From the Guidelines
The patient with abdominal pain, high lactate, and high inflammatory markers should be immediately evaluated for potential acute mesenteric ischemia (AMI) and started on fluid resuscitation with crystalloids, broad-spectrum antibiotics, and urgent CT imaging of the abdomen with IV contrast. According to the updated guidelines of the World Society of Emergency Surgery 1, elevated l-lactate, leukocytosis, and D-dimer may assist in identifying AMI, although no laboratory parameters are sufficiently accurate to conclusively diagnose the condition. The presence of lactic acidosis with elevated lactate levels > 2 mmol/l is associated with irreversible intestinal ischemia 1.
Key considerations in the management of this patient include:
- Fluid resuscitation with crystalloids (normal saline or lactated Ringer's) at 20-30 mL/kg to address potential dehydration and hypovolemia
- Broad-spectrum antibiotics such as piperacillin-tazobactam 4.5g IV every 6 hours or meropenem 1g IV every 8 hours plus metronidazole 500mg IV every 8 hours if anaerobic coverage is needed
- Urgent CT imaging of the abdomen with IV contrast to evaluate for ischemia, perforation, or abscess
- Monitoring of vital signs, including hourly urine output, and consideration of central venous access for hemodynamic monitoring if the patient is unstable
- Early surgical consultation, as many conditions causing this presentation require operative intervention
It is essential to note that the diagnosis of AMI can be challenging, and no accurate biomarkers have been identified 1. However, the combination of clinical presentation, laboratory findings, and imaging results can help guide the diagnosis and management of this condition. Serial lactate measurements every 4-6 hours will help track response to treatment, and the patient's condition should be closely monitored for signs of septic shock or multiorgan failure.
From the Research
Abdominal Pain with High Lactate and Inflammatory Markers
- Abdominal pain conditions that fall into the category of acute abdomen (AA) are the most important ones to identify quickly, as diagnostic delay can lead to death or significant complications 2.
- High lactate levels can be an indicator of poor tissue perfusion, a key element in the management of severe sepsis and septic shock in AA 2.
- Lactate is a marker of poor tissue perfusion, and its testing is easy and inexpensive, making it a useful biomarker in the emergency department 2.
- However, high lactate levels can also be caused by other conditions, such as type B lactic acidosis, which should be considered in patients with persistently elevated lactate without evidence of inadequate oxygen delivery 3.
Diagnostic Value of Lactate Levels
- The diagnostic value of lactate levels in acute abdomen disorders has been studied, and it has been found that lactate levels in peritoneal fluid (PF) can be a useful marker of surgical emergency in patients with acute intra-abdominal pathology 4.
- A study found that PF lactate levels were significantly higher in patients with surgical abdomen compared to those with non-surgical abdomen, and that a cut-off value of ≥6.4 mmol/L had a high degree of sensitivity and specificity 4.
- Serum lactate measurement has also been used in diagnosing acute mesenteric ischaemia, and it has been found to have some diagnostic value, although it is not a perfect biomarker 5.
Inflammatory Markers
- C-reactive protein (CRP) is often analyzed in the context of AA, but it is very difficult to establish a cutoff that gives good sensitivity and specificity 2.
- Procalcitonin is another biomarker that is often used in the emergency department, although its diagnostic value in AA is not as well established as that of lactate 2.
- The kinetics of CRP make it a sensitive biomarker for assessing severity before the onset of clinical signs of severe sepsis or altered hemodynamics 2.