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 and requires prompt treatment. The mainstay of treatment is surgery if bowel necrosis or gangrene has occurred , whereas medical therapy is considered initially for hemodynamically unstable patients.

Medical Therapy

The treatment of choice, medical versus surgical in mesenteric ischemia depends on three 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

Pharmacological therapy:

Pharmacologic medical therapies for mesenteric ischemia include anticoagulation with heparin, in patients who are hemodynamically stable and no evidence of bowel ischemia.

Initial management:

Mesenteric ischemia is an acute emergency condition that requires prompt intervention. The outline of initial medical management of all types of meseneteric ischemia includes:

• Supplemental oxygen
• Pain control
• Fluid resuscitation
• Hemodynamic support and monitoring
• Correction of electrolyte abnormalities
• Anticoagulation with heparin, to limit thrombus propagation
• Broad sprectrum antibiotics
• Gastrointestinal decompression
• Avoidance of vasopressors, which can exacerbate ischemia
• Proton pump inhibitors

Management according to the severity of presentation:

Acute embolic mesenteric ischemia is managed according to the hemodyanamic stabilty or the presence/abscene of peritoneal signs.

Embolic mesenteric arterial occlusion

Anticoagualation with heparin Pain management

Peritoneal signs

Yes

No

Computed tomographic angiography

Embolus present

Thrombolysis

Repeat imaging Resolution of thrombus and no persistent symptoms

No

B03

C03

D02

B01

B02

C01

B01

A01

A02

A03

B01

B02

C01

C02

D01

E01

D01

Multimodal management of mesenteric ischemia
Early management					Late management
Pathophysiological events	Vascular occlusion	Splanchnic hypoperfusion	Intestinal hypoxia	Intestinal barrier injury Translocation Local inflammatory pathway	Systemic inflammatory pathways	Necrosis Organ failure
Treatment strategy	Heparin Aspirin Revascularization	Oxygen Blood volume resuscitation Transfusion		Oral antibiotics	Intravenous antibiotics	Intestinal resection