Lethal nature of ischemic gastropathy

Gastric ischemia as an under-reported cause of death in older people

Acute gastric ischemia is a rare condition due to the rich vascular supply of the stomach. Here we present a case of fatal gastric ischemia associated with bowel ischemia, only diagnosed at autopsy, which was requested for the suspicion of medical liability. A complete post-mortem examination was conducted, along with a macroscopic analysis of the superior mesenteric artery and detailed histological analyses. Past clinical data was also reviewed. The macroscopic blackish discoloration of the stomach and the bowel, coupled with the presence of neutrophils in the mucosa and submucosal non-occlusive thrombi, were consistent with gastric and bowel ischemia, despite the presence of confounding putrefactive changes. The unique aspect of this case resides in the ante-mortem peculiar vascularization of the stomach, supplied by small collateral vessels. No mechanical occlusion was identified, and the cause of the ischemia was deemed as non-occlusive, likely due to systemic hypoperfusion. The analysis of clinical data and documentation of associated comorbidities are strongly recommended, especially when a rare cause of death is suspected. With the aging population, especially among women, and the prevalence of risk factors, the forensic pathologist could increasingly encounter rare cases of gastric ischemia.

Ischemic gastropathy with "leopard skin" stomach

Ischemic gastropathy is a rare, underreported phenomenon that is associated with a poor prognosis. Patients often present with signs of shock, gastrointestinal bleeding, and anemia. We describe a patient with alcoholic cirrhosis who presented after a fall in hemorrhagic shock. Initial endoscopy revealed evidence of ongoing bleeding, with subsequent endoscopy revealing the "leopard skin" appearance in the stomach. The patient was treated supportively but eventually succumbed to his condition. Prompt diagnosis, treatment, and awareness of the delayed changes on upper endoscopy are imperative in diagnosing ischemic gastropathy. Patients with risk factors for the condition need to be given additional consideration for this diagnosis.

Successful management of gastric remnant necrosis after proximal gastrectomy using a double elementary diet tube: a case report

Background

The stomach has many incoming vessels and is resistant to ischemia due to the rich microvascular network within its submucosal layer. Although reports of gastric remnant necrosis after gastrectomy have been rare, mortality rates remain substantially high when present. A double elementary diet (W-ED) tube, which can be used for both enteral feeding and gastrointestinal tract decompression, has been developed for anastomotic leakage and postoperative nutritional management after upper gastrointestinal surgery. The current report presents a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment with a W-ED tube.

Case presentation

A 73-year-old male was referred to our hospital for an additional resection after endoscopic submucosal dissection (ESD) for gastric cancer. Endoscopic findings showed an ESD scar on the posterior wall of the upper portion of the stomach, while computed tomography (CT) showed no obvious regional lymph node enlargement and distant metastases. The patient subsequently underwent laparoscopic proximal gastrectomy and esophagogastrostomy but developed candidemia on postoperative day 7. On postoperative day 14, endoscopy revealed gastric ischemic changes around the anastomotic site, suggesting that the patient’s candidemia developed due to gastric necrosis. His vital signs remained normal, while the gastric remnant ischemia was localized. Given that surgery in the presence of candidemia was considered extremely risky, conservative treatment was elected. A W-ED tube was placed nasally, after which enteral feeding was initiated along with gastrointestinal tract decompression. Although the patient subsequently developed anastomotic leakage due to gastric remnant necrosis, local control was achieved and conservative treatment was continued. On postoperative day 52, healing of the gastric remnant necrosis and anastomotic leakage was confirmed, after which the patient started drinking water. Although balloon dilation was required due to anastomotic stenosis, the patient was able to resume oral intake and was discharged on postoperative day 88.

Conclusions

Herein, we present our experience with a case of gastric remnant necrosis after proximal gastrectomy, wherein conservative management was achieved using a W-ED tube. In cases involving high operative risk, the management should be mindful of gastric remnant necrosis as a post-gastrectomy complication.

Acute Gastric Necrosis in a Teenager

Gastric infarction is a rare condition often associated with high mortality due to a delay in diagnosis. The stomach which has a rich supply of blood is a rare site for such a condition. Gastric infarction has a long list of etiological factors. We report a case of a patient who was managed successfully following gastric infarction from gastric dilatation. An 18-year-old female student presented with a three-day history of abdominal pain associated with abdominal distension of two days. The abdomen was distended with generalized tenderness, rebound tenderness, and guarding. Bowel sounds were absent. Digital rectal examination was unremarkable, and a pregnancy test was negative. Biochemical tests were all normal. Intraoperatively, two litres of serosanguinous fluid was suctioned from the abdomen. About 300 mL of pus was suctioned from the pelvis. The gangrenous portion was resected, and repair was done in two layers using Conell and Lambert suture techniques. Acute gastric necrosis is a rare surgical condition that requires a high index of suspicion and prompts aggressive resuscitation and surgical intervention to obviate the high mortality rate associated with the condition.

Gastric remnant necrosis secondary to cholesterol crystal embolization after distal gastrectomy in a gastric cancer patient: a case report

Background

Distal gastrectomy with lymph node dissection, a standard operative technique for gastric cancer treatment, is safely performed because the stomach has a rich vascular supply. Gastric remnant necrosis caused by cholesterol crystal embolization following distal gastrectomy has not been described previously. We report a case of gastric remnant necrosis in a patient with cholesterol crystal embolization.

Case presentation

A 70-year-old man with a history of cholesterol crystal embolization presented to our surgery department with complaints of anorexia and dysphasia. He was diagnosed with gastric cancer invading the pyloric antrum and underwent distal gastrectomy with Billroth 2 reconstruction. On postoperative day 11, he developed abdominal pain without fever. Emergency laparotomy revealed that most parts of the remnant stomach were necrosed. Total gastrectomy with Roux-en-Y reconstruction and abscess drainage were performed. After surgery, anastomotic leakage occurred and was treated conservatively. However, the superior pancreaticoduodenal artery aneurysm suddenly ruptured and he expired.

Conclusions

Gastric remnant necrosis after distal gastrectomy can be a gastrointestinal presentation of cholesterol crystal embolization. Perioperative/intraoperative risk assessments such as preventive total gastrectomy or intraoperative assessment with indocyanine green fluorescence angiography may be desirable to avoid this complication.

Gastric Necrosis and Perforation Following Massive Gastric Dilatation in an Adolescent Girl: A Rare Cause of Acute Abdomen

Gastric necrosis with perforation is a rare and potentially life-threatening condition in childhood beyond the neonatal period. We report a case of gastric necrosis and perforation of a portion of the great curvature due to a massive gastric dilatation caused by pathological aerophagia in a 13-years-old, mentally impaired adolescent girl. Despite the successful surgical treatment, the patient's condition rapidly deteriorated post-operatively and she died due to the multisystem organ failure and multiple infections. In addition, we surveyed the literature on this rare condition and assessed the preventive actions to reduce this life-treating condition.

A case of ischemic gastroduodenal disease in a patient who was receiving hemodialysis treatment that was managed by conservative treatment

A 69-year-old man was under maintenance dialysis due to diabetic renal failure. He had a drop in blood pressure during dialysis, developed hematemesis, and was transported to our hospital. Emergency upper gastrointestinal endoscopy revealed diffuse erosion, mucosal sloughing, and edematous mucosa in the upper body of the stomach to the posterior wall of the antrum and to the greater curvature, which were considered to be an ischemic change. His underlying diseases included diabetic renal failure, chronic arteriosclerosis obliterans, cerebral infarction, internal carotid artery stenosis, hypertension, and myocardial infarction. Blood evaluation showed only mild inflammation and no fibrinolytic hyperactivity. Contrast-enhanced computed tomography (CECT) showed no occlusion of blood vessels. It was considered that the patient had a transient ischemic change due to blood pressure drop. The patient's condition improved with conservative treatment.

Clinical Features and Outcomes of Gastric Ischemia

BACKGROUND AND AIMS

Gastric ischemia is a rare condition associated with poor prognosis. Our study aim was to highlight the clinical features and outcomes of patients with gastric ischemia.

METHODS

A retrospective review of patients diagnosed with isolated gastric ischemia at our institution from January 1, 2000, to May 5, 2016, was performed. Demographic, clinical, endoscopic, radiologic, and outcome variables were abstracted for analysis.

RESULTS

Seventeen patients (65% men) with mean age of 69.3 ± 11.3 years and body mass index of 28.8 ± 11.1 were identified. The etiologies for gastric ischemia included local vascular causes (n = 8), systemic hypoperfusion (n = 4), and mechanical obstruction (n = 5). The most common presenting symptoms were abdominal pain (65%), gastrointestinal bleeding (47%), and altered mental status (23%). The typical endoscopic appearance was mucosal congestion and erythema with or without ulceration. Gastric pneumatosis and portal venous air were more commonly seen on CT imaging. Radiologic and/or surgical intervention was needed in 9 patients, while the remaining 8 patients were managed conservatively with acid suppression, antibiotics, and nasogastric tube decompression. The median duration of hospital stay was 15 days (range 1-36 days). There were no cases of rebleeding and the mortality rate as a direct result of gastric ischemia was 24% within 6 months of diagnosis.

CONCLUSION

Although uncommon, gastric ischemia is associated with significant mortality. Endoscopy and CT imaging play an important role in its diagnosis. The management of gastric ischemia is dictated by its severity and associated comorbidities.

Ischemic Necrosis of the Gastric Remnant without Splenic Infarction Following Subtotal Gastrectomy

Gastric remnant necrosis after a subtotal gastrectomy is an extremely uncommon complication due to the rich vascular supply of the stomach. Despite its rareness, it must be carefully addressed considering the significant mortality rate associated with this condition. Patients vulnerable to ischemic vascular disease in particular need closer attention and should be treated more cautiously. When gastric remnant necrosis is suspected, an urgent endoscopic examination must be performed. We report a case of gastric remnant necrosis following a subtotal gastrectomy and discuss possible risk factors associated with this complication.

Chronic Gastric Ischemia Leading to Gastric Perforation

A 69-year-old man with diabetes, peripheral vascular disease, and hypertension presented with 3 months of diffuse abdominal pain that worsened with meals, weight loss, and dysphagia. Esophagogastroduodenoscopy and computed tomography revealed findings consistent with chronic gastric ischemia secondary to atherosclerosis. Gastric ischemia eventually led to perforation. We discuss causes, symptoms, diagnosis, and management of gastric ischemia, an underdiagnosed and potentially fatal condition that requires urgent diagnosis and treatment.

Sulforaphane Improves Ischemia-Induced Detrusor Overactivity by Downregulating the Enhancement of Associated Endoplasmic Reticulum Stress, Autophagy, and Apoptosis in Rat Bladder

Atherosclerosis-associated pelvic ischemia has been reported to be a risk factor for bladder dysfunction and subsequent lower urinary tract symptoms (LUTS) in the elderly population. However, the molecular mechanisms of this association remain unclear. We hypothesized that stress-induced cellular responses might play a role in the pathogenesis of ischemia-induced bladder dysfunction. In the present study, the animal model of bladder ischemia was induced by bilateral partial arterial occlusion (BPAO) in rats. We found that BPAO significantly induced the presence of detrusor overactivity (DO) and upregulated the expression of several molecular reactions, including biomarkers in endoplasmic reticulum stress (78 kDa glucose-regulated protein, GRP78 and C/EBP-homologous protein, CHOP), autophagy (Beclin-1, p62 and LC3 II) and apoptosis (caspase 3). BPAO also disturbed the Kelch-like ECH-associated protein 1–nuclear factor erythroid-2-related factor 2 (Keap1–Nrf2) pathways. These responses might collectively alter muscarinic and purinergic signaling and contribute to the presence of DO in the ischemic bladder. Therapeutically, treatment with neither a muscarinic nor purinergic receptor antagonist restored bladder function. Interestingly, sulforaphane effectively attenuated ischemia-enhanced endoplasmic reticulum stress, autophagy and apoptosis in the bladder, subsequently ameliorated ischemia-induced bladder dysfunction and might emerge as a novel strategy to protect the bladder against ischemia-induced oxidative damage.

Ischemic Gastritis: A Multicenter Case Series of a Rare Clinical Entity and a Review of the Literature

GOALS

To report a case series of ischemic gastritis and discuss its etiology, management, and associated mortality according to our results and the published English literature.

BACKGROUND

Ischemic gastritis is rare, given the rich blood supply of the stomach. It has been reported in isolated case reports and small case series. Most cases are vascular in origin and associated with a high mortality.

STUDY

Pathology databases from 3 hospitals affiliated with the University of Minnesota Medical School were searched for cases of ischemic gastritis in the last 10 years. Patients' demographics, clinical course, and 1-month and 1-year mortalities were collected from electronic medical records.

RESULTS

A total of 12 patients were identified (age range, 32.1 to 83.2), the largest series reported to date. The presenting symptom was gastrointestinal bleeding (8), abdominal pain (2), nausea (1), and symptomatic anemia (1). The etiology included postinterventional radiology embolization (2), hemodynamic changes in the setting of celiac axis stenosis (2), vasculitis (1), systemic hypotension (1), and unknown (6). Treatment included steroid therapy, revascularization by interventional radiology, surgery, or supportive treatment. Thirty-day and 1-year mortalities were 33% and 41%, respectively.

CONCLUSIONS

Ischemic gastritis is rare, but associated with a high mortality. Evaluation for treatable etiologies should be sought and corrected if present.

Ischemic Gastropathic Ulcer Mimics Gastric Cancer

Gastric ulcer due to mesenteric ischemia is a rare clinical finding. As a result, few reports of ischemic gastric ulcers have been reported in the literature. The diagnosis of ischemic gastropathy is seldom considered in patients presenting with abdominal pain and gastric ulcers. In this case report, we describe a patient with increasing abdominal pain, weight loss, and gastric ulcers, who underwent extensive medical evaluation and whose symptoms were resistant to medical interventions. Finally he was diagnosed with chronic mesenteric ischemia, and his clinical and endoscopic abnormalities resolved after surgical revascularization of both the superior mesenteric artery and the celiac trunk.

Pathogenesis, diagnosis, and management of gastric ischemia

BACKGROUND & AIMS

Gastric ischemia is infrequently reported in the medical literature and under-recognized clinically and histopathologically. Various medical terms are used to describe gastric ischemia. We define and review the pathogenesis, diagnosis, and management of gastric ischemia.

METHODS

We describe 6 cases of gastric ischemia. We discuss features of the gastric vascular supply and review literature on this disorder.

RESULTS

Gastric ischemia results from diffuse or localized vascular insufficiency caused by etiologies such as systemic hypotension, vasculitis, or disseminated thromboembolism. The disorder is managed by fluid resuscitation, nasogastric tube placement (for intermittent air and fluid aspiration, to prevent or reduce gastric distention), aggressive acid reduction (via intravenous administration of proton pump inhibitors), and selective use of broad-spectrum antibiotics for patients with sepsis or gastric pneumatosis.

CONCLUSIONS

Gastric ischemia has a poor prognosis. Early diagnosis is required for appropriate patient management.

Gastric remnant necrosis following splenic infarction after distal gastrectomy in a gastric cancer patient

INTRODUCTION

Distal gastrectomy with lymph node dissection is the standard treatment for gastric cancer. Remnant gastric necrosis after distal gastrectomy is very rare and fatal complication.

PRESENTATION OF CASE

A-78-year-old male diagnosed with advanced gastric cancer underwent distal gastrectomy with lymph node dissection. Postoperative gastric remnant necrosis occurred following splenic infarction. There was thought to be an insufficient blood supply to the gastric remnant due to the lymph node dissection along the proximal splenic artery during the initial surgery. Non-contrast abdominal computed tomography did not reveal any necrosis in the remnant stomach. An endoscopic examination confirmed this diagnosis. Total remnant gastrectomy was performed, and the patient thereafter successfully recovered.

DISCUSSION

Careful management of blood vessels and lymph node dissection above the pancreas should be performed to avoid restricting the blood flow and also to prevent gastric remnant necrosis.

CONCLUSION

The knowledge of this fatal complication is crucial for management of postoperative complication. For early and accurate diagnosis, upper gastrointestinal endoscopy is necessary in case of remnant gastric necrosis.

Ischemic bowel syndromes

Atherosclerotic vascular disease involving the mesenteric arteries occurs frequently in the elderly population. Although the prevalence of ischemic bowel disease is difficult to determine, acute mesenteric ischemia (AMI) has been reported to cause in 1 in 1000 hospital admissions, whereas chronic mesenteric ischemia (CMI) is estimated to affect 1 in 100,000 individuals. Mesenteric ischemia generally manifests in its chronic form as postprandial abdominal pain resulting in significant weight loss, and in its acute form as an abrupt development of abdominal pain, lower gastrointestinal bleeding, and subsequent intestinal necrosis. This article discusses the cause, clinical manifestations, diagnosis, and management of AMI and CMI.

Lethal nature of ischemic gastropathy: a case report of celiomesenteric vascular insufficiency

Celiomesenteric ischemia has an insidious onset and the non-specific symptoms are often misdiagnosed as cholecystitis or peptic ulcer disease with a consequential delay between the onset of symptoms and radiological evidence of vascular occlusive disease. A elderly man was hospitalized after a 2-3 week history of acute abdominal pain, frequent vomiting, and chronic diarrhea associated with bloody stools. Upper gastrointestinal endoscopy showed a cobblestone gastric pattern with multiple ulcerated areas and the specimens indicated focal full thickness coagulative necrosis of the mucosa. A magnetic resonance angiography (MRA) revealed a widespread and severe atheromatous disease characterized by a hemodynamically significant stenosis of the celiac tripod, pre-occlusive stenosis of the superior mesenteric artery and complete occlusion of the inferior mesenteric artery. MRA is now the best and most accessible noninvasive examination to help establish a diagnosis, providing high-quality three-dimensional images of the celiac axis and mesenteric arteries. However, the various features observed in this case such as the clinical history, the presence of a cobblestone pattern with multiple ulcerated areas in the stomach, the coagulative-type necrosis and ischemic atrophy of the adjacent mucosa were considered diagnostic of gastric ischemia.

[A rare cause of gastric ulcer]

Drug-induced gastrointestinal tract lesions are becoming more frequent but are generally little known. Although a large number of drugs have gastrointestinal adverse effects, there are few characteristic patterns. Acute ischemic gastritis is an uncommon entity that is rarely distinguished from other forms of intestinal ischemia. We report the case of a 69-year-old woman who was diagnosed with an unusual gastric lesion in the context of an acute exacerbation of her anemia.

Abdominal angina

Abdominal angina is an underrecognized cause of postprandial abdominal pain and weight loss. Diagnosis is often delayed and requires both a careful exclusion of more common causes and a high degree of clinical suspicion, based on the patient's age, the coexistence of multiple risk factors for atherosclerosis, and the presence of vasculopathy in other districts. Appropriate investigations include duplex ultrasound, traditional angiography, magnetic resonance angiography, computed tomography angiography, and tonometry. The purpose of this review is to discuss the pathophysiology and clinical presentation of chronic mesenteric ischemia and to suggest a diagnostic flowchart for this complex condition.

Role for endovascular therapy in chronic mesenteric ischemia

Chronic mesenteric ischemia is a rare condition that is caused by stenosis or occlusion of the mesenteric arteries and usually manifests as abdominal pain. While surgical revascularization has been the standard treatment for symptomatic patients, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Percutaneous transluminal angioplasty with stent placement is now recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate; consequently, the technique is suggested for the primary treatment of chronic mesenteric ischemia. The present article discusses the indications and principles of endovascular treatment, and reviews the literature, with emphasis on short- and long-term outcomes, particularly morbidity and mortality rates.

Chronic mesenteric ischemia: efficacy and outcome of endovascular therapy

Chronic mesenteric ischemia is a rare condition caused by occlusive disease of the mesenteric vessels and manifested most commonly as abdominal pain. While the traditional therapy in symptomatic patients has been surgery, recent improvements in interventional devices and refinement in techniques have increased the popularity of endovascular treatment. The high procedural success and the low complication rate make the catheter-based approach an interesting alternative to surgery. Percutaneous angioplasty and stenting is now recognized as a minimally invasive means of obtaining good long-term results and is consequently suggested for the primary treatment of chronic mesenteric ischemia. This article presents a review of the literature on indications and technical aspects of endovascular treatment, with emphasis on short- and long-term outcomes.

Risk factors for gastrointestinal complications in aspirin users: review of clinical and experimental data

This paper reviews recent clinical evidence that suggests that aspirin prophylaxis against cardiac and cerebral vascular ischemia is associated with significant gastrointestinal complications. The clinical and experimental evidence to confirm the role of risk factors of concomitant use of nonsteroidal anti-inflammatory drugs (NSAID), tobacco cigarette smoking, and alcohol consumption are discussed. The limitations of long-term acid suppression treatment for the prevention of these complications are considered. Future experimental studies to guide the clinical approach to develop novel and potentially cost-effective management strategies are discussed.

Association of lower urinary tract symptoms and chronic ischaemia of the lower urinary tract in elderly women and men: assessment using colour Doppler ultrasonography

OBJECTIVES

To investigate, using transrectal colour Doppler ultrasonography, (TRCDUS) whether perfusion of the bladder and prostate is reduced in elderly patients with lower urinary tract symptoms (LUTS), common in later life, as experimental data suggest that chronic ischaemia has a key role in the development of LUTS.

PATIENTS, SUBJECTS AND METHODS

In 32 elderly patients with LUTS (12 women, mean age 82.3 years, group 1; and 20 men, 79.4 years, group 2) perfusion of the bladder neck (in women) and of the bladder neck and prostate (in men) was measured using TRCDUS and the resistive index (RI) and colour pixel density (CPD) determined, assessed by a TRUS unit and special software. To assess the age-related effect two control groups of 10 young healthy women (mean age 42.3 years, group 3) and 10 age-matched healthy men (mean age 41.5 years, group 4) were also enrolled.

RESULTS

Irrespective of gender, there was markedly lower bladder perfusion in elderly patients with LUTS than in the younger subjects. The mean (SD) RI of the bladder neck in group 1, of 0.88 (0.06), and group 2, of 0.80 (0.08), was higher than in control groups 3, of 0.62 (0.05), and group 4, of 0.64 (0.09). The results were similar for the CPD measurements. The frequency of daily and nightly micturition showed a strong negative correlation with perfusion in the urinary bladder.

CONCLUSION

In elderly patients with LUTS there was decreased perfusion of the bladder neck and prostate when assessed using TRCDUS. Therefore, decreased perfusion in the urinary bladder might be responsible for the development of LUTS with advancing age.

Ischaemic gastric ulceration with endoscopic healing after revascularization

A 66-year-old man with a history of abdominal pain, diarrhoea and weight loss was admitted for evaluation. Gastroscopy disclosed a severe gastric ulceration covering the lesser curvature. There was none of the usual risk factors for peptic ulcer disease and no malignancy was found. After 2 weeks' treatment with a proton pump inhibitor no healing was observed. The patient had a known atherosclerotic vascular disease, and angiography disclosed severe mesenteric ischaemia. After a revascularization procedure with stenting of the superior mesenteric artery was performed, the patient's symptoms disappeared. Healing of the gastric ulceration was observed at a further gastroscopy 2 weeks later. Chronic ischaemia is a rare cause of gastric ulcer, but should be suspected when no other cause is found and when the usual treatment with proton pump inhibitors does not result in healing.

Endovascular therapy for chronic mesenteric ischemia

OBJECTIVES

We sought to describe the outcomes of a consecutive series of patients with chronic mesenteric ischemia (CMI) who were treated with percutaneous stent revascularization.

BACKGROUND

Historically, the treatment for CMI has been surgical revascularization. However, surgery carries a significant procedural complication rate and mortality.

METHODS

Fifty-nine consecutive patients with CMI underwent stent placement in 79 stenotic (>70%) mesenteric arteries. All patients had clinical follow-up and 90% had anatomical follow-up with angiography (computed tomography or conventional) or ultrasound at > or =6 months after the procedure.

RESULTS

Procedural success was obtained in 96% (76 of 79 arteries) and symptom relief occurred in 88% (50 patients). At a mean follow-up of 38 +/- 15 months (range, 6 to 112 months), 79% of the patients remained alive, and 17% (n = 10) experienced a recurrence of symptoms. Angiography or ultrasound obtained at 14+/- 5 months after the procedure demonstrated a restenosis rate of 29% (n = 20). All patients with recurrent symptoms had angiographic in-stent restenosis and were successfully revascularized percutaneously.

CONCLUSIONS

Percutaneous stent placement for the treatment of CMI can be performed with a high procedural success and a low complication rate. The long-term freedom from symptoms and vascular patency are comparable with surgical results. The inherent lower procedural morbidity and mortality makes the endovascular approach the preferred revascularization technique for these patients.

American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis

This literature review and the recommendations herein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on May 16, 2004, and by the AGA Governing Board on September 23, 2004.

Effect of chronic ischemia on bladder structure and function

Our studies with the animal model show that arterial stenosis and insufficiency--a common problem in the elderly--lead to marked changes in bladder structure and function. Moderate chronic ischemia leads to functional and structural changes quite different from those caused by severe chronic ischemia. The extent of histopathophysiologic changes in the chronically ischemic bladder depends on the degree of arterial stenotic disease and the severity of bladder ischemia. Histopathophysiologic changes in our animal model appear to be similar in many ways to those reported in clinical detrusor instability. This would suggest that vascular risk factors and ensuing arterial obstructive disease and bladder ischemia might play an important role in the development of bladder dysfunction. A better understanding of the involvement of vascular risk factors in voiding dysfunction may lead to more accurate assessment of LUTS, precise patient selection for prostatectomy, and the development of prophylactic strategies and newer treatment.

Increased leukotriene and prostaglandin release, and overactivity in the chronically ischemic bladder

PURPOSE

Chronic ischemia has been shown to alter bladder contractility. We studied the roles of cyclooxygenase (COX) and lipoxygenase products in ischemia induced bladder overactivity in the rabbit.

MATERIALS AND METHODS

A total of 28 male New Zealand White rabbits were divided into 2 groups. In group 1 atherosclerotic occlusion of the iliac arteries was induced by balloon endothelial injury, followed by a short period of a high cholesterol diet. Group 2 received a regular diet alone. After 12 weeks blood flow measurements and cystometry were performed. Bladder tissues were processed for enzyme immunoassay of leukotrienes and prostaglandins (PGs), Western blotting of COX and lipoxygenase, isometric tension measurement and histology.

RESULTS

Atherosclerotic occlusion of the iliac arteries significantly decreased bladder blood flow. Moderate ischemia caused bladder overactivity, while severe ischemia inhibited bladder contractions. Ischemia increased leukotriene B4, E4 and C4 release by 141%, 132% and 254%, and increased PG F2alpha and thromboxane A2 release by 95% and 93%, respectively, although it did not alter PG E2 release. Western blotting showed increased 5-lipoxygenase, COX-1 and COX-2 protein levels in ischemic bladder tissues. Moderate ischemia increased bladder smooth muscle contraction in response to carbachol and electrical field stimulation. Tissue treatment with the COX inhibitor indomethacin significantly increased control tissue contraction but had no effect on ischemic tissues. Treatment with the 5-lipoxygenase inhibitor REV5901 abolished this effect of indomethacin in control tissues. Treatment with REV5901 significantly decreased the contraction of ischemic tissues but had no significant effect on control tissues. The effect of indomethacin plus REV5901 was similar to the effect of REV5901 alone. Histology showed urothelial thickening and mild fibrosis in the moderately ischemic bladder.

CONCLUSIONS

Chronic ischemia increased bladder 5-lipoxygenase, and COX-1 and COX-2 protein expression, and altered leukotriene and PG production. Treatment with COX and lipoxygenase inhibitors produced completely different effects in the ischemic bladder compared with the control bladder. Functional changes in the ischemic bladder were concurrent with structural changes in the urothelium. PGs modulate smooth muscle contractility in the healthy bladder. However, under ischemic conditions leukotrienes dominate bladder tone and appear to have a leading role in increased smooth muscle contraction and bladder overactivity.

Endovascular treatment as first choice in chronic intestinal ischemia

The purpose of this study was to define the place of endovascular treatment in chronic intestinal ischemia (CII). We report here a series of 19 consecutive patients treated with percutaneous angioplasty of the intestinal arteries. We excluded patients with acute ischemia, from the study. From January 1, 1989 to December 31, 2001, 19 patients with symptomatic CII were treated by endovascular techniques. This study group included 11 men and 8 women with a mean age of 59 years (range 30 to 90 years). The clinical presentation included postprandial pain in 16 patients, weight loss in 14 patients, with a mean weight loss of 7.4 kg (range 0 to 30 kg); and gastroparesis in 2 patients. Stenoses were significant in the single superior mesenteric artery (SMA) in 2 patients and in two arteries in 17 patients, including the celiac artery (CA) and SMA (n = 13), CA and inferior mesenteric artery (IMA) (n = 1), and SMA and IMA (n = 3). Balloon angioplasty was performed in only one of the arteries in each patient, 15 times in the SMA and 4 times in the CA. In 7 patients, angioplasty required stenting because of recoil (n = 5) or dissection (n = 1). In one patient the lesion was stented primarily, because of adjacent thrombus on the stenosis. Our results showed that initial treatment of CII can be endovascular. Focus on one artery only, seems to be reasonable and efficient in the short and long term.

Chronic mesenteric ischemia: imaging and percutaneous treatment

Chronic mesenteric ischemia (CMI) is rare and is often diagnosed late. Fatal malabsorption-related complications or acute ischemic events occur in the absence of treatment. Diagnosis depends on careful acquisition of a medical history and elimination of other conditions. No sensitive and specific tests are available for functional diagnosis of CMI. If other causes of abdominal pain and weight loss have been confidently ruled out, evidence of visceral artery occlusion at noninvasive imaging (Doppler ultrasonography, computed tomographic angiography, and magnetic resonance angiography) suggests CMI. Until the 1990s, open surgery was considered the treatment of choice; percutaneous transluminal angioplasty (PTA) was reserved for patients for whom surgery carried a high risk. However, open surgery carries a nonnegligible risk of morbidity and mortality. In recent years, PTA with stent placement has been recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate and consequently has been suggested for primary treatment of CMI. New treatments including administration of fibrinolytic agents before PTA of chronic occlusions, routine revascularization of one or more arteries, and stent placement will probably be validated in the near future. Similarly, new data on selection of the best approach will become available soon.

Chronic splanchnic ischaemia

Chronic splanchnic ischaemia is a relatively unusual clinical entity consisting of pain and/or weight loss and caused by chronic splanchnic disease (i.e. stenosis and/or occlusion of the coeliac and superior mesenteric artery). The occlusive disease is usually caused by atherosclerosis and is in itself not rare in older individuals. Extensive collateral circulation can develop between the three splanchnic arteries and may compensate for the decreased splanchnic perfusion over time. The pathophysiology of chronic splanchnic ischaemia has still not been completely elucidated.A reliable diagnosis of chronic splanchnic ischaemia, based on a proven causal relationship between the occlusive disease and the symptoms, can be very difficult. Traditionally, tests for evaluating the haemodynamic consequences of the vascular stenoses were not available. Important improvements in establishing a more reliable diagnosis have been achieved with duplex ultrasound and magnetic resonance evaluation of the splanchnic circulation. Tonometry is another promising functional test that may prove useful not only for gaining greater insight into the pathophysiology of chronic splanchnic ischaemia but also for the clinical evaluation of this syndrome. The natural history of chronic splanchnic disease suggests that progressive disease may result in acute mesenteric ischaemia. Surgical reconstruction of the coeliac and/or the superior mesenteric artery is the therapeutic standard with excellent short and long-term results. Satisfactory early results using angioplasty with or without stent suggest that this type of intervention may relieve symptoms in selected patients with a higher surgical risk.

Overactivity and structural changes in the chronically ischemic bladder

PURPOSE

Our aim was to study the effect of chronic ischemia on bladder contraction and detrusor smooth muscle reactivity. The relationship between structural damage and functional changes in the chronically ischemic bladder was also investigated.

MATERIAL AND METHODS

Male New Zealand White rabbits were divided into arterial injury (AI), hypercholesterolemia (Hch) and control groups. The AI group (n = 18) underwent balloon endothelial injury of the iliac arteries and received a 0.5% cholesterol diet. The Hch group (n = 8) received a 0.5% cholesterol diet alone. The control group (n = 8) received a regular diet. After 16 weeks, iliac artery and bladder wall blood flows were recorded. Cystometrograms and arteriography were obtained and bladder tissues were processed for isometric tension measurement in the organ bath and for histological evaluation.

RESULTS

At 16 weeks, blood flow through the iliac arteries was significantly reduced in the AI group compared with the Hch and control groups. In the AI group, 8 animals developed severe bladder ischemia (SBI) defined as greater than 60% decrease in bladder blood flow, 7 animals developed moderate bladder ischemia (MBI) defined as 40 to 60% decrease in bladder blood flow, and 3 animals failed to develop significant bladder ischemia (<40% decrease in bladder blood flow). In the control animals, bladder blood flow increased prior to contraction, decreased during contraction and rebounded to baseline levels after contraction. In animals with MBI and SBI, the increase in bladder blood flow prior to contraction and the rebound of blood flow after contraction, both seen in control animals, were diminished. Detrusor overactivity (significant increase in the frequency of spontaneous bladder contractions) was observed in the MBI group and impaired bladder contraction in the SBI group. In the organ bath, bladder strips from the MBI group demonstrated increased contractile response to carbachol and electrical field stimulation (EFS) while bladder strips from the SBI group showed impaired contractility. Hch alone produced only short-lived ischemia during bladder contraction and caused significantly lesser functional changes compared with those seen in MBI. Histological examination showed atherosclerotic occlusion in the iliac arteries and bladder microcirculation and marked disruption of urothelium in the MBI and SBI groups. Severe fibrosis was seen in bladder tissue from the SBI group, moderate fibrosis in tissue from the MBI group and mild fibrosis in tissue from the Hch group.

CONCLUSIONS

Our studies show that chronic MBI is associated with detrusor overactivity and increased smooth muscle contractility to carbachol and EFS while chronic SBI is associated with impaired detrusor contraction. The mechanism of chronic ischemia-induced bladder dysfunction is not known and may involve multiple physiologic and structural changes in the bladder nerves, receptors and contractile components. Our studies suggest that ischemia-induced structural damage in the urothelium and possible chronic exposure of the underlying tissue and nerves to the urine may also play a role in MBI-induced detrusor overactivity. SBI-induced impairment of bladder contraction may involve, in part, extensive fibrosis and loss of bladder smooth muscle. Histopathophysiologic changes in bladder tissue from our MBI model are similar to those seen in patients with detrusor instability, suggesting that chronic ischemia may play a role in the development of idiopathic detrusor instability.

Atherosclerosis-induced chronic ischemia causes bladder fibrosis and non-compliance in the rabbit

PURPOSE

The overall goal was to determine whether chronic ischemia and hypercholesterolemia interfere with bladder function and structure. The roles of atherosclerosis-induced chronic ischemia and hypercholesterolemia in bladder fibrosis and non-compliance were studied in the rabbit. The relationship between ischemia-induced changes in the expression of transforming growth factor-beta1 (TGF-beta1) and basic fibroblast growth factor (bFGF) and the severity of bladder fibrosis was also investigated.

MATERIALS AND METHODS

Male New Zealand White rabbits were divided into chronic bladder ischemia (CBI, n = 11), hypercholesterolemia (Hch, n = 8) and control (n = 8) groups. The CBI group underwent balloon endothelial injury of the iliac arteries and received a 0.5% cholesterol diet. The Hch group received a 0.5% cholesterol diet alone. The control group was placed on a regular diet. After 16 weeks, iliac artery and bladder wall blood flow measurements, cystometrograms (CMG) and aorto-iliac arteriograms were obtained in all animals. Iliac arteries and bladder tissues were processed for histological staining and computer-assisted histomorphometric image analysis. The expressions of TGF-beta1 and bFGF in bladder tissue were determined by immunohistochemical staining utilizing monoclonal antibodies.

RESULTS

At 16 weeks, arteriography and histology showed significant diffuse atherosclerotic occlusive disease of the aorto-iliac arteries in the CBI group. Iliac artery and bladder wall blood flows were significantly decreased in the CBI group compared with the Hch and control groups. Atherosclerosis-induced CBI shifted the volume-pressure curve to the left and caused severe bladder fibrosis. Hypercholesterolemia also caused fibrosis and non-compliance but to a much lesser extent compared with those caused by CBI. In histomorphometry, the percentage of detrusor smooth muscle was moderately decreased in the Hch group and severely decreased in the CBI group compared with the control group. In immunohistochemical stains of bladder tissues, bFGF expression was similar in the three groups of animals. TGF-beta1 expression was significantly greater in bladder tissues from the CBI group compared with the Hch and control groups.

CONCLUSIONS

Our studies show that atherosclerosis-induced chronic ischemia increases TGF-beta1 expression in the bladder leading to fibrosis, smooth muscle atrophy and non-compliance. Hypercholesterolemia also interferes with bladder structure and compliance but to a significantly lesser extent compared with CBI. Our studies suggest that arterial insufficiency and hypercholesterolemia, common aging-associated disorders, may play important roles in the pathophysiology of voiding dysfunction in the elderly.

Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia

Ischemic colitis accounts for approximately half of all cases of mesenteric vasculopathy. The clinical presentation varies depending on underlying cause, extent of vascular obstruction, rapidity of ischemic insult, degree of collateral circulation, and presence of comorbidity. Ischemic colitis is usually diagnosed by colonoscopy. Only approximately 20% of patients require surgery because of signs or laboratory findings of peritonitis or because of clinical deterioration. Approximately 20% of patients develop chronic colitis from irreversible colonic ischemic injury, which manifests clinically as persistent diarrhea, rectal bleeding, or weight loss and endoscopically as a colonic stricture or mass. Chronic mesenteric ischemia is almost always caused by significant atherosclerotic stenosis involving at least two mesenteric arteries, usually the superior mesenteric artery and celiac axis. The classic symptomatic triad of postprandial pain, fear of eating, and involuntary weight loss occurs with advanced disease.

Biopsy specimen appearances of ischaemic gastritis in splanchnic arterial insufficiency

A 74 year old man presented with a one month history of epigastric discomfort, anorexia, weight loss, and postprandial vomiting. The diagnosis of ischaemia was made on endoscopic biopsies from the stomach and duodenum. He was too ill for major vascular surgery and died eight days after admission. Postmortem examination confirmed the diagnosis of splanchnic arterial insufficiency caused by atheroma and thrombosis. Ischaemic gastritis is rare but could easily be missed in unrepresentative biopsy specimens. Prompt diagnosis with revascularisation surgery is the only hope for long term survival.

Sample dilution to resolve mistaken identification of haemoglobin D as haemoglobin E using the variant automated system

High performance liquid chromatography (HPLC) is increasingly being used to estimate variant haemoglobins. A case of haemoglobin S/D (HbS/D) is presented, which was misdiagnosed as haemoglobin S/E (HbS/E) by HPLC. The patient was a 22 year old woman with sickle cell anaemia. Subsequent haemodilution by blood transfusion clearly elucidated the haemoglobin D peak on HPLC. Sample dilution experiments, using the pretransfusion sample, were done resulting in correct elution of the peak in the D window. Troubleshooting in similar problematic haemoglobin variant peaks seen on HPLC can be done by sample dilution.