What is the recommended treatment for bowel ischemia?

Treatment of Bowel Ischemia

The recommended treatment for bowel ischemia depends on the type, severity, and presence of bowel infarction, with endovascular revascularization being the preferred first-line treatment for acute mesenteric ischemia without signs of bowel infarction, while immediate surgical intervention is mandatory for patients with peritoneal signs or evidence of bowel infarction. 1, 2

Initial Management

• Immediate fluid resuscitation with crystalloids to enhance visceral perfusion 2
• Broad-spectrum antibiotics (piperacillin/tazobactam, eravacycline, or tigecycline) 2
• Anticoagulation with intravenous unfractionated heparin unless contraindicated 2
• Correction of electrolyte abnormalities and acid-base status 2
• Triple-phase CT of abdomen and pelvis (non-contrast, arterial, and portal venous phases) to assess extent of ischemia 2

Treatment Algorithm Based on Type of Ischemia

1. Acute Occlusive Mesenteric Ischemia

Without Evidence of Bowel Infarction:

• First-line: Endovascular revascularization 1, 2
  • Aspiration embolectomy for embolic occlusion
  • Angioplasty with/without stenting for thrombotic occlusion
  • Technical success rates up to 94% 1, 2
  • Lower mortality (odds ratio 0.45) compared to surgical interventions 2, 3

With Evidence of Bowel Infarction or Peritonitis:

• Immediate surgical intervention 1, 2
  • Midline laparotomy
  • Revascularization of occluded vessels
  • Resection of necrotic bowel
  • Preservation of all viable bowel
  • "Second-look" operation 24-48 hours after revascularization 1, 2

2. Acute Non-occlusive Mesenteric Ischemia (NOMI)

• Treatment of underlying shock state is the most important initial step 1
• Avoid excessive vasopressors that may worsen mesenteric perfusion 2
• Prefer combination of noradrenaline and dobutamine over vasopressors alone 2
• Angiography with catheter-directed vasodilator infusion 1
  • Nitroglycerin, papaverine, or glucagon directly into area of vasospasm 1, 2
  • High-dose intravenous prostaglandin E1 may be equally effective 1, 2
• Laparotomy and resection of nonviable bowel for persistent symptoms despite treatment 1

3. Chronic Mesenteric Ischemia

• Percutaneous endovascular treatment (angioplasty and stenting) is indicated 1
• Surgical revascularization may be considered if endovascular approach fails 1
• Lower mortality and morbidity with endovascular therapy compared to open repair 1
• Higher rate of symptom recurrence and need for reintervention with endovascular approach 1

Monitoring and Follow-up

• Continuous monitoring of lactate levels as indicator of perfusion improvement 2
• Ongoing assessment for signs of infection or systemic illness 2
• Anticoagulation therapy should be continued to prevent further clot formation 2

Prognostic Indicators

• CT findings of bowel wall thickness >10 mm correlate with 60% risk of death compared to 4.2% if <10 mm 2
• Endovascular intervention is associated with lower rates of bowel resection (14.4% vs 33.4%) and need for total parenteral nutrition (13.7% vs 24.4%) compared to open surgery 3

Pitfalls and Caveats

• Delayed diagnosis is a major contributor to high mortality rates (70-90% in arterial and functional mesenteric ischemia) 4
• Clinical judgment during first or second-look exploration remains the most reliable parameter for assessment of bowel viability 4
• Fluid overload can worsen bowel edema and impair perfusion 2
• Excessive use of vasopressors may worsen mesenteric perfusion 2

The management of bowel ischemia requires high awareness, earliest possible diagnosis, and treatment by an experienced interdisciplinary team of gastroenterologists, radiologists, and surgeons 5.