemoglobin oxygen saturation. Further research is needed to establish if the mixed venous compartment is optimal to assess gastrointestinal ischemia.

Detection of mesenteric ischemia by means of endoscopic visible light spectroscopy after luminal feeding.

BACKGROUND AND AIMS: Endoscopic visible light spectroscopy (VLS) enables measurement of mucosal oxygen saturation during upper GI endoscopy and is used in the diagnostic work-up of chronic mesenteric ischemia (CMI). Currently, VLS is performed when the patient has fasted. We aimed to determine whether food challenge improves the diagnostic performance of VLS measurements for the diagnosis of CMI. METHODS: This was a single-center prospective study of healthy controls and consecutive patients suspected of having CMI and referred to a Dutch specialized CMI center for standardized diagnostic CMI work-up. Immediately after conventional fasting, VLS measurements were taken, luminal feeding was administered, and VLS measurements were repeated 45 minutes later. Patients were classified as CMI if a multidisciplinary expert-based consensus diagnosis of CMI was established and successful revascularization therapy resulted in symptom relief. Patients were classified as no-CMI when consensus diagnosis was not reached or when symptom relief did not occur after technically successful treatment. RESULTS: We included 60 patients with suspected CMI and 16 healthy controls. Duodenal oxygen saturation was significantly higher postprandially compared with the fasting state: healthy controls: median (interquartile range) pre 54% (49%-56%), post 56% (53%-58%), P = .02), no-CMI patients (pre 55% (51%-57%), post 57% (53%-59%), P > .01); CMI patients: pre 51% (48%-53%), post 54% (50%-58%), P = .01. Mucosal oxygen saturation did not significantly increase postprandially in the duodenal bulb or antrum of the stomach. Absolute postprandial oxygen measurements and the absolute or relative difference between preprandial versus postprandial oxygen measurements did not provide additional discriminative ability for the diagnosis of CMI. CONCLUSIONS: Postprandial VLS measurements have no added benefit for the diagnosis of CMI.

Persistent symptom relief after revascularization in patients with single-artery chronic mesenteric ischemia.

OBJECTIVE: An isolated stenosis of the celiac artery (CA) or the superior mesenteric artery (SMA) is frequently detected in patients with abdominal complaints. The dilemma is whether these patients suffer from chronic mesenteric ischemia (CMI) and whether they will benefit from revascularization. We evaluated the long-term clinical success rates for single CA or SMA revascularization in patients with gastrointestinal symptoms and confirmed mucosal ischemia. METHODS: This was a retrospective cohort analysis of 59 consecutive patients with gastrointestinal symptoms and a single atherosclerotic mesenteric artery stenosis who were referred to our tertiary care institution between 2006 and 2010 for standardized diagnostic workup of CMI, including measurement of mucosal ischemia with visible light spectroscopy or gastric-jejunal tonometry. Patients with multidisciplinary consensus diagnosis of CMI underwent surgical or endovascular revascularization. The primary outcome was clinical response to revascularization, defined as relief of presenting symptoms as experienced by the patient. RESULTS: Consensus diagnosis of CMI was obtained in 37 of 59 patients. Isolated CA stenosis was present in 30 of 37 patients (81%) and isolated SMA stenosis in seven patients. After a mean follow-up of 5.0 ± 3.0 years, 27 of 37 patients (73%) experienced sustained symptom relief after revascularization. Response was not related to lesion localization (CA, 73%; SMA, 71%; P = .919). CONCLUSIONS: Revascularization of the CA or SMA provides persistent symptom relief in 73% of patients diagnosed with CMI due to single atherosclerotic mesenteric artery stenosis.

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.

Use of visible light spectroscopy to diagnose chronic gastrointestinal ischemia and predict response to treatment.

BACKGROUND & AIMS: Chronic gastrointestinal ischemia (CGI) is more common than previously thought. Visible light spectroscopy (VLS) allows for noninvasive measurements of mucosal capillary hemoglobin oxygen saturation during endoscopy. We evaluated the response of patients with occlusive CGI to treatment after evaluation by radiologic imaging of the vasculature and VLS. We also identified factors associated with response to treatment in these patients. METHODS: In a prospective study, we collected data from 212 patients referred for evaluation of suspected CGI from November 2008 through January 2011. Patients underwent an extensive evaluation that included visualization of gastrointestinal arteries and assessments of mucosal perfusion by means of VLS. Treatment response was evaluated in patients with occlusive CGI. Factors associated with response to therapy were assessed by using multivariate logistic regression analysis. RESULTS: Occlusive CGI was diagnosed in 107 patients (50%); 96 were offered treatment (90%). After median follow-up period of 13 months, data on treatment response were available from 89 patients (93%); 62 patients had a sustained response (70%). Weight loss before treatment (odds ratio [OR], 1.93), presence of an abdominal bruit (OR, 2.36), and corpus mucosal saturation level <56% (OR, 4.84) were the strongest predictors of a positive response to treatment. CONCLUSIONS: Treatment of CGI, diagnosed by a multimodal approach, provides a substantial long-term rate of response (70% in 13 months). Weight loss, abdominal bruit, and low corpus mucosal saturation identify patients most likely to respond to treatment. Multiple techniques should therefore be used to assess patients with CGI, including VLS measurements, to detect mucosal hypoxia.

Variation Between Hospitals in Outcomes and Costs of IBD Care: Results From the IBD Value Study.

BACKGROUND: Data on variation in outcomes and costs of the treatment of inflammatory bowel disease (IBD) can be used to identify areas for cost and quality improvement. It can also help healthcare providers learn from each other and strive for equity in care. We aimed to assess the variation in outcomes and costs of IBD care between hospitals. METHODS: We conducted a 12-month cohort study in 8 hospitals in the Netherlands. Patients with IBD who were treated with biologics and new small molecules were included. The percentage of variation in outcomes (following the International Consortium for Health Outcomes Measurement standard set) and costs attributable to the treating hospital were analyzed with intraclass correlation coefficients (ICCs) from case mix-adjusted (generalized) linear mixed models. RESULTS: We included 1010 patients (median age 45 years, 55% female). Clinicians reported high remission rates (83%), while patient-reported rates were lower (40%). During the 12-month follow-up, 5.2% of patients used prednisolone for more than 3 months. Hospital costs (outpatient, inpatient, and medication costs) were substantial (median: €8323 per 6 months), mainly attributed to advanced therapies (€6611). Most of the variation in outcomes and costs among patients could not be attributed to the treating hospitals, with ICCs typically between 0% and 2%. Instead, patient-level characteristics, often with ICCs above 50%, accounted for these variations. CONCLUSIONS: Variation in outcomes and costs cannot be used to differentiate between hospitals for quality of care. Future quality improvement initiatives should look at differences in structure and process measures of care and implement patient-level interventions to improve quality of IBD care. TRIAL REGISTRATION NUMBER: NL8276.

Variation in outcomes and costs cannot be used to differentiate between hospitals for quality of inflammatory bowel disease care. Future quality improvement initiatives should look at differences in structure and process measures and implement patient-level interventions to improve quality of inflammatory bowel disease care.

Covered versus bare-metal stenting of the mesenteric arteries in patients with chronic mesenteric ischaemia (CoBaGI): a multicentre, patient-blinded and investigator-blinded, randomised controlled trial.

BACKGROUND: Mesenteric artery stenting with a bare-metal stent is the current treatment for atherosclerotic chronic mesenteric ischaemia. Long-term patency of bare-metal stents is unsatisfactory due to in-stent intimal hyperplasia. Use of covered stents might improve long-term patency. We aimed to compare the patency of covered stents and bare-metal stents in patients with chronic mesenteric ischaemia. METHODS: We conducted a multicentre, patient-blinded and investigator-blinded, randomised controlled trial including patients with chronic mesenteric ischaemia undergoing mesenteric artery stenting. Six centres in the Netherlands participated in this study, including two national chronic mesenteric ischaemia expert centres. Patients aged 18 years or older were eligible for inclusion when an endovascular mesenteric artery revascularisation was scheduled and a consensus diagnosis of chronic mesenteric ischaemia was made by a multidisciplinary team of gastroenterologists, interventional radiologists, and vascular surgeons. Exclusion criteria were stenosis length of 25 mm or greater, stenosis caused by median arcuate ligament syndrome or vasculitis, contraindication for CT angiography, or previous target vessel revascularisation. Digital 1:1 block randomisation with block sizes of four or six and stratification by inclusion centre was used to allocate patients to undergo stenting with bare-metal stents or covered stents at the start of the procedure. Patients, physicians performing follow-up, investigators, and radiologists were masked to treatment allocation. Interventionalists performing the procedure were not masked. The primary study outcome was the primary patency of covered stents and bare-metal stents at 24 months of follow-up, evaluated in the modified intention-to-treat population, in which stents with missing data for the outcome were excluded. Loss of primary patency was defined as the performance of a re-intervention to preserve patency, or 75% or greater luminal surface area reduction of the target vessel. CT angiography was performed at 6 months, 12 months, and 24 months post intervention to assess patency. The study is registered with ClinicalTrials.gov (NCT02428582) and is complete. FINDINGS: Between April 6, 2015, and March 11, 2019, 158 eligible patients underwent mesenteric artery stenting procedures, of whom 94 patients (with 128 stents) provided consent and were included in the study. 47 patients (62 stents) were assigned to the covered stents group (median age 69·0 years [IQR 63·0-76·5], 28 [60%] female) and 47 patients (66 stents) were assigned to the bare-metal stents group (median age 70·0 years [63·5-76·5], 33 [70%] female). At 24 months, the primary patency of covered stents (42 [81%] of 52 stents) was superior to that of bare-metal stents (26 [49%] of 53; odds ratio [OR] 4·4 [95% CI 1·8-10·5]; p<0·0001). A procedure-related adverse event occurred in 17 (36%) of 47 patients in the covered stents group versus nine (19%) of 47 in the bare-metal stent group (OR 2·4 [95% CI 0·9-6·3]; p=0·065). Most adverse events were related to the access site, including haematoma (five [11%] in the covered stents group vs six [13%] in the bare-metal stents group), pseudoaneurysm (five [11%] vs two [4%]), radial artery thrombosis (one [2%] vs none), and intravascular closure device (none vs one [2%]). Six (13%) patients in the covered stent group versus one (2%) in the bare-metal stent group had procedure-related adverse events not related to the access site, including stent luxation (three [6%] vs none), major bleeding (two (4%) vs none), mesenteric artery perforation (one [2%] vs one [2%]), mesenteric artery dissection (one [2%] vs one [2%]), and death (one [2%] vs none). INTERPRETATION: The findings of this trial support the use of covered stents for mesenteric artery stenting in patients with chronic mesenteric ischaemia. FUNDING: Atrium Maquet Getinge Group.

Validity of the self-administered comorbidity questionnaire in patients with inflammatory bowel disease.

Background: The International Consortium for Health Outcomes Measurement has selected the self-administered comorbidity questionnaire (SCQ) to adjust case-mix when comparing outcomes of inflammatory bowel disease (IBD) treatment between healthcare providers. However, the SCQ has not been validated for use in IBD patients. Objectives: We assessed the validity of the SCQ for measuring comorbidities in IBD patients. Design: Cohort study. Methods: We assessed the criterion validity of the SCQ for IBD patients by comparing patient-reported and clinician-reported comorbidities (as noted in the electronic health record) of the 13 diseases of the SCQ using Cohen's kappa. Construct validity was assessed using the Spearman correlation coefficient between the SCQ and the Charlson Comorbidity Index (CCI), clinician-reported SCQ, quality of life, IBD-related healthcare and productivity costs, prevalence of disability, and IBD disease activity. We assessed responsiveness by correlating changes in the SCQ with changes in healthcare costs, productivity costs, quality of life, and disease activity after 15 months. Results: We included 613 patients. At least fair agreement (κ > 0.20) was found for most comorbidities, but the agreement was slight (κ < 0.20) for stomach disease [κ = 0.19, 95% CI (-0.03; 0.41)], blood disease [κ = 0.02, 95% CI (-0.06; 0.11)], and back pain [κ = 0.18, 95% CI (0.11; 0.25)]. Correlations were found between the SCQ and the clinician-reported SCQ [ρ = 0.60, 95% CI (0.55; 0.66)], CCI [ρ = 0.39, 95% CI (0.31; 0.45)], the prevalence of disability [ρ = 0.23, 95% CI (0.15; 0.32)], and quality of life [ρ = -0.30, 95% CI (-0.37; -0.22)], but not between the SCQ and healthcare or productivity costs or disease activity (|ρ| ⩽ 0.2). A change in the SCQ after 15 months was not correlated with a change in any of the outcomes. Conclusion: The SCQ is a valid tool for measuring comorbidity in IBD patients, but face and content validity should be improved before being used to correct case-mix differences.

Gelatinous bone marrow transformation due to extensive weight loss in median arcuate ligament syndrome.

A 34-year-old man was referred to the outpatient clinic because of progressive abdominal pain, weight loss and pancytopenia. His body mass index (BMI) had fallen to 14.2 kg/m2 A CT angiography (CTA) showed narrowing of the truncus coeliacus with poststenotic dilation, and duodenal biopsy revealed ischaemia establishing a rare diagnosis: median arcuate ligament syndrome (MALS). This explained the postprandial pain and minimal intake. Further pancytopenia workup was performed. The bone marrow displayed gelatinous marrow transformation (GMT), a rare disorder of unknown pathogenesis, which has been associated with severe malnutrition. The final diagnosis was pancytopenia secondary to GMT due to severe malnutrition caused by MALS. The abnormalities in the bone marrow may be reversible by restoring nutritional status. This case emphasises the awareness of GMT in patients with weight loss, malnutrition and cytopenias. To our knowledge, this is the first report demonstrating an association between pancytopenia and MALS.

MRI-based pre- and postprandial flow in the mesenteric vasculature of patients with suspected chronic mesenteric ischemia.

PURPOSE: The physiological increase of mesenteric blood flow after a meal is impaired in patients with occlusive chronic mesenteric ischemia (CMI). This principle could be used to develop a highly desired diagnostic test assessing the sufficiency of the collateral mesenteric circulation. This study assesses the potential to identify CMI patients using two-dimensional time-resolved phase-contrast magnetic resonance imaging (2D PC-MRI) flow measurements. METHOD: This prospective cohort study included patients with suspected CMI, based on: typical history, imaging, and functional testing. Cardiac gated 2D PC-MRI flow measurements (expressed as ml/min/kg) were performed in mesenteric arteries and veins during inspiration and expiration, after six hours of fasting and 20, 30, and 40 min after a meal challenge with a high caloric drink. RESULTS: Flow measurements were obtained in 19 patients: 8 CMI and 11 non-CMI. CMI patients showed a significantly smaller increase in postprandial blood flow in the superior mesenteric artery (SMA) at 30 and 40 min (30 min CMI 1.27(0.12-2.44) vs. non-CMI 7.82(6.28-10.90); 40 min CMI 0.30(-0.26-3.16) vs. non-CMI 7.94(6.32-10.90)) and a lower total arterial flow at 40 min (CMI 3.21(-0.72-5.05) vs. non-CMI 9.31(5.58-13.83)). Repeated flow measurements showed normalization of impaired postprandial venous flow after mesenteric artery stenting in one patient. CONCLUSIONS: The significantly lower increase in postprandial mesenteric blood flow in CMI patients confirms the promise of mesenteric blood flow measurements, before and 30-40 min after a meal, as a future diagnostic test to identify CMI patients among patients with a high clinical suspicion of CMI and mesenteric artery stenosis.

Value-based care pathway for inflammatory bowel disease: a protocol for the multicentre longitudinal non-randomised parallel cluster IBD Value study with baseline period.

INTRODUCTION: Biologics are effective for the treatment of inflammatory bowel disease (IBD). However, unwarranted variation in processes and outcomes has been reported in the treatment of IBD. A care pathway for the treatment of IBD has the potential to reduce practice variation and improve outcomes. This study aims to compare the effect of a uniform care pathway for the treatment of patients with IBD with biologics to the current situation. METHODS AND ANALYSIS: IBD Value is a longitudinal multicentre non-randomised parallel cluster trial with a baseline period. The study takes place in eight centres in the Netherlands. The baseline period will run for 12 months, after which the care pathway will be implemented in 6 of the 8 participating hospitals during the implementation phase of 3 months. Hereafter, the effect of the care pathway will be assessed for 12 months. Total study period is 27 months. The primary outcome is the effect of the care pathway on disease control (IBD-Control questionnaire). Secondary outcomes are the effect of the care pathway on the other outcomes of the International Consortium of Health Outcomes Measurement IBD standard set, health-related generic quality of life, patient experiences and degree of variation; cost effectiveness of the care pathway; and the variation between hospitals in the aforementioned outcomes in the baseline period. Outcomes will be measured every 6 months. The study started on 1 December 2020 and a minimum of 200 patients will be included. ETHICS AND DISSEMINATION: The study was deemed not to be subject to Dutch law (WMO; Medical Research Involving Human Subjects Act) by the Medical Ethics Committee of the Erasmus MC, the Netherlands (registration number: MEC-2020-075) and a waiver was provided. Results will be disseminated through peer-reviewed journals and presented at (inter)national conferences. TRIAL REGISTRATION NUMBER: NL8276.

Radiological imaging and gastrointestinal tonometry add value in diagnosis of chronic gastrointestinal ischemia.

BACKGROUND & AIMS: The diagnosis of chronic gastrointestinal ischemia (CGI) remains a clinical challenge. We aimed to assess the diagnostic value of clinical features, visualization of the gastrointestinal arteries, and evaluation of mucosal perfusion in patients clinically suspected of CGI. METHODS: A total of 186 patients referred for suspicion of CGI were prospectively included and followed up. All patients had an extensive diagnostic work-up, including visualization of the gastrointestinal arteries with computed tomography, magnetic resonance, or conventional angiography, and mucosal perfusion with tonometry. The reference standard for CGI was persistent clinical response after adequate therapy. The diagnostic value of individual and combined tests was assessed with multivariable logistic regression analysis. RESULTS: A total of 116 (62%) patients were diagnosed with CGI. In a multivariable model solely based on clinical features, the strongest predictors for CGI were the presence of postprandial pain, weight loss per month in kilograms, concomitant cardiovascular disease, and presence of an abdominal bruit. However, this model showed limited discriminative ability for the presence or absence of CGI (c-statistic, 0.62). Adding radiologic imaging to the prediction model improved the discriminative ability substantially (c-statistic, 0.81). Adding tonometry to the prediction model further improved the discriminative ability of the model (c-statistic, 0.90). The combination of clinical features and tonometry with a c-statistic of 0.88 approximated the discriminative ability of the latter model. CONCLUSIONS: Clinical features alone have a limited value to assess CGI correctly. Visualization of the gastrointestinal arteries and evaluation of mucosal perfusion substantially improve the diagnosis of CGI. The strongest diagnostic contribution comes from mucosal perfusion assessment.

Endoscopic visible light spectroscopy: a new, minimally invasive technique to diagnose chronic GI ischemia.

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.

Serum markers and intestinal mucosal injury in chronic gastrointestinal ischemia.

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.