We congratulate Reintam Blaser et al. for their insightful overview of the management of acute mesenteric ischemia (AMI) [1]. Nonspecific symptoms and the lack of established biomarkers complicate the diagnosis of AMI, likely resulting in numerous undetected cases [2]. Non-occlusive mesenteric ischemia (NOMI) is rare and it affects primarily patients with critical illness in the intensive care unit (ICU) [2, 3]. However, diagnosing NOMI is difficult and prognosis is poor with mortality rates exceeding 70% [2, 4]. Computed tomography angiography (CTA) is the gold standard for diagnosing AMI, yet, diagnostic accuracy is low for NOMI [4]. Since NOMI often affects the colon, colonoscopy can be a useful diagnostic tool in these patients [4].
To further assess diagnostic utility of CTA and endoscopy, we retrospectively analyzed all patients who received CTA for suspected colon ischemia and consecutive colonoscopy between 03/2009 and 08/2020 in our center (n = 125). CTA detected unspecific signs of intraabdominal pathology, such as free abdominal fluid (79/125, 63.2%), bowel wall thickening (70/125 patients, 56%), and concomitant local inflammatory reaction of the surrounding fat tissue (28/125 patients, 22.4%). Less frequent, direct evidence of reduced colon perfusion (10/112, 8.9%), stenosis (17/112, 15.2%) or even occlusion (4/112, 3.6%) of superior or inferior mesenteric arteries was found (Table 1).
In only 58/125 patients (46.4%), colon ischemia was confirmed by endoscopy. Out of these, 48/58 (82.8%) were treated in the ICU, 26/58 (44.8%) were mechanically ventilated and 4/58 (6.9%) were supported with extracorporeal membrane oxygenation when AMI was diagnosed (supplementary Table 1). However, CTA was not able to reliably distinguish between patients with or without colon ischemia. Only distension of the colon [14/58 (24.1%) vs. 7/67 (10.4%); p = 0.041] and local inflammatory reaction of the fat tissue [20/58 (34.5%) vs. 8/67 (11.9%); p = 0.003]) were significantly more common in patients with colon ischemia compared to those without. Yet, overall, these signs occurred only rarely in all patients both with and without AMI. All other CTA findings were found equally frequent in both groups (Table 1 and electronic supplementary material). None of the typical diagnostic criteria for colon ischemia in CTA assessed in this cohort proved both high sensitivity and specificity for detection of colon ischemia (supplementary Table 4).
Given the low accuracy of CTA in detecting NOMI, relying on this diagnostic measure alone is not advisable. Colonoscopy, as a complementary, safe, cost-effective, and widely available diagnostic tool may enhance the detection of colon ischemia. Colonoscopy can help confirm or rule out the suspicion of acute colon ischemia, particularly in critically ill patients in the ICU—even without the risks associated with and the resources needed for CTA assessment.
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All data will be available from the corresponding author on reasonable request.
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The authors thank Maximilian Walgenbach for data collection and support for the statistical analyses.
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DB reports travel grants from Gilead Science, lecture honoria from the Falk Foundation and research grants from the German Research Foundation and the Dr. Rolf M. Schwiete Stiftung. AS reports research grants, travel support and lecture honoraria from CytoSorbents Europe, travel support from Artcline, and lecture honoraria from Getinge and AstraZeneca. The other authors report no competing interests.
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Käser, R., Bettinger, D., Neeff, H. et al. Non-occlusive mesenteric ischemia: the wolf in sheep’s clothing. Intensive Care Med (2024). https://doi.org/10.1007/s00134-024-07432-5
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DOI: https://doi.org/10.1007/s00134-024-07432-5