The Diagnosis of Acute Mesenteric Ischemia: A Systematic Review and Meta-analysis

Acute mesenteric ischemia is an infrequent cause of abdominal pain in emergency department (ED) patients; however, mortality for this condition is high. Rapid diagnosis and surgery are key to survival, but presenting signs are often vague or variable, and there is no pathognomonic laboratory screening test. A systematic review and meta-analysis of the available literature was performed to determine diagnostic test characteristics of patient symptoms, objective signs, laboratory studies, and diagnostic modalities to help rule in or out the diagnosis of acute mesenteric ischemia in the ED. In concordance with published guidelines for systematic reviews, the medical literature was searched for relevant articles. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was used to evaluate the overall quality of the trials included. Summary estimates of diagnostic accuracy were computed by using a random-effects model to combine studies. Those studies without data to fully complete a two-by-two table were not included in the meta-analysis portion of the project. The literature search identified 1,149 potentially relevant studies, of which 23 were included in the final analysis. The quality of the diagnostic studies was highly variable. A total of 1,970 patients were included in the combined population of all included studies. The prevalence of acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity for l-lactate of 86% (95% confidence interval CI = 73% to 94%) and a pooled specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for D-dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI = 33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94% (95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to 51.29), and the negative likelihood ratio (–LR) was 0.09 (95% CI = 0.05 to 0.17). The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI = 40% to 54%). Given these findings, the test threshold of 2.1% (below this pretest probability, do not test further) and a treatment threshold of 74% (above this pretest probability, proceed to surgical management) were calculated. The quality of the overall literature base for mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are insufficiently diagnostic for the condition. Only CT angiography had adequate accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of laparotomy. La isquemia mesentérica aguda es una causa infrecuente de dolor abdominal en los servicios de urgencias (SU); sin embargo la mortalidad para esta enfermedad es alta. El diagnóstico rápido y la cirugía son clave para la supervivencia, pero los signos de presentación son a menudo vagos o variables, y no hay una prueba de despistaje de laboratorio patognomónica. Se realizó una revisión sistemática y un metanálisis de la literatura disponible para determinar las características diagnósticas de los síntomas del paciente, los signos objetivos, los estudios de laboratorio y las modalidades diagnósticas para ayudar a descartar el diagnóstico de isquemia mesentérica aguda en el SU. En consonancia con las guías clínicas publicadas para revisiones sistemáticas, la bibliografía médica se buscó para los artículos relevantes. Se uso Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) para las revisiones sistemáticas para evaluar la calidad global de los estudios incluidos. Las estimaciones resumidas de certeza diagnóstica se calcularon mediante un modelo de efectos aleatorios para combinar estudios. Aquellos estudios sin datos para completar totalmente una tabla de dos por dos no se incluyeron en la parte del metanálisis del estudio. La búsqueda bibliográfica identificó 1.149 estudios potencialmente relevantes, de los cuales 23 se incluyeron en el análisis final. La calidad de los estudios diagnósticos fue muy variable. Un total de 1.970 pacientes se incluyeron en la población combinada de todos los estudios incluidos. La prevalencia de isquemia aguda mesentérica osciló de un 8% a un 60%. Hubo una sensibilidad acumulada para el lactato de un 86% (IC 95% = 73% a 94%), y una especificidad acumulada de un 44% (IC 95% = 32% a 55%). Hubo una sensibilidad acumulada para el D-dímero de un 96% (IC 95% = 89% a 99%), y una especificidad acumulada de un 40% (IC 95% = 33% a 47%). Para la tomografía computarizada (TC), se encontró una sensibilidad acumulada de un 94% (IC 95% = 90% a 97%) y especificidad de un 95% (IC 95% = 93% a 97%). La razón de probabilidad positiva para una TC positiva fue de 17,5 (IC 95% = 5,99 a 51,29) y la razón de probabilidad negativa de 0,09 (IC 95% = 0,05 a 0,17). El porcentaje de mortalidad acumulada para la isquemia mesentérica fue de un 47% (IC 95% = 40% a 54%). Dados estos hallazgos, se calculó el umbral diagnóstico de un 2,1% (por debajo de esta probabilidad pre-test, no hacer más pruebas diagnósticas), y un umbral de tratamiento de un 74% (por encima de esta probabilidad pre-test, proceder a un tratamiento quirúrgico). La calidad de la bibliografía global para la isquemia mesentérica es variada. Los signos, síntomas y pruebas de laboratorio son insuficientes para diagnosticar esta enfermedad. Sólo la angio-TC tuvo una adecuada certeza para establecer el diagnóstico de isquemia mesentérica aguda en lugar de la laparotomía. CME Editor: Hal Thomas, MD Authors: Michael T. Cudnik, MD, Subrahmanyam Darbha, MSc, Janice Jones, MD, Julian Macedo, MD, Sherrill W. Stockton, MD, PhD, and Brian C. Hiestand, MD, MPH Article Title: The Diagnosis of Acute Mesenteric Ischemia: A Systematic Review and Meta-analysis If you wish to receive free CME credit for this activity, please refer to the website: http://www.wileyhealthlearning.com/aem. Accreditation and Designation Statement: Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Blackwell Futura Media Services is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Educational Objectives After completing this exercise the participant will better understand the diagnosis of acute mesenteric ischemia. Activity Disclosures No commercial support has been accepted related to the development or publication of this activity. Faculty Disclosures: CME editor – Hal Thomas, MD: No relevant financial relationships to disclose. Authors Michael T. Cudnik, MD, Subrahmanyam Darbha, MSc, Janice Jones, MD, Julian Macedo, MD, Sherrill W. Stockton, MD, PhD, and Brian C. Hiestand, MD, MPH. This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by Academic Emergency Medicine. The peer reviewers have no relevant financial relationships. The peer review process for Academic Emergency Medicine is double-blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review. Conflicts of interest have been identified and resolved in accordance with Blackwell Futura Media Services's Policy on Activity Disclosure and Conflict of Interest. No relevant financial relationships exist for any individual in control of the content and therefore there were no conflicts to resolve. 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