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Clinical management of chronic mesenteric ischemia

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      This review provides an overview on the clinical management of chronic mesenteric ischemia (CMI). CMI is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. However, patients may present with, atypically, symptoms such as abdominal discomfort, nausea, vomiting, diarrhea or constipation. Early consideration and diagnosis of CMI is important to timely treat, to improve quality of life and to prevent acute-on-chronic mesenteric ischemia. The diagnosis of CMI is based on the triad of clinical symptoms, radiological evaluation of the mesenteric vasculature and if available, functional assessment of mucosal ischemia. Multidisciplinary consensus on the diagnosis of CMI is of paramount importance to adequately select patients for treatment. Patients with a consensus diagnosis of single-vessel or multi-vessel atherosclerotic CMI are preferably treated with endovascular revascularization.

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      To generate a classification of methods to evaluate medical tests when there is no gold standard. Multiple search strategies were employed to obtain an overview of the different methods described in the literature, including searches of electronic databases, contacting experts for papers in personal archives, exploring databases from previous methodological projects and cross-checking of reference lists of useful papers already identified. All methods available were classified into four main groups. The first method group, impute or adjust for missing data on reference standard, needs careful attention to the pattern and fraction of missing values. The second group, correct imperfect reference standard, can be useful if there is reliable information about the degree of imperfection of the reference standard and about the correlation of the errors between the index test and the reference standard. The third group of methods, construct reference standard, have in common that they combine multiple test results to construct a reference standard outcome including deterministic predefined rules, consensus procedures and statistical modelling (latent class analysis). In the final group, validate index test results, the diagnostic test accuracy paradigm is abandoned and research examines, using a number of different methods, whether the results of an index test are meaningful in practice, for example by relating index test results to relevant other clinical characteristics and future clinical events. The majority of methods try to impute, adjust or construct a reference standard in an effort to obtain the familiar diagnostic accuracy statistics, such as sensitivity and specificity. In situations that deviate only marginally from the classical diagnostic accuracy paradigm, these are valuable methods. However, in situations where an acceptable reference standard does not exist, applying the concept of clinical test validation can provide a significant methodological advance. All methods summarised in this report need further development. Some methods, such as the construction of a reference standard using panel consensus methods and validation of tests outwith the accuracy paradigm, are particularly promising but are lacking in methodological research. These methods deserve particular attention in future research.
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            Author and article information

            [1 ]Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
            [2 ]Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
            [3 ]Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
            [4 ]Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
            [5 ]Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
            [6 ]Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
            [7 ]Technical Medical Center, Faculty Science and Technology, University Twente, Enschede, the Netherlands
            [8 ]Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
            Author notes
            Louisa JD van Dijk, Department of Gastroenterology and Hepatology and Department of Radiology, Erasmus MC University Medical Center, ‘s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands. Email: l.vandijk@
            United European Gastroenterol J
            United European Gastroenterol J
            United European Gastroenterology Journal
            SAGE Publications (Sage UK: London, England )
            04 December 2018
            March 2019
            : 7
            : 2
            : 179-188
            6498801 10.1177/2050640618817698 10.1177_2050640618817698
            © Author(s) 2018

            This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (

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