Clinical approach to chronic gastrointestinal ischaemia: From 'intestinal angina' to the spectrum of chronic splanchnic disease

Stenotic disorders of the splanchnic arteries are not rare, and it is generally assumed that symptoms are rare in patients with a single splanchnic stenosis, and even in patients with multiple-vessel stenoses. Currently, only gastric exercise tonometry aids the diagnostic evaluation, as it indicates actual ischaemia. Patients with stenotic disorders without complaints are referred to as having chronic splanchnic disease (CSD) and those with ischaemic complaints as having chronic splanchnic syndrome (CSS). The classical presentation of CSS, including the triad postprandial pain, weight loss and upper abdominal bruit, is also known as 'intestinal angina'. From the experience of our multidisciplinary working team on gastrointestinal ischaemia in 110 patients with stenoses of at least one splanchnic artery, two different clinical patterns were observed. In our series approximately 60% of patients with single-vessel stenoses, including the coeliac artery compression syndrome, have CSS. They have fewer complications, very low mortality, but most can be successfully treated by stenting or surgical treatment. Patients with multivessel splanchnic stenoses have more classical ischaemic complaints. Progression to a bowel infarction was seen in 34%, and mortality was 21%, mostly from bowel or myocardial infarction. Treatment should be tailored based upon perioperative risk assessment and local vascular anatomy. This may consist of autologous arterial bypass of one or two vessels, preferably antegrade, stenting or a combination of both. This differentiation between single- and multivessel splanchnic disease has considerable consequences for optimal work-up and treatment.