A systematic review and meta-analysis of disease severity and risk of recurrence in young versus elderly patients with left-sided acute diverticulitis.

Young patients are thought to have a more severe disease course and a higher rate of recurrent diverticulitis. However, these understandings are mainly based on studies with important limitations. This review aimed to clarify the true natural history of acute diverticulitis in young patients compared to elderly patients. PubMed and MEDLINE were searched for studies reporting outcomes on disease severity or recurrences in young and elderly patients with a computed tomography-proven diagnosis of acute diverticulitis. Twenty-seven studies were included. The proportion of complicated diverticulitis at presentation (21 studies) was not different for young patients (age cut-off 40-50 years) compared to elderly patients [risk ratio (RR) 1.19; 95% confidence interval 0.94-1.50]. The need for emergency surgery (11 studies) or percutaneous abscess drainage (two studies) yielded comparable results for both groups with a RR of 0.93 (95% confidence interval 0.70-1.24) and 1.65 (95% confidence interval 0.60-4.57), respectively. Crude data on recurrent diverticulitis rates (12 studies) demonstrated a significantly higher RR of 1.47 (95% confidence interval 1.20-1.80) for young patients. Notably, no association between age and recurrent diverticulitis was found in the studies that used survival analyses, taking length of follow-up per age group into account. In conclusion, young patients do not have a more severe course of acute diverticulitis. Published data on the risk of recurrent diverticulitis in young patients are conflicting, but those with the most robust design do not demonstrate an increased risk. Therefore, young patients should not be treated more aggressively nor have a lower threshold for elective surgery just because of their age.

Jejunal tonometry for the diagnosis of gastrointestinal ischemia. Feasibility, normal values and comparison of jejunal with gastric tonometry exercise testing.

BACKGROUND AND AIM: In most patients with chronic splanchnic syndrome the celiac artery is involved, enabling the use of gastric exercise tonometry as a diagnostic function test. In this study, we investigated the feasibility of combining gastric and jejunal exercise tonometry and determined the normal values. We investigated the potential diagnostic value of combining gastric with jejunal exercise tonometry. MATERIALS AND METHOD: Between 1998 and 2000, combined gastric and jejunal exercise tonometry tests were performed in a healthy volunteer and in patients suspected of chronic gastrointestinal ischemia. Using automated air tonometry, gastric (PgCO2) and jejunal PCO2 (PjCO2) were measured before, during and after 10-min of exercise. Luminal-arterial PCO2 gradients (DeltagPCO2 respectively DeltajPCO2) were calculated. In the patient cohort, final diagnosis of chronic ischemia was made by our institutional multidisciplinary working group on gastrointestinal ischemia. RESULTS: Jejunal tonometry was possible in 25 of 27 participants. The healthy volunteer was tested twice, yielding a total of 26 combined tests. Mean normal basal PjCO2 was 0.9 kPa higher than PgCO2. The calculated upper threshold (mean+2SD) of normal DeltajPCO2 was 1.4 kPa. In five of eight patients with chronic gastrointestinal ischemia gastric exercise tonometry was abnormal, in one, both gastric and jejunal tonometry were abnormal, in two only jejunal exercise tonometry was abnormal. CONCLUSION: Combined gastric and jejunal exercise tonometry is a feasible procedure that is relatively easy to perform. On the basis of this pilot study, jejunal tonometry seems to have a small additional value in the diagnosis of chronic gastrointestinal ischemia.

What is the best diagnostic approach for chronic gastrointestinal ischemia?

BACKGROUND: Chronic gastrointestinal ischemia is still a difficult diagnosis to establish. The diagnosis depends on a high degree of clinical suspicion as well as selective angiography. Duplex sonography may serve as a screening tool, providing information on splanchnic vessel patency and flow patterns. GET is a minimally invasive test that can be used for diagnosis in patients with chronic gastrointestinal ischemia, and can differentiate between symptomatic and asymptomatic splanchnic artery stenosis. In the present study, we compared four different diagnostic approaches. METHODS: Between 1997 and 2000, 84 patients were evaluated for suspected chronic gastrointestinal ischemia. All underwent splanchnic arterial angiography, duplex sonography, and GET. For the presence or absence of stenosis, angiography was used as the gold standard. For diagnosing ischemia, we relied on a panel decision. The diagnostic approaches studied were: (a) angiography, only in patients with classic abdominal angina; (b) screening with duplex sonography, angiography if sonography abnormal or unreliable; (c) screening with gastric tonometry and angiography if tonometry not normal; (d) both gastric tonometry exercise and duplex sonography, angiography if one of both screening tests not normal. RESULTS: In 28 patients, chronic gastrointestinal ischemia was diagnosed. Using clinical suspicion only, 16 patients (57%) would have been missed. Screening by duplex sonography or gastric tonometry only would have missed 4 or 6 patients, respectively. Screening with combined gastric tonometry and duplex sonography would not have missed patients with symptomatic ischemia, while 21% of angiographies would have been avoided. CONCLUSION: Screening by combined GET and duplex sonography has excellent diagnostic accuracy. Currently, this approach represents the best diagnostic workup strategy in patients with suspected chronic gastrointestinal ischemia.

Triggering for submaximal exercise level in gastric exercise tonometry: serial lactate, heart rate, or respiratory quotient?

Gastric exercise tonometry is a functional diagnostic test in chronic gastrointestinal ischemia. As maximal exercise can cause false-positive tests, exercise buildup should be controlled to remain submaximal. We evaluated three parameters for monitoring and adjusting exercise levels (heart rate [HR], respiratory quotient [RQ], and serial lactate measurements) in 178 tests in both healthy volunteers and patients suspected of gastrointestinal ischemia. Exercise levels above submaximal occurred in 20% of HR-, 2% of RQ-, and 5% of lactate-monitored tests (P<0.05 for HR vs. RQ and lactate). Low levels were seen in 5% of HR-, 10% of RQ-, and 41% of lactate-monitored tests (P<0.01 for lactate vs. HR and RQ). High levels resulted in 43% false-positive tonometry results compared to 19% of all tests (P<0.001); low levels did not result in more false negatives (5% vs. 6%). Although RQ monitoring yielded the greatest proportion of optimal exercise tests, serial lactate monitoring is our method of choice, combining optimal diagnostic accuracy, low cost, and simplicity.

Gastric exercise tonometry: the key investigation in patients with suspected celiac artery compression syndrome.

INTRODUCTION: Controversy continues about the mere existence of the celiac artery compression syndrome. Earlier results of treatment of unselected patients groups showed varying, mostly disappointing, results. The recently introduced gastric exercise tonometry test is able to identify patients with actual gastrointestinal ischemia. We prospectively studied the use of gastric exercise tonometry as a key criterion for revascularization treatment in patients with otherwise unexplained abdominal complaints and significant stenosis of the celiac artery by compression of the arcuate ligament. METHODS: Patients were prospectively selected using abdominal artery angiography and gastric exercise tonometry. Patients with a significant compression of the celiac artery, typical abdominal complaints, and abnormal tonometry were considered for revascularization. RESULTS: Over a 7-year period, 43 patients with significant celiac artery compression were included in this study, and 30 patients were diagnosed as ischemic. Twenty-nine patients had revascularization, 22 (76 %) had a trunk release only. After a median follow-up of 39 months, 83% of patients were free of symptoms. The repeated tonometry after treatment improved in 100% of patients free of symptoms, compared with 25% in patients with persistent complaints after revascularization. CONCLUSIONS: The results of this study suggest that the celiac axis compression syndrome exists and that the actual ischemia can be detected by gastric exercise tonometry and treated safely, with success.

Clinical impact of gastric exercise tonometry on diagnosis and management of chronic gastrointestinal ischemia.

BACKGROUND & AIMS: Chronic gastrointestinal ischemia or chronic splanchnic syndrome is a difficult diagnosis. The use of a physiologic test, combined with clinical and anatomic data, should improve diagnostic accuracy. This study evaluates the diagnostic accuracy and clinical impact of gastric tonometry during exercise (GET) in a patient cohort suspected of chronic splanchnic syndrome. METHODS: From 1997 to 2000, 102 patients with chronic abdominal pain were analyzed. The workup included GET and selective biplane angiography. The diagnosis of gastrointestinal ischemia was based on consensus in a multidisciplinary working group and sustained on follow-up. RESULTS: Gastrointestinal ischemia was diagnosed in 38 patients. In 33 patients chronic splanchnic syndrome was found, with single vessel involvement in 20 (17 celiac artery, 3 mesenteric superior) and multivessel disease in 13. In 5 patients nonocclusive ischemia was found. By using receiver operator curve analysis, the difference between gastric and arterial partial pressure of carbon dioxide (PCO2 gradient) proved to be the best GET parameter. The criteria for diagnosing ischemia in GET were Pco2 gradient > 0.8 kPa and increase gastric PCO2, with base excess decrease <8 mmol/L during exercise. GET had 78% sensitivity and 92% specificity. Twenty-five patients underwent vascular treatment (19 operative, 6 stent/percutaneous transluminal angioplasty). After 4 years of follow-up 83% of patients were alive and free of symptoms. CONCLUSIONS: GET is an accurate diagnostic tool to show gastrointestinal ischemia. Including GET into clinical decision making enabled selecting patients with ischemia, who benefited from vascular and medical treatment. These benefits were sustained during 4-year follow-up. GET should be considered in the workup of patients with a suspected diagnosis, of gastrointestinal ischemia.