From the Guidelines
Treatment of bowel ischemia should prioritize rapid restoration of inline arterial flow to the affected bowel, with endovascular interventions being the initial approach, given their lower morbidity and high technical success rates, as supported by the most recent study from 2022 1. The primary goal of treatment is to avoid potentially life-threatening complications, and this can be achieved through a combination of medical management and surgical intervention, depending on the severity of the condition.
- Initial treatment includes:
- Fluid resuscitation to enhance visceral perfusion
- Broad-spectrum antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours or ciprofloxacin 400mg IV every 12 hours plus metronidazole 500mg IV every 8 hours, to prevent infection
- Pain control
- Anticoagulation with heparin, with an initial bolus of 80 units/kg followed by continuous infusion at 18 units/kg/hour, in cases of embolic or thrombotic occlusion
- Surgical intervention is necessary for patients with peritoneal signs, perforation, or necrotic bowel, and typically involves resection of the necrotic segments and, when possible, primary anastomosis
- Endovascular procedures, such as angioplasty or stenting, may be options for some patients with arterial occlusions, and have been shown to have lower morbidity and high technical success rates, as reported in a systematic review and meta-analysis including 3,362 patients 1
- Following treatment, patients require close monitoring for complications, such as short bowel syndrome, malabsorption, or recurrent ischemia, and the underlying cause of ischemia must be addressed to prevent recurrence, which may involve management of cardiac arrhythmias, atherosclerosis, or hypercoagulable states, as recommended by the World Society of Emergency Surgery in their updated guidelines from 2022 1.
From the Research
Treatment of Bowel Ischemia
The treatment of bowel ischemia can vary depending on the severity of the condition.
- For less severe cases, treatment is supportive, with:
- Intravenous fluids
- Bowel rest
- Broad-spectrum antibiotics, as mentioned in 2
- In cases of severe disease, pancolonic ischemia, and isolated right colonic ischemia, surgical consultation should be obtained, and surgery may be necessary for:
- Peritonitis
- Hemodynamic instability
- Failure of non-operative management, as stated in 2
- The use of vasoactive agents in acute mesenteric ischemia is also being explored, with a systematic review highlighting the need for further research to determine the optimal vasoactive drug to use in these settings 3
- Additionally, the role of empiric antibiotics in the management of acute mesenteric ischemia is not well defined, with some studies suggesting their potential benefit in mitigating the consequences of ischemia/reperfusion injury, but more clinical studies are needed to support their use 4
- A multidisciplinary approach to treatment, including prompt recognition and therapy, as well as identification of underlying causes, is crucial for a favorable outcome in severe cases of bowel ischemia, as emphasized in 5