What is the management of acute mesenteric ischemia in adolescents?

Management of Acute Mesenteric Ischemia in Adolescents

Acute mesenteric ischemia in adolescents should be managed using the same aggressive, multidisciplinary approach as in adults, with immediate CT angiography, rapid resuscitation, systemic anticoagulation, and either endovascular revascularization or emergency laparotomy depending on the presence of peritonitis. 1, 2

Initial Recognition and Diagnosis

Clinical Suspicion

• Assume AMI until proven otherwise in any adolescent presenting with severe abdominal pain out of proportion to physical examination findings, particularly with risk factors for thromboembolism 1, 3
• The classic presentation includes sudden onset of severe abdominal pain, often with acidosis and organ dysfunction 1
• Plain radiographs have minimal diagnostic value except for detecting intestinal perforation 1

Diagnostic Imaging

• Obtain triphasic CT angiography (non-contrast, arterial, and portal venous phases) immediately as the first-line diagnostic tool 2, 3
• CTA provides high diagnostic accuracy and identifies the specific etiology (embolic, thrombotic, non-occlusive, or venous) 1, 2
• Laboratory markers like elevated lactate and D-dimer may assist but are insufficiently accurate to rule in or rule out AMI 1, 2

Immediate Resuscitation (Parallel to Diagnosis)

Fluid and Hemodynamic Management

• Begin aggressive crystalloid resuscitation immediately to enhance visceral perfusion, but avoid excessive volumes that risk abdominal compartment syndrome 1, 2, 3
• Correct electrolyte abnormalities promptly 1, 2
• If vasopressors are necessary, prefer dobutamine, low-dose dopamine, or milrinone over agents that severely compromise mesenteric blood flow 3

Pharmacologic Interventions

• Administer broad-spectrum antibiotics immediately to prevent septic complications from bacterial translocation 1, 2, 3
• Start intravenous unfractionated heparin unless contraindicated to prevent thrombosis propagation 1, 2
• Place nasogastric tube for decompression to reduce aspiration risk and improve intestinal perfusion 1, 2

Treatment Algorithm Based on Clinical Presentation

Patients WITH Overt Peritonitis

• Proceed directly to emergency laparotomy 1, 2, 3
• Surgical goals include: restoring arterial blood flow, resecting all non-viable bowel, and preserving all viable intestine 3
• For arterial occlusions at the SMA root, consider retrograde open mesenteric stenting or percutaneous approach during the same operation rather than bypass 4
• Employ damage control surgery with temporary abdominal closure using negative pressure wound therapy 1, 2, 3, 5
• Mandatory planned second-look laparotomy at 24-48 hours to reassess bowel viability and avoid unnecessary resection 1, 2

Patients WITHOUT Peritonitis (Arterial Occlusive Disease)

• Endovascular revascularization is first-line treatment: aspiration embolectomy, catheter-directed thrombolysis, or angioplasty with stenting 2, 3, 6
• Endovascular approaches achieve technical success rates up to 94% and are associated with decreased bowel resection, lower respiratory/renal failure, and reduced mortality compared to open surgery 2, 6
• A significant proportion of arterial occlusive AMI can be managed endovascularly without laparotomy 4
• Close observation is critical—if symptoms fail to resolve or peritonitis develops, proceed immediately to laparotomy 2, 4

Non-Occlusive Mesenteric Ischemia (NOMI)

• Focus on correcting the underlying cause: optimize cardiac output, eliminate vasopressors when possible 2, 3
• Administer intra-arterial vasodilators via catheter: papaverine is traditional first-line, with nitroglycerin or glucagon as alternatives 2
• High-dose intravenous prostaglandin E1 may be equally effective as an alternative to intra-arterial therapy 2
• Do NOT use systemic nitrates (like ISMN)—no evidence supports this and may worsen perfusion through hypotension 2
• If bowel infarction is present, proceed to laparotomy for resection 2, 3

Mesenteric Venous Thrombosis

• Continuous infusion of unfractionated heparin is primary treatment 1, 2
• Supportive measures include nasogastric decompression, fluid resuscitation, and bowel rest 2
• Surgery is only indicated if bowel infarction occurs 1, 2
• Most cases resolve with anticoagulation alone without need for operative intervention 2

Surgical Technique Considerations

Intraoperative Decisions

• Resect only obviously necrotic bowel at initial operation—marginal viability should be reassessed at second-look 1
• Delay intestinal anastomosis until bowel viability is confirmed at second-look procedure 2
• Use careful hand-sewn techniques rather than staples in edematous bowel to reduce anastomotic leak risk 1

Damage Control Principles

• Temporary abdominal closure with negative pressure wound therapy and continuous fascial traction facilitates delayed closure 1, 5
• Monitor for abdominal compartment syndrome, reperfusion injury, and coagulopathy 1, 3
• Use viscoelastic techniques (TEG, ROTEM) to guide blood product administration 1

Postoperative Management

• Intensive care focused on improving intestinal perfusion and preventing multiple organ failure 2
• Continue anticoagulation to prevent recurrence 2
• Monitor lactate clearance and central venous oxygen saturation as indicators of adequate resuscitation 1

Critical Pitfalls to Avoid

• Delayed diagnosis dramatically increases mortality (50-80%) 1, 2, 3—maintain high index of suspicion
• There is no reliable tool for predicting transmural necrosis—clinical judgment and experience are essential 4
• Avoid excessive crystalloid that causes abdominal compartment syndrome 3
• Do not use systemic nitrate therapy—no evidence supports it and may worsen outcomes 2
• Mortality remains 40-70% despite optimal care 2—early recognition and aggressive intervention are paramount

Special Consideration for Adolescents

While the guidelines do not specifically address adolescents separately, the same principles apply. Adolescents may have different risk factors (hypercoagulable states, vasculitis, trauma) compared to typical adult etiologies (atrial fibrillation, atherosclerosis), but the diagnostic and therapeutic approach remains identical. 1