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 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 in patients who are hemodynamically stable and no evidence of bowel ischemia include the following
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:[1][2][3][4]
- Supplemental oxygen
- Pain control
- Fluid resuscitation
- Hemodynamic support and monitoring[3]
- Correction of electrolyte abnormalities
- Anticoagulation with heparin, to limit thrombus propagation
- Broad sprectrum antibiotics[4][5]
- Gastrointestinal decompression
- Avoidance of vasopressors, which can exacerbate ischemia
- Proton pump inhibitors
- Measurement of electrolytes and acid base status
Pain control:
Parenteral opoids are used to control the pain.
Fluid resuscitation:
Patients suspected of having mesentric ischemia should be resuscitated with crystalloids and blood products to prevent cardiovascular collapse.
Hemodynamic support and monitoring:
In order to guide effective resuscitation, effective hemodyanamic support and monitoring should be implemented.
Anticoagulation with heparin:
Broad sprectrum antibiotics:
Broad spectrum antibiotics should be administered early in the course of treatment of mesenteric ischemia to prevent the risk of infection.
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.
Measurement of electrolytes and acid base status:
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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| A01 | A02 | A03 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| B01 | B02 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| C01 | C02 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| D01 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| D01 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
| Treatment strategy |
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Oral antibiotics | Intravenous antibiotics | Intestinal resection | |
Disease Name
- ↑ 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.
- ↑ 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.
- ↑ 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.