Table of contents
Acute mesenteric ischemia
What's new
Updated 2024 ESC guidelines for the management of acute mesenteric ischemia.
Background
Overview
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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Guidelines
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 European Society of Cardiology (ESC 2024), 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 American College of ...
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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
Classification and risk stratification
Diagnostic investigations
General principles: as per ESC 2024 guidelines, obtain assessment by a vascular team in patients with AMI.
B
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Diagnostic imaging
Laboratory tests
Diagnostic procedures
Respiratory support
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
Inpatient care
Intra-abdominal pressure monitoring
As per ESVS 2017 guidelines:
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
Nonpharmacologic interventions
Therapeutic procedures
Nasogastric decompression: as per WSES 2022 guidelines, perform nasogastric decompression in patients with AMI.
B
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Endovascular revascularization
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
Specific circumstances
Patients with isolated mesenteric artery dissection: as per ESVS 2017 guidelines, 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)
Preventative measures
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