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 Inhibitory effect of modified citrus pectin on live metastases

Abstract
Splanchnic or gastrointestinal ischemia is rare and randomized studies are absent. This review focuses on new developments in clinical presentation, diagnostic approaches, and treatments. Splanchnic ischemia can be caused by occlusions of arteries or veins and by
physiological vasoconstriction during low-flow states.The prevalence of signifcant splanchnic arterial stenoses is high, but it remains mostly asymptomatic due to abundant collateral circulation. This is known as chronic splanchnic disease (CSD). Chronic splanchnic syndrome(CSS) occurs when ischemic symptoms develop. Ischemic symptoms are characterized by postprandial pain, fear of eating and weight loss. CSS is diagnosed by a test for actual ischemia. Recently, gastro-intestinal tonometry has been validated as a diagnostic test to detect splanchnic ischemia and to guide treatment. In singlevessel CSD, the complication rate is very low, but some patients have ischemic complaints, and can be treated successfully. In multi-vessel stenoses, the complication rate is considerable, while most have CSS and treatment should be strongly considered. CT and MR-based angiographic reconstruction techniques have emerged as alternatives for digital subtraction angiography for imaging of splanchnic vessels. Duplex ultrasound is still the first choice for screening purposes. The strengths and weaknesses of each modality will be discussed.CSS may be treated by minimally invasive endoscopic treatment of the celiac axis compression syndrome,
endovascular antegrade stenting, or laparotomy-assisted retrograde endovascular recanalization and stenting.

The treatment plan is highly individualized and is mainly based on precise vessel anatomy, body weight, comorbidity and severity of ischemia.
© 2008 The WJG Press. All rights reserved.
Key words: Splanchnic ischemia; Mesenteric ischemia;Tonometry; Blood flow; Chronic splanchnic syndrome;Chronic splanchnic disease; Chronic mesenteric ischemia; Celiac artery compression syndrome; Ischemic
colitis
Peer reviewer: Dr. Daniel R Gaya, Gastrointestinal Unit,Molecular Medicine Centre, School of Molecular and ClinicalMedicine, University of Edinburgh, Western General Hospital,Crewe Road, Edinburgh EH4 2XU, United Kingdom
Kolkman JJ, Bargeman M, Huisman AB, Geelkerken RH.Diagnosis and management of splanchnic ischemia. World JGastroenterol 2008; 14(48): 7309-7320 Available from: URL:http://www.wjgnet.com/1007-9327/14/7309.asp DOI: http://dx.doi.org/10.3748/wjg.14.7309
INTRODUCTION
In this review we will cover the current insights insplanchnic or gastrointestinal ischemia. This disorderis still rarely seen in daily practice, and randomized controlled trials are absent,therefore the view of this paper is highly personal and partly authority-based in its
conclusions. The spectrum of ischemic bowel disease is broad, ranging from transient left-sided ischemic colitis (with a good prognosis) to full blown intestinal infarction, with a high death rate. We will focus on new developments in clinical presentation, diagnostic approaches, and treatment options. Splanchnic ischemia can develop during low-flow states in patients with
patent vessels, and in subjects with varying degree of splanchnic artery stenoses or splanchnic venous thrombosis. The prevalence of significant splanchnic arterial stenoses, or chronic splanchnic disease (CSD) is high, ranging from 30% to 50%[1,2]. Chronic splanchnic
syndrome (CSS) occurs when ischemic symptoms develop. The most characteristic ischemic symptoms
consist of postprandial pain, with resultant fear of eating and weight loss. When epigastric bruit is included, these are the so-called classical triad of CSS. In most patientswith CSS, this triad is incomplete. The true incidence of CSS is currently unclear, but is rare compared to CSD due to abundant collateral circulation.
  Two important developments occurred in the last decade. Firstly, validation of the gastric exercise tonometry, which is currently the only clinically available and validated diagnostic test to ascertain the presence of splanchnic ischemia[3,4]. Using an ischemia-specific test it should be possible (1) to identify patients with symptomatic vessel stenoses, or CSS, which can be
treated, and (2) to make this diagnosis in time and thus prevent the disaster of acute intestinal infarction. Secondly, the increasing evidence that one vessel CSD may cause splanchnic ischemia resulting in one vessel CSS, and can be successfully treated with appropriate
selection procedures[5]. An important difference in presentation, treatment and outcome has been shown to exist between single and multi-vessel disease[6]. In the latter group, the clinical presentation is often less typical,with diarrhea, unexplained gastric ulcers, or dyspepsialike symptoms. These insights stem mainly from our work with tonometry.An entirely different entity consists of patients suffering from splanchnic ischemia without splanchnic stenoses; the so-called non-occlusive mesenteric ischemia (NOMI). It can be seen as a consequence of physiological adaptation mechanisms during low-flowstates were blood is dispersed from the gastrointestinal region to more vital organs[7]. This situation is very common in intensive care and operative units, but can also be seen in outpatients. Treatment consists of aggressive fluid resuscitation and medication. However,bowel infarction can still occur.
In the last decade a change in imaging of the splanchnic vessels occurred. Duplex ultrasound,
although operator dependent and suitable for 80% of patients, is still the first choice. Visceral angiography has increasingly been replaced by CT and MR-based angiographic reconstruction techniques. The clinically important advantages and disadvantages of these techniques will be discussed. Whichever technique is used,it leaves the clinician with only anatomical information.To decide whether a given stenosis has caused the symptoms, information on actual ischemia is required.This information can be obtained using tonometry,which has a proven accuracy of 80%-90%. Other tests including, serological iFABP, endothelial progenitor cell measurement, or MR angiography (MRA)-based saturation measurements, may serve that purpose in the near future.Treatment options have changed considerably over the last decade. Apart from the classical transabdominal vascular reconstructive surgery techniques, minimally invasive endoscopic treatment of the celiac axis compression syndrome, endovascular antegrade stenting, or laparotomy-assisted retrograde endovascular recanalization and stenting have broadened our therapeutic“armory” considerably. The main patient characteristics to guide therapy choice, which include anatomical considerations, as well as body weight, co-morbidity and severity of ischemia, will be discussed.

CONClUsION
Splanchnic ischemia has developed into a broad spectrum of diseases. These are characterized by onset, vessel anatomy, and presence of ischemia. Each syndrome has different characteristics, outcome, and treatment options, therefore a state-of-the art vessel anatomy assessment and accurate functional test are crucial. Tonometry is the only validated test assessing the adequacy of the splanchnic blood-flow and consequently is crucial in proper patient selection. Treatment options,including noninvasive, minimal invasive and classical open vascular reconstructive techniques, are wide and require a multi-disciplinary team-approach for proper selection and follow-up.