From the Guidelines
Treatment for ischemic bowel disease should prioritize endovascular interventions, such as aspiration embolectomy, as the initial approach to restore blood flow to the affected intestinal segment, given their lower morbidity and high technical success rates, as supported by the most recent study 1. The primary goal of treatment is to rapidly restore inline arterial flow to the affected bowel to avoid potentially life-threatening complications. Initial management includes:
- Fluid resuscitation with IV crystalloids
- Bowel rest with nothing by mouth
- Nasogastric tube decompression
- Broad-spectrum antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours or meropenem 1g IV every 8 hours
- Pain management
- Anticoagulation with heparin may be necessary for mesenteric venous thrombosis Surgical intervention is often required for intestinal infarction, with resection of necrotic bowel segments. However, endovascular interventions should be exhausted before pursuing operative management, as they have been shown to have lower morbidity, such as lower rates of bowel resection and acute renal failure, and high technical success rates up to 94% 1. Long-term management includes addressing underlying cardiovascular risk factors, antiplatelet therapy with aspirin 81mg daily, and possibly long-term anticoagulation for those with hypercoagulable states. Nutritional support is crucial during recovery, with gradual reintroduction of oral intake as tolerated. The urgency of treatment stems from the high mortality rate associated with intestinal infarction and the narrow window for tissue salvage, as prolonged ischemia leads to irreversible intestinal damage and potential sepsis from bacterial translocation across compromised intestinal barriers.
Some key points to consider in the management of ischemic bowel disease include:
- Prompt use of CT angiography to establish the diagnosis, as recommended by the World Society of Emergency Surgery 1
- Evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel
- Resection of necrotic intestine
- Use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure
- Consideration of endovascular approaches, such as open, retrograde SMA stenting, which has been reported to have a 1-year primary patency rate of 92% 1
From the Research
Treatment Options for Ischemic Bowel Disease
- The treatment for ischemic bowel disease varies depending on the severity and type of the disease, and may include conservative measures, surgical resection, and revascularization 2.
- For acute mesenteric ischemia without evidence of frank bowel necrosis, an endovascular-first strategy employing thrombolysis, pharmacomechanical thrombectomy, and/or adjunctive angioplasty/stenting has been shown to have positive outcomes 3.
- In cases of ischemic colitis, the mainstay of medical management is conservative/supportive treatment, with bowel rest, fluid resuscitation, and antibiotics 4, 5.
- Surgical intervention may be necessary in cases of severe disease, peritonitis, hemodynamic instability, or failure of non-operative management 4, 5.
Diagnostic Approaches
- Imaging studies, such as CT scans with intravenous contrast, and colonoscopy with biopsy are the main diagnostic tests for ischemic bowel disease 4, 2, 5.
- Laboratory testing and medical history should also be obtained to identify possible etiologies of ischemia and to guide treatment decisions 5.
Multidisciplinary Care
- Involvement of a multidisciplinary team, including gastroenterology and surgery, is essential in managing ischemic bowel disease 3, 4, 2.
- A comprehensive approach to diagnosis and treatment, including consideration of patient-specific factors and disease severity, is necessary to optimize outcomes 4, 2, 5.