Improving clinical suspicion of acute mesenteric ischemia among patients with acute abdomen: A cross-sectional study from an intestinal stroke center
Open accessAbstract
Background: Early diagnosis of acute mesenteric ischemia (AMI) is essential for a favorable outcome. Selection of patients requiring a dedicated multiphasic computed tomography (CT) scan remains a clinical challenge. Methods: In this cross-sectional diagnostic study conducted from 2016 to 2018, we compared the presentation of AMI patients admitted to an intestinal stroke center to patients with acute abdominal pain of another origin admitted to the emergency room (controls). Results: We included 137 patients—52 with AMI and 85 controls. Patients with AMI [median age: 65 years (interquartile range 55–74)] had arterial and venous AMI in 65% and 35% of cases, respectively. Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations. On multivariate analysis, two independent factors were associated with the diagnosis of AMI: the sudden-onset (OR = 20, 95%CI 7–60, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 6, 95%CI 2–16, p = 0.002). Sudden-onset and/or morphine-requiring abdominal pain was present in 88% of AMI patients versus 28% in controls (p < 0.001). The area under the receiver operating characteristic curve for the diagnosis of AMI was 0.84 (95%CI 0.77–0.91), depending on the number of factors. Conclusions: Sudden onset and the need for morphine are suggestive of AMI in patients with acute abdominal pain and should prompt multiphasic CT scan including arterial and venous phase images for confirmation.
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Written from the paper’s full text.
TL;DR
In a cross-sectional study of 137 patients with acute abdominal pain, sudden-onset and morphine-requiring pain were independently associated with acute mesenteric ischemia (AMI). These two bedside factors yielded an AUROC of 0.84 for AMI and may help select patients for multiphasic CT.
Key findings
- Among 52 AMI patients and 85 controls, multivariate analysis identified sudden-onset abdominal pain (OR = 20.2, 95%CI 6.9–59.6, p < 0.001) and morphine-requiring abdominal pain (OR = 5.5, 95%CI 1.9–15.9, p = 0.002) as independent factors associated with AMI.
- Sudden-onset and/or morphine-requiring pain was present in 88% of AMI patients (97% arterial AMI, 73% venous AMI) versus 28% of controls (p < 0.001); the overall AUROC for AMI diagnosis was 0.84 (95%CI 0.77–0.91).
- AMI patients had arterial and venous causes in 65% and 35% of cases, respectively; median age was 65 years (IQR 55–74) versus 48 years (IQR 35–70) in controls. Plasma lactate was normal (< 2 mmol/L) at admission in 69% of AMI patients.
- Diagnostic accuracy varied by criteria: one factor had sensitivity 0.88 and specificity 0.72; two factors had sensitivity 0.48 and specificity 0.95.
Methods
- Cross-sectional diagnostic study conducted from January 4, 2016, to March 5, 2018, within the SURVIBIO study; 179 patients with acute abdominal pain undergoing contrast-enhanced CT were assessed, and 137 were enrolled (52 AMI admitted to an intestinal stroke center, 85 controls admitted to the emergency room).
- AMI was defined by acute clinical, biological, and contrast-enhanced CT features of bowel injury plus vascular insufficiency of the celiac trunk, superior mesenteric artery, and/or superior mesenteric vein, with no alternative diagnosis; all included patients underwent multiphasic CT with arterial and venous phases.
- Associations were assessed with multivariate logistic regression including sudden-onset and morphine-requiring pain, guarding, SOFA score > 2, and white blood cell count; diagnostic performance was evaluated with AUROC, sensitivity, specificity, and positive/negative likelihood ratios.
Limitations
- The paper states the study was originally designed to assess biomarkers of AMI and excluded patients with strangulated bowel obstruction, left-sided colon ischemia, or mesenteric vessel occlusion without acute small bowel injury, which may decrease generalizability to those conditions.
- The paper states that sudden onset and morphine requirement may be partially subjective, and that because AMI prevalence was high in this referral-center cross-sectional study, predictive values could not be calculated.
- Evident from the text: this was a single-center intestinal stroke center study with a relatively small AMI sample (n = 52), and the findings were not externally validated.
Model-written summary. Check it against the paper before relying on it.
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Claims the paper makes
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- Findingown data
AMI patients had normal plasma lactate concentrations (<2 mmol/L) upon admission in 69% of cases (n=36).
“Notably, AMI patients had normal plasma lactate concentrations (< 2 mmol/L) upon admission in 69% of cases (n = 36).”
Quote in the paperSubstantial claim - Findingown data
AMI patients had higher white blood cell counts than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
AMI patients had higher plasma C-reactive protein concentrations than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
The AUROC for the diagnosis of AMI of neutrophil count was 0.61 (95%CI 0.51-0.71, p=0.03).
“The AUROC curve for the diagnosis of AMI of white blood cell and neutrophil counts and plasma CRP and procalcitonin were 0.61 (95%CI 0.52–0.71, p = 0.02), 0.61 (95%CI 0.51–0.71, p = 0.03), 0.73 (95%CI 0.64–0.82, p < 0.001), and 0.74 (95%CI 0.64–0.83, p < 0.001), respectively (Additional file 1: Fig. S1).”
Quote in the paperNot a substantial claim - Findingown data
AMI patients were more likely to present with sudden-onset abdominal pain than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperSubstantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
One-third of AMI patients had no history of cardiovascular disease.
“Most importantly, one-third of AMI patients had no history of cardiovascular disease whatsoever.”
Quote in the paperSubstantial claim - Findingown data
AMI patients were significantly older than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“Patients with AMI were significantly older and were more likely to have risk factors or a history of cardiovascular disease than those with non-ischemic abdominal pain (Table 1).”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
On multivariate analysis, morphine-requiring nature of acute abdominal pain was independently associated with the diagnosis of AMI (OR = 5.5, 95%CI 1.9-15.9, p = 0.002).
“On multivariate analysis, two independent factors were associated with the diagnosis of AMI: the sudden-onset (OR = 20, 95%CI 7–60, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 6, 95%CI 2–16, p = 0.002).”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“On multivariate analysis (Table 3), two independent factors were associated with the diagnosis of AMI: the sudden onset (OR = 20.2, 95%CI 6.9–59.6, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 5.5, 95%CI 1.9–15.9, p = 0.002).”
Quote in the paperSubstantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
Sudden-onset and/or morphine-requiring abdominal pain was present in 88% of AMI patients versus 28% of controls (p < 0.001).
“Sudden-onset and/or morphine-requiring abdominal pain was present in 88% of AMI patients versus 28% in controls (p < 0.001).”
Quote in the paperSubstantial claim - Findingown data
The AUROC for the diagnosis of AMI of white blood cell count was 0.61 (95%CI 0.52-0.71, p=0.02).
“The AUROC curve for the diagnosis of AMI of white blood cell and neutrophil counts and plasma CRP and procalcitonin were 0.61 (95%CI 0.52–0.71, p = 0.02), 0.61 (95%CI 0.51–0.71, p = 0.03), 0.73 (95%CI 0.64–0.82, p < 0.001), and 0.74 (95%CI 0.64–0.83, p < 0.001), respectively (Additional file 1: Fig. S1).”
Quote in the paperNot a substantial claim - Findingown data
AMI patients were more likely to present with hematochezia than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
AMI patients were more likely to present with guarding than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
The area under the receiver operating characteristic curve for the diagnosis of AMI was 0.84 (95%CI 0.77-0.91), depending on the number of factors.
“The area under the receiver operating characteristic curve for the diagnosis of AMI was 0.84 (95%CI 0.77–0.91), depending on the number of factors.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“The overall AUROC curve for the diagnosis of AMI was 0.84 (95%CI 0.77–0.91), depending on the number of diagnostic factors (Table 4; Additional file 1: Fig. S2).”
Quote in the paperSubstantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
The AUROC for the diagnosis of AMI of plasma CRP was 0.73 (95%CI 0.64-0.82, p<0.001).
“The AUROC curve for the diagnosis of AMI of white blood cell and neutrophil counts and plasma CRP and procalcitonin were 0.61 (95%CI 0.52–0.71, p = 0.02), 0.61 (95%CI 0.51–0.71, p = 0.03), 0.73 (95%CI 0.64–0.82, p < 0.001), and 0.74 (95%CI 0.64–0.83, p < 0.001), respectively (Additional file 1: Fig. S1).”
Quote in the paperNot a substantial claim - Findingown data
AMI patients were more likely to have a history of cardiovascular disease than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“Patients with AMI were significantly older and were more likely to have risk factors or a history of cardiovascular disease than those with non-ischemic abdominal pain (Table 1).”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
AMI patients were more likely to have risk factors for cardiovascular disease than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“Patients with AMI were significantly older and were more likely to have risk factors or a history of cardiovascular disease than those with non-ischemic abdominal pain (Table 1).”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
AMI patients were more likely to present with morphine-requiring abdominal pain than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperSubstantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
AMI patients had higher neutrophil counts than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
On multivariate analysis, sudden onset of abdominal pain was independently associated with the diagnosis of AMI (OR = 20.2, 95%CI 6.9-59.6, p < 0.001).
“On multivariate analysis, two independent factors were associated with the diagnosis of AMI: the sudden-onset (OR = 20, 95%CI 7–60, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 6, 95%CI 2–16, p = 0.002).”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“On multivariate analysis (Table 3), two independent factors were associated with the diagnosis of AMI: the sudden onset (OR = 20.2, 95%CI 6.9–59.6, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 5.5, 95%CI 1.9–15.9, p = 0.002).”
Quote in the paperSubstantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
AMI patients had higher plasma procalcitonin concentrations than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperNot a substantial claim - Also stated in: § Factors associated with the diagnosis of AMI · plain
- Findingown data
The AUROC for the diagnosis of AMI of plasma procalcitonin was 0.74 (95%CI 0.64-0.83, p<0.001).
“The AUROC curve for the diagnosis of AMI of white blood cell and neutrophil counts and plasma CRP and procalcitonin were 0.61 (95%CI 0.52–0.71, p = 0.02), 0.61 (95%CI 0.51–0.71, p = 0.03), 0.73 (95%CI 0.64–0.82, p < 0.001), and 0.74 (95%CI 0.64–0.83, p < 0.001), respectively (Additional file 1: Fig. S1).”
Quote in the paperNot a substantial claim - Premisecitation
In a retrospective cohort study of survivors from mesenteric infarction, a delayed diagnosis was more frequent when initial plasma lactate concentrations were <2 mmol/L.
“Indeed, in a retrospective cohort study of survivors from mesenteric infarction, a delayed diagnosis was more frequent when initial plasma lactate concentrations were < 2 mmol/L, suggesting that physicians might be misguided by such unremarkable lactate levels [15].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [15] Nuzzo A, Joly F, Ronot M, et al. Normal lactate and unenhanced CT-scan result in delayed diagnosis of acute mesenteric ischemia. Am J Gastroenterol. 2020;115(11):1902–5. source
Not checked in the free run.
- Premisecitation
No specific clinical or biological signs have proven to be sufficiently sensitive or specific to suggest the diagnosis of AMI in the emergency setting.
“Indeed, no specific clinical or biological signs have proven to be sufficiently sensitive or specific to suggest the diagnosis in the emergency setting [1, 9, 13, 26].”
Quote in the paperSubstantial claim0 of 4 sources checked- cites [1] Clair DG, Beach JM. Mesenteric ischemia. N Engl J Med. 2016;374(10):959–68. source
Not checked in the free run.
- cites [9] Nuzzo A, Corcos O. Reversible acute mesenteric ischemia. N Engl J Med. 2016;375(15): e31. source
Not checked in the free run.
- cites [13] Peoc’h K, Nuzzo A, Guedj K, et al. Diagnosis biomarkers in acute intestinal ischemic injury: so close, yet so far. Clin Chem Lab Med. 2018;56(3):373–85. source
Not checked in the free run.
- cites [26] Derikx JP, Schellekens DH, Acosta S. Serological markers for human intestinal ischemia: a systematic review. Best Pract Res Clin Gastroenterol. 2017;31(1):69–74. source
Not checked in the free run.
- Premisecitation
No biomarker is currently validated or available for AMI.
“Moreover, no biomarker is currently validated or available [12, 13].”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [12] Nuzzo A, Guedj K, Curac S, et al. Accuracy of citrulline, I-FABP and D-lactate in the diagnosis of acute mesenteric ischemia. Sci Rep. 2021;11(1):18929. source
Not checked in the free run.
- cites [13] Peoc’h K, Nuzzo A, Guedj K, et al. Diagnosis biomarkers in acute intestinal ischemic injury: so close, yet so far. Clin Chem Lab Med. 2018;56(3):373–85. source
Not checked in the free run.
- Interpretationcitation
The discriminative weight of epidemiological and biological factors was insufficient.
“As the discriminative weight of epidemiological and biological factors was insufficient, we suggest the diagnosis be evoked irrespective of the patients’ age, prior cardiovascular history, or laboratory values (such as CRP or l-lactate levels) [14].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [14] Lehtimaki TT, Karkkainen JM, Saari P, et al. Detecting acute mesenteric ischemia in CT of the acute abdomen is dependent on clinical suspicion: review of 95 consecutive patients. Eur J Radiol. 2015;84(12):2444–53. source
Not checked in the free run.
- Premisecitation
Early recognition of AMI relies on a high index of clinical and radiological suspicion before confirmation on a multiphasic CT scan.
“As a result, the early recognition of AMI is still a major clinical challenge and relies on a high index of clinical and radiological suspicion before confirmation on a multiphasic CT scan [32].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [32] Garzelli L, Nuzzo A, Copin P, et al. Contrast-enhanced CT for the diagnosis of acute mesenteric ischemia. AJR Am J Roentgenol. 2020;215(1):29–38. source
Not checked in the free run.
- Interpretationreasoning
The exclusion of certain conditions may have decreased the generalizability of the findings.
“This may have decreased the generalizability of our findings for the discrimination of AMI from these other excluded conditions, although these conditions may share pathophysiological ischemic processes comparable to those of AMI.”
Quote in the paperNot a substantial claim - Premisecitation
Lower sensitivity of CT scans has been observed in real-life clinical settings when the CT-scan protocol does not include both arterial and venous phases.
“Furthermore, lower sensitivity of CT scans has been observed in real-life clinical settings when the CT-scan protocol does not include both arterial and venous phases [14, 33, 34].”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [14] Lehtimaki TT, Karkkainen JM, Saari P, et al. Detecting acute mesenteric ischemia in CT of the acute abdomen is dependent on clinical suspicion: review of 95 consecutive patients. Eur J Radiol. 2015;84(12):2444–53. source
Not checked in the free run.
- cites [33] Anglaret S, Dallongeville A, Beaussier H, et al. Influence of clinical suspicion on CT accuracy of acute mesenteric ischemia: retrospective study of 362 patients. Eur J Radiol. 2021;138: 109652. source
Not checked in the free run.
- cites [34] Wadman M, Block T, Ekberg O, et al. Impact of MDCT with intravenous contrast on the survival in patients with acute superior mesenteric artery occlusion. Emerg Radiol. 2010;17(3):171–8. source
Not checked in the free run.
- Premisecitation
When clinical suspicion of AMI is not evoked, it may be underdiagnosed on CT scans of the abdomen due to inappropriate IV contrast protocol and/or analysis not focusing on mesenteric vessels.
“In addition, when clinical suspicion of AMI is not evoked, it may be underdiagnosed on computed tomography (CT) scans of the abdomen as a result of either an inappropriate IV contrast protocol and/or an analysis that does not focus on the mesenteric vessels [14, 15].”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [14] Lehtimaki TT, Karkkainen JM, Saari P, et al. Detecting acute mesenteric ischemia in CT of the acute abdomen is dependent on clinical suspicion: review of 95 consecutive patients. Eur J Radiol. 2015;84(12):2444–53. source
Not checked in the free run.
- cites [15] Nuzzo A, Joly F, Ronot M, et al. Normal lactate and unenhanced CT-scan result in delayed diagnosis of acute mesenteric ischemia. Am J Gastroenterol. 2020;115(11):1902–5. source
Not checked in the free run.
- May combine two claims. 13
- The quote only partly states this claim. 3
- Classified as probably not a substantial claim. 16
May combine two claims.
Findingown dataThe study included 137 patients with acute abdominal pain, 52 with AMI and 85 controls.
“We included 137 patients—52 with AMI and 85 controls.”
- Also stated in: § Characteristics of the SURVIBIO population · plain
“We enrolled 137 patients, including 52 admitted to our ISC for AMI and 85 admitted to the ER for acute abdominal pain of another origin (see flowchart, Fig. 1).”
Quote in the paperSubstantial claim- Also stated in: § Characteristics of the SURVIBIO population · plain
May combine two claims.
Findingown dataAMI patients presented without severe signs in most cases, with no abdominal guarding in 67% and no organ failure in 70%.
“Nevertheless, AMI patients presented without severe signs in most cases, with no reporting of abdominal guarding in 67% of cases and no organ failure in 70% of cases.”
Quote in the paperSubstantial claimThe quote only partly states this claim.
Findingown dataAMI patients were more likely to have organ dysfunction (SOFA >2) than controls.
“Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations.”
- Also stated in: § Factors associated with the diagnosis of AMI · plain
“At admission, AMI patients were also more likely to present with sudden-onset and/or morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and CRP and plasma procalcitonin concentrations.”
Quote in the paperNot a substantial claim- Also stated in: § Factors associated with the diagnosis of AMI · plain
May combine two claims.
Findingown dataAmong AMI patients, 65% had arterial AMI and 35% had venous AMI.
“Patients with AMI [median age: 65 years (interquartile range 55–74)] had arterial and venous AMI in 65% and 35% of cases, respectively.”
- Also stated in: § Characteristics of the SURVIBIO population · plain
“Patients with AMI [median age: 65 years (IQR 55–74), 37% women] included arterial and venous causes in 65% and 35% of cases, respectively.”
Quote in the paperNot a substantial claim- Also stated in: § Characteristics of the SURVIBIO population · plain
The quote only partly states this claim.
Findingown dataPlasma lactate levels did not significantly differ between AMI patients and controls.
“Other admission clinical and laboratory characteristics, including l-lactate levels, did not significantly differ (Tables 1, 2).”
Quote in the paperSubstantial claimMay combine two claims.
Study design and conductown dataThe study included a homogeneous population of 52 well-defined patients with confirmed arterial and venous AMI, treated with a standardized care protocol, enrolled on admission, at an early stage in 73% of cases.
“Instead, our study included a homogeneous population of 52 well-defined patients with confirmed arterial and venous AMI, treated with a standardized care protocol in an intestinal stroke center, enrolled on admission, at the time of diagnosis, and at an early stage in 73% of cases.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenA series of sensitivity analyses were performed to assess the robustness of the findings.
“A series of sensitivity analyses were performed to assess the robustness of the findings (Additional file 1).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataResults remained similar in all sensitivity analyses.
“Overall, results remained similar in all sensitivity analyses (Additional file 1: Tables).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataNeutrophil counts were excluded from the multivariate model because of collinearity with white blood cell counts.
“Neutrophil counts were excluded from the multivariate model because of collinearity with white blood cell counts.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductown dataThe main multivariate model included sudden-onset and morphine-requiring abdominal pain, abdominal guarding, SOFA score >2, and WBC.
“The main model included the following covariates: sudden-onset and morphine-requiring abdominal pain, abdominal guarding, SOFA score > 2, and WBC.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductcitationThe study was reported according to the STROBE guidelines.
“This study was performed following the ethical standards of our institution's Committee on Human Experimentation (Institutional Review Board N°00006477, approval 15-062) and reported according to the Strengthening the Reporting of Observational Studies Epidemiology (STROBE) guidelines [16].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [16] von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7. source
Not checked in the free run.
Classified as probably not a substantial claim. May combine two claims.
Study design and conductnone givenThe diagnosis of AMI was confirmed or ruled out by CT scan and alternative final diagnoses were based on clinical, laboratory, and CT findings.
“The diagnosis of AMI was confirmed or ruled out by the CT scan and alternative final diagnoses were based on clinical, laboratory, and CT findings.”
Quote in the paperSubstantial claim- Rests on an assumption: The reference standard used to classify patients as AMI or controls correctly identifies the true disease status.
May combine two claims.
Interpretationown dataPlasma lactate concentrations were initially within the normal range in the cohort of AMI patients, confirming their diagnostic inutility in the early stages of AMI.
“Of note, plasma lactate concentrations were initially within the normal range in our cohort of AMI patients, thus confirming their diagnostic inutility in the early stages of AMI.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenPatient clinical records, CT scans, and pathological specimens were reviewed in a monthly multidisciplinary meeting including experts to avoid misdiagnosis.
“Patient clinical records, CT scans, and pathological specimens were reviewed in a monthly multidisciplinary meeting that included gastroenterologists, radiologists, digestive and vascular surgeons, and intensivists, all experts in digestive vascular diseases to avoid misdiagnosis.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenMulticollinearity between selected variables was assessed using VIF.
“Multicollinearity between selected variables was assessed using the variance inflation factor (VIF).”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationElevated plasma lactate levels and organ failure are late findings associated with intestinal necrosis.
“Elevated plasma lactate levels and organ failure are late findings associated with intestinal necrosis [18].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [18] Nuzzo A, Maggiori L, Ronot M, et al. Predictive factors of intestinal necrosis in acute mesenteric ischemia: prospective study from an intestinal stroke center. Am J Gastroenterol. 2017;112(4):597–605. source
Not checked in the free run.
Classified as probably not a substantial claim.
Study design and conductnone givenAll CT scans were reviewed by two senior radiologists specialized in AMI and digestive diseases.
“All CT-scans were reviewed by two senior radiologists specialized in both AMI and digestive diseases (LG and MR).”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenNo imputation of missing data was performed.
“No imputation of missing data was performed.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe incidence of AMI is 8.6/100,000 person-years.
“AMI accounts for approximately 1% of acute abdominal pain and its incidence was shown to be 8.6/100,000 person-years in a large population-based study [2, 3].”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [2] Karkkainen JM, Acosta S. Acute mesenteric ischemia (part I)—incidence, etiologies, and how to improve early diagnosis. Best Pract Res Clin Gastroenterol. 2017;31(1):15–25. source
Not checked in the free run.
- cites [3] Acosta S, Ogren M, Sternby NH, et al. Incidence of acute thrombo-embolic occlusion of the superior mesenteric artery—a population-based study. Eur J Vasc Endovasc Surg. 2004;27(2):145–50. source
Not checked in the free run.
Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.
Interpretationnone givenThe sudden onset characteristic of the pain and the morphine requirement may be partially subjective.
“However, one can argue that the sudden onset characteristic of the pain and the morphine requirement may be partially subjective.”
Quote in the paperNot a substantial claim- Rests on an assumption: The sudden onset and morphine requirement can be assessed reliably enough for clinical use.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenInformed consent was obtained from all patients.
“Informed consent was obtained from all patients.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationThe pilot study showed an improvement in survival and lower resection rates.
“Following the results of a pilot study showing an improvement in survival and lower resection rates [4], we created an intestinal stroke center (ISC) that provides 24/7 standardized multimodal and multidisciplinary care to AMI patients referred from the Paris region.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [4] Corcos O, Castier Y, Sibert A, et al. Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure. Clin Gastroenterol Hepatol. 2013;11(2):158–65. source
Not checked in the free run.
May combine two claims.
PremisecitationEarly AMI is a fully reversible condition, as opposed to late AMI with irreversible transmural necrosis.
“Indeed, early AMI is a fully reversible condition, as opposed to late AMI, with irreversible transmural necrosis [1, 4, 9].”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [1] Clair DG, Beach JM. Mesenteric ischemia. N Engl J Med. 2016;374(10):959–68. source
Not checked in the free run.
- cites [4] Corcos O, Castier Y, Sibert A, et al. Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure. Clin Gastroenterol Hepatol. 2013;11(2):158–65. source
Not checked in the free run.
- cites [9] Nuzzo A, Corcos O. Reversible acute mesenteric ischemia. N Engl J Med. 2016;375(15): e31. source
Not checked in the free run.
Classified as probably not a substantial claim. The quote only partly states this claim.
Interpretationown dataThe study provides prospective and comparative evidence further supporting the recommendation to assume AMI in severe abdominal pain out of proportion.
“As a reminder of the importance of the clinical exam and clinical suspicion in the diagnosis of AMI, our study provides prospective and comparative evidence further supporting this recommendation, and suggests that suspicion of an AMI diagnosis be raised in the presence of any acute abdominal pain when at least one of these two factors is present: (1) a reported sudden onset or (2) the requirement”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
PremisecitationThe estimated prevalence of AMI among acute abdominal pain patients is 1%.
“AMI accounts for approximately 1% of acute abdominal pain and its incidence was shown to be 8.6/100,000 person-years in a large population-based study [2, 3].”
- Also stated in: § Discussion · hedged
“Considering an estimated prevalence of AMI of 1% among acute abdominal pain patients [2, 3], the probability of AMI would be approximately 0.01% or 10% for a patient with no or two factors, respectively [21].”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [2] Karkkainen JM, Acosta S. Acute mesenteric ischemia (part I)—incidence, etiologies, and how to improve early diagnosis. Best Pract Res Clin Gastroenterol. 2017;31(1):15–25. source
Not checked in the free run.
- cites [3] Acosta S, Ogren M, Sternby NH, et al. Incidence of acute thrombo-embolic occlusion of the superior mesenteric artery—a population-based study. Eur J Vasc Endovasc Surg. 2004;27(2):145–50. source
Not checked in the free run.
- Also stated in: § Discussion · hedged
May combine two claims.
InterpretationcitationConsidering an estimated prevalence of AMI of 1% among acute abdominal pain patients, the probability of AMI would be approximately 0.01% or 10% for a patient with no or two factors, respectively.
“Considering an estimated prevalence of AMI of 1% among acute abdominal pain patients [2, 3], the probability of AMI would be approximately 0.01% or 10% for a patient with no or two factors, respectively [21].”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [2] Karkkainen JM, Acosta S. Acute mesenteric ischemia (part I)—incidence, etiologies, and how to improve early diagnosis. Best Pract Res Clin Gastroenterol. 2017;31(1):15–25. source
Not checked in the free run.
- cites [3] Acosta S, Ogren M, Sternby NH, et al. Incidence of acute thrombo-embolic occlusion of the superior mesenteric artery—a population-based study. Eur J Vasc Endovasc Surg. 2004;27(2):145–50. source
Not checked in the free run.
- cites [21] Fagan TJ. Letter: nomogram for bayes theorem. N Engl J Med. 1975;293(5):257. source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe study was approved by the Institutional Review Board (N°00006477, approval 15-062).
“This study was performed following the ethical standards of our institution's Committee on Human Experimentation (Institutional Review Board N°00006477, approval 15-062) and reported according to the Strengthening the Reporting of Observational Studies Epidemiology (STROBE) guidelines [16].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [16] von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7. source
Not checked in the free run.
May combine two claims.
InterpretationcitationIn the absence of a validated available diagnostic biomarker of AMI, broad and timely clinical suspicion and subsequent confirmation by an appropriate multiphasic CT scan is currently the only way to achieve an earlier diagnosis and better outcomes.
“In the absence of a validated available diagnostic biomarker of AMI, broad and timely clinical suspicion and subsequent confirmation by an appropriate multiphasic CT scan is currently the only way to achieve an earlier diagnosis and better outcomes [1, 28].”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [1] Clair DG, Beach JM. Mesenteric ischemia. N Engl J Med. 2016;374(10):959–68. source
Not checked in the free run.
- cites [28] Bala M, Kashuk J, Moore EE, et al. Acute mesenteric ischemia: guidelines of the world society of emergency surgery. World J Emerg Surg. 2017;12:38. source
Not checked in the free run.
May combine two claims.
Study design and conductreasoningThe prevalence of AMI was high in this cross-sectional study, so predictive values could not be calculated.
“Finally, as a referring hospital for AMI, the prevalence of AMI was high in this cross-sectional study and, thus, the predictive values could not be calculated.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
The reference standard used to classify patients as AMI or controls correctly identifies the true disease status.
“The diagnosis of AMI was confirmed or ruled out by the CT scan and alternative final diagnoses were based on clinical, laboratory, and CT findings.”
“Patient clinical records, CT scans, and pathological specimens were reviewed in a monthly multidisciplinary meeting that included gastroenterologists, radiologists, digestive and vascular surgeons, and intensivists, all experts in digestive vascular diseases to avoid misdiagnosis.”
The paper relies on this without support.
The sudden onset and morphine requirement can be assessed reliably enough for clinical use.
“However, one can argue that the sudden onset characteristic of the pain and the morphine requirement may be partially subjective.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Sudden-onset pain or pain requiring morphine has been correlated with acute mesenteric ischemia in recent studies.
“Recent studies have correlated sudden-onset pain or pain requiring morphine with acute mesenteric ischemia [13].”
From Revascularization Strategies for Acute and Chronic Mesenteric Ischemia: A Narrative Review (2024) · cites this paper as [13]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Discussion overstates the frequency of morphine requirement
MinorThe discussion says more than 65% of AMI patients required morphine, whereas Table 1 reports 64%.
“more than 65% of patients reported a sudden onset and required morphine treatment”
“| Morphine-requiring abdominal pain | 33 (64) | 19 (22) | < 0.001 |”
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Self-citationContrast-Enhanced CT for the Diagnosis of Acute Mesenteric Ischemia
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Inter-reader agreement of CT features of acute mesenteric ischemia
Copin, P., Ronot, M., Nuzzo, A., Maggiori, L., Bouhnik, Y., Corcos, O., & Vilgrain, V. (2018) · European Journal of Radiology · doi:10.1016/j.ejrad.2018.05.027 · Cited by 45 · see citing works
Self-citationOral Antibiotics Reduce Intestinal Necrosis in Acute Mesenteric Ischemia: A Prospective Cohort Study
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Self-citationSerum value of procalcitonin as a marker of intestinal damages: type, extension, and prognosis
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Reversible Acute Mesenteric Ischemia
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Self-citationNormal Lactate and Unenhanced CT-Scan Result in Delayed Diagnosis of Acute Mesenteric Ischemia
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Self-citationPrise en charge moderne des ischémies mésentériques
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Self-citationEarly Acute Mesenteric Ischemia: Many Rivers to Cross
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Self-citation
Flagged first, then by citations
Cited by
Sorted by citations
Revascularization Strategies for Acute and Chronic Mesenteric Ischemia: A Narrative Review
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“However, other studies have indicated that specific markers like L-lactate, D-dimer, leukocytosis, and neutrophil-to-lymphocyte ratio may not have strong predictive value [21].”
BackgroundDiagnostic Role of Multi-Detector Computed Tomography in Acute Mesenteric Ischemia
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Self-citationImpact on the prognosis with the creation of a dedicated stroke to mesenteric ischaemia
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Self-citationThe Importance of Predicting Bowel Necrosis in Acute Mesenteric Ischemia: Narrative Review
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Mesenteric Ischemia: 2026 Update— AJR Expert Panel Narrative Review
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Self-citationRetrospective Analysis of Factors Associated With Mortality in Acute Mesenteric Ischemia
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Akute mesenteriale Ischämie: Warum vaskuläre Expertise entscheidend ist
Larena-Avellaneda, A. (2026) · Gefässchirurgie · doi:10.1007/s00772-026-01359-5
- Authors
- Nuzzo, A., Peoc’h, K., Vaittinada Ayar, P., Tran-Dinh, A., Weiss, E., Panis, Y., Ronot, M., Garzelli, L., Eloy, P., Ben Abdallah, I., Castier, Y., & Corcos, O.
- Affiliations
- Inserm (FR)
- Hôpital Beaujon (FR)
- Assistance Publique – Hôpitaux de Paris (FR)
- Corresponding author
- Nuzzo, Alexandre
- ORCID
- Venue
- World Journal of Emergency Surgery
- Published
- 2023-06-07
- Volume
- 18
- Issue
- 1
- Pages
- 37-37
- ISSN
- 1749-7922 (ISSN-L)
- PMC
- PMC10246417
- OpenAlex
- W4379768191
- Semantic Scholar
- 960b64072ea0b8a45896e4dbc90292e7989d1226
- Cited by
- 22
- References
- 35
- Citations by year
- 2026: 8 · 2025: 10 · 2024: 4
- FWCI
- 5.87
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- World Journal of Emergency Surgery (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Assistance publique-Hôpitaux de Paris
- Topics
- Health Sciences › Medicine › Surgery › Abdominal vascular conditions and treatments
- Health Sciences › Medicine › Emergency Medicine › Appendicitis Diagnosis and Management
- Health Sciences › Medicine › Rheumatology › Omental and Epiploic Conditions
- Keywords
- acute mesenteric ischemia, acute abdomen, clinical suspicion, morphine consumption, multiphase CT, diagnostic criteria, C-reactive protein, procalcitonin, emergency department diagnosis
- MeSH terms
- Abdomen, Acute, Aged, Cross-Sectional Studies, Humans, Morphine Derivatives, Abdominal Pain, Stroke, Mesenteric Ischemia
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-07.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-07.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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