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 and reduced mortality rates 1. Initial management includes:
- Fluid resuscitation with isotonic crystalloids to enhance visceral perfusion
- Correction of electrolyte abnormalities
- 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
- Nasogastric decompression to reduce intestinal distension
- Anticoagulation with unfractionated heparin, unless contraindicated, if embolic or thrombotic etiology is suspected
- Pain management with opioid analgesics
Definitive treatment typically requires surgical intervention, including:
- Embolectomy
- Thrombectomy
- Bypass grafting
- Resection of necrotic bowel Endovascular approaches with thrombolysis using tissue plasminogen activator may be considered in select cases, as they have been shown to have lower 30-day mortality rates compared to surgical interventions 1. Continuous monitoring of vital signs, urine output, and serial physical examinations are essential, as is frequent reassessment of laboratory values, including lactate, which serves as a marker of tissue hypoperfusion. The goal of surgical intervention is to re-establish blood supply to the ischemic bowel, resect non-viable regions, and preserve viable bowel, with intestinal viability being the most important factor influencing outcome in patients with acute mesenteric ischemia 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 survival rates 2, 3, 4, 5, 6
- The management of acute bowel ischemia involves a multidisciplinary approach, including surgical intervention, endovascular treatment, and supportive care 2, 4, 5, 6
- Surgical management may involve emergency resection of ischemic bowel, damage control surgery, and formation of a laparostomy, with definitive surgery considered after stabilization 2, 5, 6
- Endovascular treatment, including thrombolysis, pharmacomechanical thrombectomy, and angioplasty/stenting, may be employed in cases of acute mesenteric ischemia without evidence of frank bowel necrosis 4, 5
Diagnostic Approaches
- Computed tomography (CT) scan of the abdomen and pelvis with oral and IV contrast is recommended for patients presenting with symptoms concerning for ischemia 3
- Laboratory testing, including white blood cell count, serum lactate levels, and serum creatinine, may be useful in diagnosing acute bowel ischemia 2, 3
- Colonoscopy should be performed in patients without evidence of peritonitis to evaluate the extent of ischemia 3
Treatment Options
- Supportive care, including intravenous fluids and bowel rest, may be sufficient for less severe cases of ischemic colitis 3
- Broad-spectrum antibiotics should be initiated in cases of severe disease, pancolonic ischemia, and isolated right colonic ischemia 3
- Surgery should be performed for peritonitis, hemodynamic instability, or failure of non-operative management 2, 3, 5, 6
- Endovascular intervention may be considered in cases of acute mesenteric ischemia, particularly in patients with isolated right colon ischemia 4, 5