Recurrent abdominal pain is a common reason for repeated visits to outpatient clinics and emergency departments, reflecting a substantial unmet need for timely and accurate diagnosis. A lack of awareness of some of the rarer causes of recurrent abdominal pain may impede diagnosis and delay effective management. This article identifies some of the key rare but diagnosable causes that are frequently missed by gastroenterologists and provides expert recommendations to support recognition, diagnosis, and management with the ultimate aim of improving patient outcomes.
Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.
Introduction
Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Chronic mesenteric ischaemia can progress to acute mesenteric ischaemia (AMI), a much dreaded and often lethal complication. Nevertheless, chronic mesenteric ischaemia remains an underappreciated, underdiagnosed and undertreated disease entity, mainly due to lack of knowledge and awareness among physicians. The increased incidence of cardiovascular disease in the elderly population and the rise in the prevalence of obesity and diabetes mellitus is likely to contribute to an increasing incidence of chronic mesenteric ischaemia. Although weight loss is still a consistent finding in patients with chronic mesenteric ischaemia, modern, faster diagnostic workup compared to the pre-computed tomography (CT) era has lowered the proportion of chronic mesenteric ischaemia patients who are underweight at diagnosis.1 2 Some patients may still be overweight at diagnosis, while others will have a normal body mass index (BMI) at diagnosis but were overweight at the onset of symptoms, which usually precede diagnosis by at least six months.3 Hence, the misconception that patients with chronic mesenteric ischaemia are all cachectic, as stated in older textbooks, is a diagnostic pitfall leading to further diagnostic delay and no longer applies in the current clinical context.
Even though criteria and recommendations for mesenteric ischaemia have been formulated by radiology, interventional radiology and vascular surgery societies, a multidisciplinary guideline covering the full multidisciplinary spectrum of chronic mesenteric ischaemia and suitable to the needs of all physicians involved in the care for chronic mesenteric ischaemia patients is urgently needed.4–6
United European Gastroenterology (UEG) acknowledged the need for a multidisciplinary guideline by supporting this guideline with a UEG Activity Grant. Other organizations including European Association for Gastroenterology, Endoscopy and Nutrition (EAGEN), European Society of Gastrointestinal and Abdominal Radiology (ESGAR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), Dutch Mesenteric Ischemia Study group (DMIS) and national societies such as Netherlands Association of Hepatogastroenterologists (NVMDL) and Hellenic Society of Gastroenterology (HSG) also recognised the need for a multidisciplinary guideline. We therefore jointly aimed to develop a guideline that provides a comprehensive overview and repository of current evidence and expert agreement, and offers guidance to physicians involved in the multidisciplinary field of gastrointestinal (GI) diseases.
Thanks for this Meleber. I have always advocated for the use of multi-disciplinary teams to get to the bottom of complex cases. IBS can be considered a complex case.
Ideally, no one should be suffering from symptoms without getting a final diagnosis and treatment programme. I love the BBC program ,The Diagnosis Detectives. It is where patients have been passed from pillar to post to various specialists, but no one can identify what is wrong with them. A team of specialists get their heads together and in each case they have jointly found the root cause of that person's issues.
It seems the medical profession is stuck in a mode of working. This approach may seem expensive, but probably would work out cheaper in the end since the patient involved would stop having repeat visits to their GP since, without it, they remain very ill.
Research should also be conducted this way. For instance, we have microbiologists working on some aspects of IBS research e.g. the microbiome and gastroenterologists working on the pipework of the digestive system. However, the body is a system as a whole, with these components all interacting with one another.
Ideally, you'd need a large group of people who are presenting with IBS like symptoms, with each person worked on by a multi-disciplinary team of microbiologists, neurologists, gastroenterologists, ENT etc etc. and the expert group as a whole getting to the bottom of what is causing that person's IBS. Once large numbers of these people have been studied, the causes of IBS will start to fall into different categories to the point where you could almost predict where the next patient is going to land since you are able to test them for a specific category and treat them for those specific causes - or at least develop treatments for those causes.
I don't know if anyone in the medical community is listening. I've tried to contact various parties about this but since I am a nobody, it is hard to have any influence or get people to listen who can really make changes that will make a difference to our lives.
Thank you so much for this. Interesting. It is what my Mum died from, having been wrongly diagnosed with IBS for some years. She had x-rays and ultrasound but only finally got to have a CT scan on the day she died, in so much pain and with drastic weight loss. She was however in her 90's and didn't want any intervention. I would have given anything to be able to alleviate her suffering.
I read this with interest and trepidation. The symptoms ring so true with me and despite having been investigated by two gastroenterologists and having had various tests (including CT scans) I have been discharged and referred for pain management. I am now in constant pain and in despair. Does anyone know of a hospital that would take the approach recommended in the article?
Hi, I live in the Netherlands and therefore can't be of any help for you in suggesting a gastroenterologist/hospital in the UK.
I have seen four different gastroenterologist till now. They still don't know what's going on in my adomen, what's wrong with the functioning of my intestines.
Till now the conclusion/working diagnosis is a functional gastrointestinal disorder, probably IBS, but they can't say for sure, haven't ruled out yet other currently known disorders/diseases.
That's why I tried to make an appointment in a tertiary hospital in Belgium and based on the letter of the latest gastroenterologist, working in a tertiary hospital in the Netherlands, they did invite me for a first consult. Due to waiting lists my appointment/consult is in August this year.
I would like to have a manometry of my small intestine and maybe also the ceacum and first part of the ascending colon because it could be chronic intestinal pseudo obstruction. However, the last gastroenterologist in the Netherlands I did spoke with doesn't think this is the case based on his knowledge and my symptoms (but because he's young he doesn't have a lot of clinical experience yet).
Besides I tried to contact the gastroenterologist in the regional hospital I did see some time ago. I asked her if it could be an underlying problem with the arteries, blood supply and if I already have had a scan for this. Since I did sent her a message just a few days ago I don't expect to receive an answer soon but I do hope she will send an answer.
Thank you for your reply. It seems there are similar problems in the Netherlands as in the UK. I think I should ask for referral to a London teaching hospital. I will also write to my previous consultants to ask whether my previous scans excluded abnormalities with blood supply.
Content on HealthUnlocked does not replace the relationship between you and doctors or other healthcare professionals nor the advice you receive from them.
Never delay seeking advice or dialling emergency services because of something that you have read on HealthUnlocked.
Does anyone know if prebiotics are OK for IBS symptoms?
Chronic constipation and IBS
What Can I do to help myself?
Been told IBS got second opinion and GP wasn't convinced 
Ibs or something else confused!!!
