What is the management of acute intestinal ischemia?

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. The initial management of acute bowel ischemia includes fluid resuscitation with 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.

• Bowel rest with nasogastric tube decompression should be implemented to reduce the risk of further bowel injury and to manage any potential bowel obstruction.
• Pain control with IV opioids like morphine 2-4mg every 4 hours as needed is appropriate to manage pain and discomfort associated with the condition.
• Laboratory studies should include complete blood count, comprehensive metabolic panel, lactate, and coagulation studies to assess the severity of the condition and to guide further management.
• Imaging with CT angiography of the abdomen is the preferred diagnostic modality to confirm the diagnosis and to assess the extent of bowel ischemia. Definitive treatment typically involves surgical exploration with revascularization or resection of nonviable bowel.
• In cases of embolic occlusion, anticoagulation with unfractionated heparin (80 units/kg bolus followed by 18 units/kg/hour infusion, titrated to aPTT 1.5-2.5 times normal) should be initiated to prevent further clot formation and to reduce the risk of recurrent embolism.
• Endovascular interventions including thrombolysis with recombinant tissue plasminogen activator (tPA) or mechanical thrombectomy may be options in select cases, particularly in patients who are not suitable candidates for surgical intervention 1. Rapid intervention is critical as bowel ischemia can progress to necrosis within 6-12 hours, leading to perforation, peritonitis, septic shock, and death.
• The mortality rate remains high (50-80%) despite optimal management, emphasizing the need for prompt diagnosis and treatment 1.

From the Research

Acute Bowel Ischemia Management

• Acute bowel ischemia is a serious condition that requires prompt management to prevent short bowel syndrome and improve patient outcomes 2.
• The management of acute bowel ischemia involves a multidisciplinary approach, including surgical and endovascular interventions 3.
• In cases of acute mesenteric ischemia, an endovascular-first strategy employing thrombolysis, pharmacomechanical thrombectomy, and/or adjunctive angioplasty/stenting has been shown to have positive outcomes 3.
• Damage control surgery and early angiography can improve survival in patients suffering acute mesenteric ischemia 4.
• Supportive therapy, including intravenous fluids and bowel rest, is often the only required treatment for less severe cases of ischemic colitis 5, 6.
• Surgical consultation should be obtained in cases of severe disease, pancolonic ischemia, and isolated right colonic ischemia 5.
• Surgery should be performed for peritonitis, hemodynamic instability, or failure of non-operative management 5, 4.

Diagnostic Approaches

• Computed tomography (CT) scan of the abdomen and pelvis with oral and IV contrast is a useful diagnostic tool for acute bowel ischemia 5, 6.
• Colonoscopy should be performed in patients without evidence of peritonitis to evaluate the extent of ischemia 5.
• Laboratory tests, including white blood cell count, serum lactate levels, and serum creatinine, can help identify patients with acute bowel ischemia 2.
• Medical history should be obtained to identify possible etiologies of ischemia, and thrombophilia workup should be considered in young patients and those with recurrent ischemia 5.

Treatment Outcomes

• The 3-day survival was significantly higher in patients treated with a multidisciplinary approach, including surgical and endovascular interventions 2.
• Post-operative morbidity was significantly lower in patients treated with a damage control approach and early angiography 4.
• Only one patient among both groups (1.6%) developed a short bowel syndrome, highlighting the importance of prompt and effective management of acute bowel ischemia 2.