From the Guidelines
Mesenteric ischemia should be promptly diagnosed and treated with endovascular intervention or surgical revascularization to reduce the high mortality rate associated with this condition. The workup for mesenteric ischemia should begin immediately with laboratory tests including complete blood count, comprehensive metabolic panel, lactate, and coagulation studies. Elevated white blood cell count, metabolic acidosis, and elevated lactate suggest intestinal compromise. Imaging is crucial, with CT angiography being the first-line diagnostic test due to its high sensitivity and specificity for detecting vascular occlusions or narrowing, as recommended by the American College of Radiology 1. If CT angiography is unavailable, conventional angiography can be performed, which also allows for therapeutic intervention.
Key Considerations
- Duplex ultrasonography may be used to evaluate chronic mesenteric ischemia but is less reliable in acute settings.
- For patients with high clinical suspicion but negative initial imaging, diagnostic laparoscopy or laparotomy should be considered as intestinal ischemia can rapidly progress to necrosis and perforation.
- Early surgical consultation is essential regardless of initial findings.
- Treatment depends on the cause but typically involves anticoagulation, endovascular intervention, or surgical revascularization.
- The high mortality rate of mesenteric ischemia (60-80% for acute cases) underscores the importance of rapid diagnosis and treatment, as highlighted by the World Society of Emergency Surgery 1.
Recent Guidelines
The most recent guidelines from the American College of Radiology 1 and the World Society of Emergency Surgery 1 emphasize the importance of prompt diagnosis and treatment of mesenteric ischemia. These guidelines recommend the use of endovascular intervention or surgical revascularization to reduce the high mortality rate associated with this condition.
Evidence-Based Recommendations
The evidence suggests that endovascular interventions, such as aspiration embolectomy and thrombolysis, are effective in treating mesenteric ischemia and may be associated with lower mortality rates compared to surgical interventions, as shown in a systematic review and meta-analysis 1. However, the choice of treatment depends on the individual patient's condition and the underlying cause of the mesenteric ischemia. Endovascular intervention is recommended as the first-line treatment for mesenteric ischemia, with surgical revascularization reserved for cases where endovascular treatment is not feasible or has failed.
From the Research
Mesenteric Ischemic Symptoms
- Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality 2
- The presentation depends on the underlying pathophysiology, with symptoms including:
- Sudden, severe pain in arterial embolic disease
- Vague symptoms such as generalized abdominal pain, weight loss, vomiting, and diarrhea in the early stages of the disease and other forms 2
- Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis 2
Workup
- The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases 2
- Diagnosis of acute mesenteric ischaemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase 3
- Current guidelines on the diagnostic approach and essential resuscitative steps that should be initiated in the emergency department are available 4
Treatment Approach
- The treatment strategy is straightforward, aiming at rapid restoration of blood flow to the intestine, with bowel resection performed on demand 5
- Endovascular therapy has become an important alternative, especially in patients with acute thrombotic superior mesenteric artery (SMA) occlusion 3
- Endovascular treatment may serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis, while open surgery should be reserved for emergency conditions requiring exploratory laparotomy 6
- Hybrid technique may be an especially effective approach for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET 6