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Acute mesenteric ischemia

Definition
AMI is a sudden interruption of blood flow to the small intestine, leading to ischemia and potential tissue death.
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Pathophysiology
The pathophysiology of AMI can be categorized into four types based on the clinical scenario and risk factors: mesenteric arterial embolism, mesenteric arterial thrombosis, non-occlusive mesenteric ischemia, and mesenteric venous thrombosis.
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Epidemiology
The incidence of AMI in Finland is estimated at 2 per 100,000 person-years. It is reported to account for 0.01% of hospital admissions in the US and 1% of acute abdomens in Germany.
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Disease course
Clinically, it often presents with severe abdominal pain, nausea, vomiting, and bloody diarrhea. Patients may also exhibit signs of a systemic inflammatory response, including fever and tachycardia.
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Prognosis and risk of recurrence
The prognosis is often poor, with a mortality rate reaching up to 80%.
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Key sources
The following summarized guidelines for the evaluation and management of acute mesenteric ischemia are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2022), the American Association for the Study of Liver Diseases (AASLD 2021), the American College of Gastroenterology (ACG 2020), the European Society of Cardiology (ESC/ESVS 2018), the American College of Radiology (ACR 2018), the European Society for Vascular Surgery (ESVS 2017), the European Society for Trauma and Emergency Surgery (ESTES 2016), and the European Association for the Study of the Liver (EASL 2016).
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Guidelines

1.Screening and diagnosis

Diagnosis
As per WSES 2022 guidelines:
Suspect AMI in patients with severe abdominal pain out of proportion to physical examination until disproven.
B
Suspect non-occlusive mesenteric ischemia in critically ill patients with abdominal pain or distension requiring vasopressor support and evidence of multiorgan dysfunction.
B
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2.Classification and risk stratification

Classification: differentiate AMI into the following types based on the clinical scenario and risk factors:
mesenteric arterial embolism
mesenteric arterial thrombosis
non-occlusive mesenteric ischemia
mesenteric venous thrombosis
B

3.Diagnostic investigations

Diagnostic imaging
As per WSES 2022 guidelines:
Obtain CTA without delay in any patient with suspected AMI.
A
Do not obtain plain radiographs for the evaluation of intestinal ischemia.
D

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  • Laboratory tests

4.Diagnostic procedures

Laparoscopy: insufficient evidence to support routine use of laparoscopy in patients with AMI.
I

5.Respiratory support

Oxygen therapy: administer immediate supplementary oxygen in patients with AMI.
B

6.Medical management

General principles
As per WSES 2022 guidelines:
Manage patients with AMI in dedicated centers using a focused care bundle and a multidisciplinary team.
B
Treat the underlying cause and improve mesenteric perfusion in patients with suspected non-occlusive mesenteric ischemia.
B

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  • Supportive therapy

  • Antibiotic therapy

  • Antithrombotic therapy

  • Antihypertensive therapy

  • Lipid-lowering therapy

  • Palliative care

7.Inpatient care

Intra-abdominal pressure monitoring
Obtain intra-abdominal pressure monitoring to prevent non-occlusive mesenteric ischemia in patients with known risk factors for intraabdominal hypertension/abdominal compartment syndrome.
B
Initiate medical treatment in patients with intraabdominal pressure > 12 mmHg to prevent abdominal compartment syndrome and non-occlusive mesenteric ischemia.
B

8.Nonpharmacologic interventions

Lifestyle modifications: as per ESC 2018 guidelines, advise smoking cessation
B
, healthy diet and physical activity in all patients with PADs.
B

9.Therapeutic procedures

Nasogastric decompression: perform nasogastric decompression in patients with AMI.
B

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  • Endovascular revascularization

10.Surgical interventions

Indications for open surgery: as per WSES 2022 guidelines, perform prompt laparoscopy/laparotomy in patients with overt peritonitis.
B

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  • Bowel resection

  • Damage control surgery

11.Specific circumstances

Patients with isolated mesenteric artery dissection: consider offering conservative management with antiplatelet therapy and control of hypertension in patients with asymptomatic isolated mesenteric artery dissection.
C
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  • Patients with mesenteric vein thrombosis (diagnostic imaging)

  • Patients with mesenteric vein thrombosis (evaluation for etiology)

  • Patients with mesenteric vein thrombosis (anticoagulation therapy, indications)

  • Patients with mesenteric vein thrombosis (anticoagulation therapy, duration)

  • Patients with mesenteric vein thrombosis (prevention of variceal bleeding)

12.Preventative measures

Secondary prevention: as per ESVS 2017 guidelines, offer secondary medical prevention including smoking cessation, statin therapy, and antiplatelet or anticoagulation therapy in patients surviving AMI.
B

13.Follow-up and surveillance

Second-look procedures: as per ESVS 2017 guidelines, consider performing second-look laparotomy and damage control surgery in patients undergoing acute intestinal revascularization.
C

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  • Follow-up imaging

14.Quality improvement

Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs.
B