What is the management approach for acute mesenteritis?

Management of Acute Mesenteritis

The management of acute mesenteritis requires prompt diagnosis, aggressive fluid resuscitation, broad-spectrum antibiotics, and early surgical intervention when peritonitis is present, with damage control techniques employed for bowel assessment and potential revascularization.

Diagnostic Approach

• Acute mesenteritis should be suspected in patients with severe abdominal pain that is often out of proportion to physical examination findings, especially in those with risk factors for thromboembolism 1
• Triple-phase CT (non-contrast, arterial, and portal venous phases) is the preferred diagnostic modality to identify the underlying cause of ischemia and evaluate for bowel complications 1
• Clinical presentation may include:
  • Sudden, severe abdominal pain in arterial embolism 1
  • Subacute presentation with worsening pain over 2 weeks in mesenteric venous thrombosis 1
  • Postprandial pain, nausea, vomiting, and fear of eating in chronic cases 2

Initial Management

• Immediate fluid resuscitation with crystalloids to enhance visceral perfusion and correct electrolyte abnormalities 1
• Broad-spectrum antibiotics should be administered immediately to prevent septic complications from bacterial translocation 1
• Nasogastric decompression should be initiated 1
• Systemic anticoagulation with intravenous unfractionated heparin unless contraindicated 1
• Careful use of vasopressors; dobutamine, low-dose dopamine, and milrinone have less impact on mesenteric blood flow 1

Surgical Management

• Prompt laparotomy/laparoscopy is indicated for patients with overt peritonitis 1
• The goals of surgical intervention include:
  1. Re-establishment of blood supply to ischemic bowel
  2. Resection of all non-viable regions
  3. Preservation of all viable bowel 1
• Damage control surgery (DCS) with temporary abdominal closure is recommended for:
  • Patients requiring intestinal resection
  • Cases needing reassessment of bowel viability
  • Situations with severe abdominal sepsis 1
• Planned second-look procedures should be performed within 24-48 hours to reassess bowel viability and make decisions regarding anastomosis, stoma, or additional resection 1

Management Based on Etiology

Arterial Embolism/Thrombosis

• Rapid restoration of inline arterial flow is the primary goal 1
• Endovascular approaches:
  • Aspiration embolectomy and transcatheter thrombolysis show high technical success rates (up to 94%) 1
  • Lower morbidity compared to open surgery, with lower rates of bowel resection and acute renal failure 1
• Surgical approaches:
  • Surgical embolectomy may be necessary when endovascular approaches fail 1
  • Up to 70% of patients may need surgical intervention for bowel resection regardless of initial treatment approach 1

Mesenteric Venous Thrombosis (MVT)

• Systemic anticoagulation is the mainstay of treatment 1
• Non-operative management is feasible when:
  • Diagnosis is certain on CT scan
  • No evidence of transmural necrosis or bowel perforation 3
• Early diagnosis with CT scanning and prompt anticoagulation can improve outcomes 4
• Surgical intervention is indicated for peritonitis or failure of medical treatment 4

Non-occlusive Mesenteric Ischemia (NOMI)

• Focus on correcting the underlying cause and improving mesenteric perfusion 1
• Treatment includes:
  • Fluid resuscitation
  • Optimization of cardiac output
  • Elimination of vasopressors
  • Infarcted bowel should be resected promptly 1

Special Considerations for Sclerosing Mesenteritis

• Medical therapy shows better response than surgery alone 5
• Treatment options include:
  • Tamoxifen in combination with prednisone (60% improvement rate) 5
  • Corticosteroids with azathioprine 6
  • Cyclophosphamide for aggressive forms with prompt, dramatic improvement 7

Monitoring and Follow-up

• Continuous assessment of lactate clearance and central venous oxygen saturation to guide resuscitation 1
• Monitoring for complications such as short bowel syndrome, recurrent thrombosis, and portal hypertension 3
• Long-term anticoagulation may be necessary, especially in cases of thrombophilia 4

Pitfalls and Caveats

• Delayed diagnosis significantly increases mortality rates (50-80%) 1
• Extensive crystalloid resuscitation should be used carefully to avoid abdominal compartment syndrome 1
• Multiple adjuncts have been suggested to assess intestinal viability during surgery, but none have proven to be uniformly reliable 1
• Hybrid operating rooms equipped for both endovascular and open surgical approaches may provide optimal management options 1