What is the treatment for ischemic enteritis?

Treatment of Ischemic Enteritis

The treatment of ischemic enteritis requires immediate fluid resuscitation, broad-spectrum antibiotics, and surgical intervention for patients with overt peritonitis, while conservative management is appropriate for those without signs of bowel infarction. 1

Initial Management

Resuscitation and Stabilization

• Immediate fluid resuscitation with crystalloids to enhance visceral perfusion 1
• Correction of electrolyte abnormalities and acid-base status 1
• Nasogastric decompression to reduce intestinal distention 1
• Careful use of vasopressors (if needed):
  • Dobutamine, low-dose dopamine, or milrinone are preferred as they have less impact on mesenteric blood flow 1

Antimicrobial Therapy

• Immediate administration of broad-spectrum antibiotics 1
• Recommended regimens:
  • Piperacillin/tazobactam 4g/0.5g every 6 hours or 16g/2g by continuous infusion 1
  • For beta-lactam allergic patients: Eravacycline 1 mg/kg every 12 hours or Tigecycline 100 mg loading dose then 50 mg every 12 hours 1
  • For septic shock: Consider carbapenems (meropenem 1g every 6 hours by extended infusion) 1
• Duration: 4 days in immunocompetent, non-critically ill patients; up to 7 days in immunocompromised or critically ill patients 1

Anticoagulation

• Unless contraindicated, patients should receive intravenous unfractionated heparin to prevent further clot formation 1, 2
• Target aPTT between 40-60 seconds 2

Surgical Management

Indications for Immediate Surgery

• Overt peritonitis 1
• Signs of bowel infarction or perforation 1
• Failed endovascular therapy 2

Surgical Approach

1. Midline laparotomy for direct assessment of bowel viability 1
2. Resection of all frankly necrotic areas 1
3. Re-establishment of blood supply to ischemic but viable bowel 1
4. Preservation of all viable bowel 1

Damage Control Surgery

• For critically ill patients or those with extensive necrosis 1, 2
• Resection of clearly necrotic intestine without immediate restoration of gastrointestinal continuity 2
• Temporary abdominal closure (laparostomy) 2
• Planned second-look operation within 24-48 hours to reassess bowel viability 2

Endovascular Therapy

Indications

• Partial arterial occlusion without signs of bowel infarction 1
• Early cases of acute mesenteric ischemia before bowel infarction occurs 1

Techniques

• Aspiration embolectomy for embolic occlusion 2
• Angioplasty with/without stenting for thrombotic occlusion 2
• Technical success rates up to 94% with lower 30-day mortality compared to surgical interventions 2

Special Considerations

Non-Occlusive Mesenteric Ischemia (NOMI)

• Focus treatment on correcting the underlying cause and restoring mesenteric perfusion 1
• Infarcted bowel should be resected promptly 1

Mesenteric Venous Thrombosis

• Can often be successfully treated with continuous infusion of unfractionated heparin 1

Monitoring and Follow-up

• Continuous monitoring of lactate levels as an indicator of perfusion improvement 1
• Ongoing assessment for signs of infection or systemic illness beyond the initial treatment period 1

Prognosis and Pitfalls

Mortality Considerations

• Despite advances in treatment, mortality remains high (25-50%) 2, 3
• Delayed diagnosis significantly worsens outcomes 1, 3
• CT findings of bowel wall thickness >10 mm correlate with 60% risk of death compared to 4.2% if <10 mm 1

Common Pitfalls

• Delaying surgical intervention when peritoneal signs are present
• Overreliance on laboratory values alone for diagnosis
• Failure to consider a second-look procedure to reassess bowel viability
• Excessive use of vasopressors that may further compromise mesenteric perfusion

Ischemic enteritis is a rare but potentially fatal condition requiring prompt diagnosis and aggressive management to improve survival outcomes 3.