Treatment of Ischemic Enteritis
The treatment of ischemic enteritis requires immediate fluid resuscitation with crystalloids, broad-spectrum antibiotics, and careful assessment for surgical intervention, with endovascular therapy being the preferred initial treatment for mesenteric ischemia when peritonitis is absent. 1
Initial Management
Resuscitation and Medical Therapy
- Immediate fluid resuscitation with crystalloids to enhance visceral perfusion
- Correction of electrolyte abnormalities and acid-base status
- Broad-spectrum antibiotics administration (options include):
- Piperacillin/tazobactam
- Eravacycline
- Tigecycline
- Antibiotic duration: 4 days for immunocompetent non-critically ill patients; up to 7 days for immunocompromised or critically ill patients 1
- Nasogastric decompression to reduce intestinal distention
- Anticoagulation with intravenous unfractionated heparin (target aPTT 40-60 seconds) unless contraindicated 1
Vasopressor Management
- Careful use of vasopressors that have minimal impact on mesenteric blood flow:
- Dobutamine
- Low-dose dopamine
- Milrinone
- Combination of noradrenaline and dobutamine is preferred over vasopressin to minimize negative effects on intestinal microcirculation 1
Definitive Treatment Options
Endovascular Therapy
- First-line treatment for mesenteric ischemia without peritonitis or bowel infarction
- Associated with lower 30-day mortality (odds ratio 0.45) compared to surgical interventions
- Technical success rates up to 94% 1
- Specific approaches:
- Aspiration embolectomy for embolic occlusion
- Angioplasty with/without stenting for thrombotic occlusion 1
Surgical Intervention
- Mandatory for patients with:
- Overt peritonitis
- Signs of bowel infarction
- Bowel perforation
- Failed endovascular therapy 1
- Surgical approach includes:
- Midline laparotomy
- Resection of all frankly necrotic areas
- Re-establishment of blood supply to ischemic but viable bowel
- Preservation of all viable bowel
- Second-look procedure within 24-48 hours to reassess bowel viability 1
Monitoring and Follow-up
- Continuous monitoring of lactate levels as an indicator of perfusion improvement
- CT assessment of bowel wall thickness (>10 mm correlates with 60% risk of death vs. 4.2% if <10 mm) 1
- Ongoing assessment for signs of infection or systemic illness
- Intensive care focused on improving intestinal perfusion and preventing multi-organ failure 1
- Continuation of anticoagulation therapy with systemic heparin or low-molecular-weight heparin at therapeutic doses 1
Prognostic Considerations
- Delayed diagnosis significantly worsens outcomes
- Mortality remains high (25-50%) despite optimal management 1
- Lesser degrees of mesenteric ischemia may contribute to systemic sepsis and multiple organ failure syndrome 2
- Fibrotic stenosis may develop as a late complication, requiring surgical intervention 3, 4
Special Considerations
- In cases of infectious etiology (e.g., Clostridium perfringens, Candida albicans), targeted antimicrobial therapy is essential 5, 6
- Early recognition and timely surgical intervention are critical in severe cases to reduce mortality 5
- Patients with arrhythmias or other cardiovascular conditions have increased risk and require careful monitoring 4