eMedicine Specialties > General Surgery > Abdomen

Acute Mesenteric Ischemia: Follow-up

Author: Chat V Dang, MD, Professor of Emergency Medicine, Charles R Drew University of Medicine and Science; Clinical Professor, Department of Medicine, University of California at Los Angeles
Coauthor(s): Jeff Wade, MD, Staff Physician, Department of Emergency Medicine, Long Beach Community Hospital, Greater El Monte Medical Center; Ashis Mandal, MD, Professor, Department of Surgery, Drew University of Medicine and Science and UCLA College of Medicine
Contributor Information and Disclosures

Updated: Sep 2, 2008

Follow-up

Further Inpatient Care

  • After initial medical and/or surgical stabilization, patients with AMI typically have a prolonged inpatient recovery time. This is especially true when resection of necrotic bowel is performed. Such patients may need to be kept NPO, and they may be maintained on parenteral nutrition for some time. If sepsis is evident, liver abscess should be actively searched for. During the inpatient stay, every effort must be made to find and, if possible, treat any predisposing cause(s) of AMI.

Further Outpatient Care

  • Patients who have had extensive small bowel resection have severe diarrhea for a few weeks, but many appear to be able to compensate for the reduced bowel length after a few months. Thereafter, they may have 1-3 liquid bowel movements a day, and maintain or gain weight with oral intake. On the other hand, patients who have had total small intestine resection need lifelong intravenous hyperalimentation (ie, total parenteral nutrition [TPN]).
  • A number of patients who recover from ileus secondary to intestinal ischemia may develop fibrosis of a segment of small bowel with intermittent partial obstruction.
  • Patients who have had MVT need warfarin therapy for at least 6 months or for life if a hypercoagulable state was discovered during treatment. Patients with atrial fibrillation should also be discharged on warfarin.
  • Patients with other treatable predisposing conditions should be continued on appropriate therapy.
  • Patients should be appropriately monitored in an anticoagulation clinic.

Inpatient & Outpatient Medications

  • Inpatient medications
    • Papaverine - For patients with arterial occlusive AMI or NOMI
    • Heparin - For patients with MVT or after revascularization
    • Warfarin - For long-term treatment of patients with MVT or atrial fibrillation
    • Broad-spectrum antibiotics and pain medications - For all patients
    • Thrombolytics - For selected patients with embolic AMI
  • Outpatient medications
    • Antiarrhythmics - For patients with atrial fibrillation
    • Warfarin - For long-term treatment of patients with MVT or atrial fibrillation

Transfer

  • Because timing is essential in preventing bowel necrosis with its attendant severe morbidity and mortality, patients should be transferred only if the primary hospital lacks adequate services to diagnose and treat the patient. Patients should be optimally resuscitated before transfer. Appropriate services should be available at the receiving hospital.

Deterrence/Prevention

  • No preventive measures are known for AMI other than timely diagnosis and treatment of predisposing conditions. In the presence of a clinical syndrome suggesting chronic mesenteric insufficiency, color Doppler evaluation of the mesenteric vessels may help select patients at risk for further workup and those who might need angioplasty.

Complications

  • Bowel necrosis requiring bowel resection
  • Septic shock
  • Death

Prognosis

  • The prognosis of AMI of any type is grave. Patients in whom the diagnosis is missed until infarction occurs have a mortality rate of 90%. Even with good treatment, up to 50-80% of patients die. Survivors of extensive bowel resection face lifelong disability. However, with rapid treatment, the mortality rate can be reduced considerably, and patients may be spared bowel resection. A long-term follow-up study of 31 patients who had surgery and survived the acute episode, revealed 2- and 5-year survival rates of 70% and 50%. Deaths were mainly related to cardiovascular comorbidity and malignant disease. With appropriate anticoagulation, only 1 patient died after a recurrent attack of arterial mesenteric thrombosis.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • A review of 180 consecutive malpractice claims at a Veterans Affairs Medical Center in Virginia over a 12-year period ending in 1998 revealed 7 cases involving AMI. Failure to make a timely diagnosis was alleged in 5 cases, and failure to administer anticoagulation was alleged in 1 case. The remaining allegation was failure to prevent NOMI.
  • Legal risk is reduced with early surgical consultation and the ordering of CT scan or angiography as soon as AMI is noted in the differential diagnosis.
  • Because AMI is a condition with an unclear initial presentation, serious morbidity, and a high mortality rate without proper treatment, clinical suspicion should remain high. Obtain early angiography if any suspicion of AMI exists. Subsequent treatment should be initiated as rapidly as possible. No patient in whom AMI is suspected should be discharged unless AMI can be ruled out.

Special Concerns

  • Elderly patients: Consider a diagnosis of AMI in all elderly patients with abdominal pain, especially if the pain is disproportionate to physical examination findings. Patients with atrial fibrillation, cardiovascular disease, or peripheral vascular disease, especially those with recent MI, are at higher risk.
 


More on Acute Mesenteric Ischemia

Overview: Acute Mesenteric Ischemia
Differential Diagnoses & Workup: Acute Mesenteric Ischemia
Treatment & Medication: Acute Mesenteric Ischemia
Follow-up: Acute Mesenteric Ischemia
Multimedia: Acute Mesenteric Ischemia
References
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Further Reading

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Keywords

acute mesenteric ischemia, mesenteric vascular occlusion, occlusive mesenteric arterial ischemia, acute mesenteric arterial embolus, acute mesenteric arterial thrombosis, nonocclusive mesenteric ischemia, acute mesenteric venous thrombosis, acute mesenteric infarction, acute mesenteric occlusive disease, AMI, NOMI, OMAI, AMAE, AMAT, MVT

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Contributor Information and Disclosures

Author

Chat V Dang, MD, Professor of Emergency Medicine, Charles R Drew University of Medicine and Science; Clinical Professor, Department of Medicine, University of California at Los Angeles
Chat V Dang, MD is a member of the following medical societies: American Academy of Wound Management and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jeff Wade, MD, Staff Physician, Department of Emergency Medicine, Long Beach Community Hospital, Greater El Monte Medical Center
Jeff Wade, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Ashis Mandal, MD, Professor, Department of Surgery, Drew University of Medicine and Science and UCLA College of Medicine
Ashis Mandal, MD is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Surgeons, Royal College of Physicians and Surgeons of Canada, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York, Upstate Medical Center; 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, and Society for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of 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 Other; AstraZeneca Grant/research funds Other

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