From the Guidelines
Acute bowel ischemia requires immediate surgical consultation and intervention, with prompt laparotomy for patients with overt peritonitis, as this approach is associated with improved outcomes in terms of morbidity, mortality, and quality of life 1. Initial management includes fluid resuscitation with isotonic crystalloids, correction of electrolyte abnormalities, and broad-spectrum antibiotics such as piperacillin-tazobactam 4.5g IV every 6 hours or a combination of ciprofloxacin 400mg IV every 12 hours plus metronidazole 500mg IV every 8 hours to cover enteric pathogens.
- Bowel rest with nasogastric tube decompression should be instituted.
- Pain management with IV opioids like morphine 2-4mg or hydromorphone 0.5-1mg every 4 hours as needed is appropriate.
- Laboratory studies including lactate, CBC, comprehensive metabolic panel, and coagulation studies should be obtained.
- Imaging with CT angiography is the preferred diagnostic modality.
- Anticoagulation with unfractionated heparin (80 units/kg bolus followed by 18 units/kg/hr infusion, targeting aPTT 1.5-2.5 times normal) should be started unless contraindicated. Definitive treatment depends on the cause and extent of ischemia, with surgical options including embolectomy, bypass, resection of necrotic bowel, or endovascular interventions, with recent studies suggesting that endovascular interventions may have a lower 30-day mortality compared to surgical interventions 1.
- Vasopressors should be avoided if possible as they may worsen splanchnic perfusion. Rapid intervention is critical as bowel ischemia can progress to necrosis within hours, leading to sepsis, multiorgan failure, and death, with mortality rates of 60-80% if treatment is delayed, highlighting the importance of prompt recognition and management of acute bowel ischemia 1.
From the Research
Acute Bowel Ischemia Management
- Acute bowel ischemia is a serious condition that requires prompt management to prevent complications such as short bowel syndrome 2.
- The condition can be caused by various factors, including embolism, vascular spasm, and thrombosis, and can affect different parts of the gastrointestinal tract, including the small bowel and colon 3, 4.
- Diagnosis of acute bowel ischemia typically involves computed tomography (CT) scan of the abdomen and pelvis with oral and IV contrast, laboratory testing, and colonoscopy in patients without evidence of peritonitis 3.
- Treatment of acute bowel ischemia can be medical or surgical, depending on the severity of the condition and the presence of complications such as peritonitis or hemodynamic instability 3, 4.
- Surgical management may involve thrombectomy, bowel resection, and anastomosis, and may be performed using an open or endovascular approach 2, 4, 5.
- A damage control approach, which involves emergency resection of ischemic bowel with no attempt to restore gastrointestinal continuity and formation of a laparostomy, can be effective in improving survival in patients with acute mesenteric ischemia 5.
- Endovascular intervention, including thrombolysis, pharmacomechanical thrombectomy, and angioplasty/stenting, can also be effective in managing acute bowel ischemia, particularly in cases where open surgery is not feasible or is associated with high risk 4, 5.
- Multidisciplinary management by a dedicated team, including surgeons, radiologists, and intensivists, is essential to achieve the best outcomes in patients with acute bowel ischemia 2, 4.