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Chronic Mesenteric Ischemia Medication

  • Author: Aref Alrayes, MD; Chief Editor: Julian Katz, MD  more...
 
Updated: Mar 24, 2014
 

Medication Summary

Drugs used in the management of chronic mesenteric ischemia (CMI) include heparin and warfarin for anticoagulation and intra-arterial papaverine for vasodilation.

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Anticoagulants

Class Summary

Anticoagulants are given to prevent an acute thrombotic or embolic event.

Warfarin (Coumadin, Jantoven)

 

Warfarin is an anticoagulant that interferes with epoxide reductase, preventing production of vitamin K–dependent factors II, VII, IX, and X and proteins C and S. Because proteins C and S are the first factors to be inhibited, a prothrombic effect occurs during the initial few days after the start of warfarin therapy. Patients are started on heparin, then switched to warfarin when the prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) are in the therapeutic range. Duration of action is 2-5 day.

Heparin

 

Heparin is a sulfated mucopolysaccharide. Its anticoagulant effect is related to its ability to activate plasma antithrombin. The main role of heparin in CMI patients is to prevent thrombus propagation.

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Vasodilators

Class Summary

Used during arteriogram to decrease vasospasm in occluded arteries, with the objective of improving blood flow.

Papaverine

 

Papaverine is a benzylisoquinoline derivative with a direct nonspecific relaxant effect on vascular, cardiac, and other smooth muscle.

Nitroprusside (Nitropress)

 

Nitroprusside causes peripheral vasodilation by direct action on venous and arteriolar smooth muscle, thus reducing peripheral resistance. It is commonly given intravenously because of its rapid onset and short duration of action. It is easily titratable to reach the desired effect.

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Antibiotics

Class Summary

Antibiotic therapy must cover all likely pathogens in the context of the clinical setting.

Clindamycin (Cleocin)

 

Clindamycin is active against anaerobic gram-negative bacilli. It is a lincosamide that is useful in treating serious skin and soft tissue infections caused by most staphylococcal strains. It is also effective against aerobic and anaerobic streptococci, except enterococci. Clindamycin inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, which is where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.

Ticarcillin and clavulanate potassium (Timentin)

 

This drug combination inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage of active growth. It consists of an antipseudomonal penicillin plus a beta-lactamase inhibitor and provides coverage against most gram positives, most gram negatives, and most anaerobes.

Metronidazole (Flagyl, Metro)

 

Metronidazole is an imidazole ring-based antibiotic that is active against anaerobes. It is usually given in combination with other antimicrobial agents, except in the setting of Clostridium difficile enterocolitis, where monotherapy is appropriate.

Aztreonam (Azactam)

 

Aztreonam is a monobactam that inhibits cell-wall synthesis during bacterial growth. It is active against aerobic gram-negative bacilli.

Cefoxitin (Mefoxin)

 

Cefoxitin is active against aerobic and anaerobic gram-negative bacilli. It is a second-generation cephalosporin that is indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria, which are resistant to some cephalosporins and penicillins, respond to cefoxitin.

Cefotetan

 

Cefotetan is active against aerobic and anaerobic gram-negative bacilli. It is a second-generation cephalosporin that is indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods. Proper dosage and route of administration are determined on the basis of the patient's condition, the severity of the infection, and the susceptibility of the causative organism.

Meropenem (Merrem)

 

Meropenem is a bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. It is effective against most gram-positive and gram-negative bacteria.

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Contributor Information and Disclosures
Author

Aref Alrayes, MD Fellow, Department of Gastroenterology, Providence Hospital

Aref Alrayes, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michael H Piper, MD Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates, PLC

Michael H Piper, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, Michigan State Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Mounzer Al Samman, MD Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Texas Tech University School of Medicine

Mounzer Al Al Samman, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association

Disclosure: Nothing to disclose.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: lippincott Royalty textbook royalty; wiley Royalty textbook royalty

Burt Cagir, MD, FACS Assistant Professor of Surgery, State University of New York Upstate Medical University; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Association of Program Directors in Surgery, and Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Brian James Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Southern Surgical Association, andTennessee Medical Association

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Chandler Long, MD Resident Physician, Department of Surgery, University of Tennessee Medical Center-Knoxville

Disclosure: Nothing to disclose.

Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Daniel K Nishijima, MD Assistant Professor, Department of Emergency Medicine, University of California Davis Medical Center

Daniel K Nishijima, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Yale D Podnos, MD, MPH Consulting Surgeon, Department of Surgery, City of Hope National Medical Center

Disclosure: Nothing to disclose.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Mark Su, MD, FACEP, FACMT Consulting Staff and Director of Fellowship in Medical Toxicology, Department of Emergency Medicine, North Shore University Hospital; Consulting Staff, North Shore University Hospital

Mark Su, MD, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Deron J Tessier, MD Staff Surgeon, Kaiser Permanente Medical Center, Fontana, CA

Deron J Tessier, MD is a member of the following medical societies: American College of Surgeons and American Medical Association

Disclosure: Nothing to disclose.

Russell A Williams, MBBS Program Director, Professor, Department of Surgery, University of California Medical Center at Irvine

Disclosure: Nothing to disclose.

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Angiogram of patient with chronic mesenteric ischemia. Note diffuse occlusive disease.
Radiograph showing tortuous, dilated, meandering artery.
Narrowing of superior mesenteric artery.
Chronic aortic occlusion (Leriche syndrome) with acute embolic occlusion of superior mesenteric artery.
Gas in colon wall, typical of advanced ischemia.
Meandering artery, sign of chronic mesenteric arterial ischemia.
Management of chronic mesenteric ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. MRA=magnetic resonance angiography; CT=computed tomography. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
 
 
 
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