Mesenteric ischemia medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]
Overview
Mesenteric ischemia is a medical emergency that requires prompt treatment. The mainstay of treatment is surgery if bowel necrosis or gangrene has occurred, whereas medical therapy is considered initially for hemodynamically stable patients.
Medical Therapy
The treatment of choice, medical versus surgical in mesenteric ischemia depends on the following key elements:
- Duration and severity of ischemia of the intestine
- Nature of the occlusive lesion
- Availability of the immediate surgical or interventional radiology facility in the emergency room
- Hemodyanamic stability of the patient
(A)Conservative management:
Mesenteric ischemia is an acute emergency condition that requires prompt intervention. The outline of initial medical management of all types of mesenteric ischemia includes:[1][2][3][4][3]
- Supplemental oxygen
- Pain control
- Fluid resuscitation
- Hemodynamic support and monitoring
- Correction of electrolyte abnormalities
- Anticoagulation with heparin, to limit thrombus propagation[5][1]
- Broad sprectrum antibiotics[4][6]
- Gastrointestinal decompression
- Avoidance of vasopressors, which can exacerbate ischemia
- Proton pump inhibitors
- Measurement of electrolytes and acid base status
- Nutritional assessment and support
1.Pain control:
Parenteral opioids are used to control the pain.
2.Fluid resuscitation:
Patients suspected of having mesenteric ischemia should be resuscitated with crystalloids and blood products to prevent cardiovascular collapse.
3.Hemodynamic support and monitoring:
In order to guide effective resuscitation, effective hemodyanamic support and monitoring should be implemented.
4.Anticoagulation with heparin:[7][8]
Early use of heparin is asscociated with improved survival especially in cases of mesenteric venous thrombosis.
5.Broad sprectrum antibiotics:
Broad spectrum antibiotics should be administered early in the course of treatment of mesenteric ischemia to prevent the risk of infection.
6.Avoidance of vasopressors:
Vasopressors should be used with caution. Dobutamine, low dose dopamine and milrinone can be used to improve cardiac function as they have less effect on mesenteric blood flow.
7.Measurement of electrolytes and acid base status:
8.Nutritional assessment and support:[9][2]
For patients presenting with chronic mesenteric ischemia, nutritional assessment and support is an important factor as they usually present with malnutrition (BMI<20 and albumin <3).
(B)Management according to the severity of presentation
| History, symptoms and signs suggest mesenteric ischemia(abdominal pain out of proportion to physical exmaination findings) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hemodyanamically unstable, signs of sepsis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Resuscitate, Intravenous fluid therapy, empiric antibiotic therapy,consider systemic antibiotic therapy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Plain abdominal films | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Free air, signs of advanced ischemia (infarcted bowel) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Improved and hemodyanamically stable, but persistent signs and symptoms | Laprotomy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| CT abdomen (without intravenous contrast) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Multimodal management of mesenteric ischemia | ||||||
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| Early management | Late management | |||||
| Pathophysiological events | Vascular occlusion | Splanchnic hypoperfusion | Intestinal hypoxia |
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Systemic inflammatory pathways | Necrosis
Organ failure |
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Oral antibiotics | Intravenous antibiotics | Intestinal resection | ||
Refernces
- ↑ 1.0 1.1 Klempnauer J, Grothues F, Bektas H, Pichlmayr R (1997). "Long-term results after surgery for acute mesenteric ischemia". Surgery. 121 (3): 239–43. PMID 9068664.
- ↑ 2.0 2.1 Corcos O, Castier Y, Sibert A, Gaujoux S, Ronot M, Joly F; et al. (2013). "Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure". Clin Gastroenterol Hepatol. 11 (2): 158–65.e2. doi:10.1016/j.cgh.2012.10.027. PMID 23103820.
- ↑ 3.0 3.1 Wyers MC (2010). "Acute mesenteric ischemia: diagnostic approach and surgical treatment". Semin Vasc Surg. 23 (1): 9–20. doi:10.1053/j.semvascsurg.2009.12.002. PMID 20298945.
- ↑ 4.0 4.1 Silvestri L, van Saene HK, Zandstra DF, Marshall JC, Gregori D, Gullo A (2010). "Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials". Crit Care Med. 38 (5): 1370–6. doi:10.1097/CCM.0b013e3181d9db8c. PMID 20308882.
- ↑ Reinus JF, Brandt LJ, Boley SJ (1990). "Ischemic diseases of the bowel". Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.
- ↑ Petros A, Silvestri L, Booth R, Taylor N, van Saene H (2013). "Selective decontamination of the digestive tract in critically ill children: systematic review and meta-analysis". Pediatr Crit Care Med. 14 (1): 89–97. doi:10.1097/PCC.0b013e3182417871. PMID 22805154.
- ↑ Hmoud B, Singal AK, Kamath PS (2014). "Mesenteric venous thrombosis". J Clin Exp Hepatol. 4 (3): 257–63. doi:10.1016/j.jceh.2014.03.052. PMC 4284291. PMID 25755568.
- ↑ al Karawi MA, Quaiz M, Clark D, Hilali A, Mohamed AE, Jawdat M (1990). "Mesenteric vein thrombosis, non-invasive diagnosis and follow-up (US + MRI), and non-invasive therapy by streptokinase and anticoagulants". Hepatogastroenterology. 37 (5): 507–9. PMID 2253928.
- ↑ Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F; et al. (2009). "ESPEN Guidelines on Parenteral Nutrition: surgery". Clin Nutr. 28 (4): 378–86. doi:10.1016/j.clnu.2009.04.002. PMID 19464088.