Gastro-Intestinal Vascular Emergencies (GIVE) result from ‘gastro-intestinal ischaemic injury’ (Gi3). Recent works on the pathophysiology of intestinal perfusion and ischaemia, from the onset of a vascular event to the development of bowel necrosis, suggest that each involved mechanism-vascular and digestive- should be known, recognized and treated specifically, not only by digestive and vascular surgeons and intensivists, but also gastroenterologists and interventional radiologists. In the absence of powerful biomarkers the time, between symptom onset and an irreversible ischaemia is unpredictable, thus all suspicions of GIVE should lead to an urgent diagnostic and therapeutic strategy. Although controlled trials in mesenteric ischaemia are almost unfeasible, a new management strategy, coordinated by gastroenterologists, has been proposed with the dual goal to avoid death and large intestinal resections.
Gastro-intestinal ischaemic injury (Gi3) represents acute digestive ischaemia with systemic consequences, due to an interruption or decrease of splanchno-mesenteric blood flow. Gi3 is a multistep process starting with splanchno-mesenteric occlusion or low flow, leading to bowel necrosis, multi-organ failure and death [1], [2]. Acute mesenteric ischaemia (AMI) itself is one step of Gi3 process and occurs in the first moments after vascular or haemodynamic injury. If the phenomenon prolongs, AMI
Positive diagnosis of GIVE is based on the association of a Gi3 and vascular disorders (occlusion and/or low flow). Main pathological conditions, considered as GIVE and leading to Gi3 are illustrated Fig. 2. However, vascular pathologies not usually encountered by gastroenterologists, such as aortic dissections and traumatic lesions, will not be discussed here.
The famous sentence pronounced by Cokkinis about mesenteric ischaemia « the diagnosis is impossible, the prognosis hopeless and the treatment useless » is now obsolete [3]. Until now, AMI has always been considered an abdominal emergency associated with a high mortality rate and often, intestinal failure in survivors [51]. A systematic review of 45 observational studies, including 3692 AMI patients, reported overall in-hospital death rates of about 70% and almost 100% in untreated patients [3].
None. Early and specific biomarkers of gastro-intestinal ischaemic injury need to be identified Survivors of gastro-intestinal ischaemic injuries should be studied to identify predictive factors of intestinal resection and short-bowel syndrome Specific splanchno-mesenteric vasoactive agents need to be developed in ischaemia-related vasospasm Further development of morphological techniques to determine digestive viabilityResearch agenda
Gastro-Intestinal Vascular Emergencies are most often misunderstood by gastroenterologists and may occur with or without digestive vascular occlusion. Whatever the involved mechanisms the incidence is increasing and the prognosis could be improved by an innovative multimodal and multidisciplinary management initiated at early presentation. Diagnosis must be suspected with any sudden, continuous and unusual abdominal pain, contrasting with normal physical examination at the initial stage.
Amy Whereat and Pamela Heuer for writing assistance.
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