eMedicine Specialties > General Surgery > Abdomen
Acute Mesenteric Ischemia: Treatment & Medication
Updated: Sep 2, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Make all efforts to improve patients' cardiovascular status. Avoid use of vasopressors because they worsen ischemia. Provide oxygen at 100% or by intubation if needed. Fluid resuscitation is accomplished with isotonic sodium chloride solution, and blood products are provided as needed. Adequacy of resuscitation can be monitored by urinary output, central venous pressure, or Swan-Ganz pressure monitoring. Insert a nasogastric tube, and optimize cardiac status by treating arrhythmia, CHF, or myocardial infarction. Start broad-spectrum antibiotics early. Provide pain control while maintaining stable blood pressure.
- Angiographically infused papaverine
- Papaverine infused through the angiogram catheter at the affected vessel is useful for all arterial forms of AMI. It relieves reactive vasospasm in occluded arterial vessels and is the only treatment of NOMI other than resection of gangrenous bowel.
- Start an infusion of 30-60 mg/h after angiogram, and adjust the dose for clinical response. Continue this for at least 24 hours.
- If the catheter slips into the aorta, significant hypotension can occur. Papaverine is incompatible with heparin.
- Angiographically infused thrombolytics
- Thrombolytics infused through the angiogram catheter can be a life-saving therapy for selected patients with embolic AMI.
- Bleeding is the main complication. Thrombolytic administration is risky and should only be undertaken if peritonitis or other signs of bowel necrosis are absent. It must be started within 8 hours of symptom onset.
- If symptoms do not improve within 4 hours or if peritonitis develops, stop the infusion and perform surgery.
- Angioplasty after thrombolysis
- A very select group of patients who have atherosclerotic plaques at the origin of the SMA after thrombolysis are eligible for angioplasty. Angioplasty is technically difficult because of the anatomy of the SMA. Restenosis rates are 20-50%.
- Limited study findings indicate a definite role for angioplasty in the treatment of AMI. A case of successful transcutaneous catheter aspiration of a SMA embolic clot was reported from the CzechRepublic.
- Heparin for MVT
- Heparin anticoagulation is the main treatment of MVT. If no signs of bowel necrosis exist, the patient may not even need an operation. Heparin may increase the chance of bleeding complications. An avenue of study for possible future clinical trials may be the use of enoxaparin (Lovenox) or other low molecular weight heparins as a potential substitute for heparin in the treatment of MVT.
- Administer heparin as a bolus of 80 U/kg, not to exceed 5000 U, and then as an infusion at 18 U/kg/h until full conversion to oral warfarin. Appropriate monitoring of anticoagulation using activated partial thromboplastin time (aPTT) is mandatory.
- Percutaneous endovascular interventions
- Experience with percutaneous endovascular interventions has been accumulated.
- In select cases, especially in isolated spontaneous dissection of the SMA, stent placement may offer the best option.7
Surgical Care
Recognition of AMI before permanent tissue damage occurs is the best way to improve patient survival, and only angiography or exploratory surgery makes early diagnosis possible. Experience with CT and MR angiography is rapidly changing the therapeutic approach, allowing for prompt laparotomy in patients with suspected AMI when expeditious formal angiography is not available. A second-look procedure is indicated whenever bowel of questionable viability is not resected.
- Preoperative care: Stabilize patients using IV fluids, antibiotics covering the colonic flora, nasogastric tube decompression, and bladder catheterization, with heparin or papaverine administered as indicated. Blood should be available.
- Operative care: All types of AMI may require resection of necrotic bowel if signs of peritonitis develop. Differentiation of nonviable versus viable bowel can be enhanced by intraoperative fluorescein use. Because of fat absorption, fluorescein can be used only once. Most patients can benefit from a 24- to 48-hour second-look operation to assess for viability of the remaining bowel.
- Embolic AMI
- Unless the involved bowel is clearly gangrenous, an attempt at reperfusion is necessary. The SMA is isolated, and the location of the blockage is determined by palpation of pulses. Because most emboli are near the origin of the middle colic artery, note the proximal SMA pulse in embolic AMI.
- A transverse arteriotomy is made proximal to the point of occlusion, and a balloon-tipped Fogarty catheter (size 3 or 4) is passed distally. The balloon is then inflated and the clot extracted.
- The arteriotomy can be closed primarily or vein-patched to avoid lumen compromise. A bypass may be required if thrombectomy is unsuccessful.
- Observe the intestines for 10-15 minutes after restoration of flow to assess viability of bowel. This can be enhanced by intraoperative duplex ultrasound, fluorescein use, and palpation of pulses distal to the occlusion.
- Thrombotic AMI
- Emergency surgical revascularization is indicated. Simple thrombectomy has little or no benefit because most patients have clinically significant atherosclerosis at the time of the acute decompensation. Unlike patients with embolic AMI, these patients have a lesion at the origin of the SMA and no SMA pulsation is detected at the origin.
- If the gut is not irreparably gangrenous, proceed with the revascularization procedure. An antegrade aortomesenteric bypass is the best technique. Transaortic endarterectomy is an alternative when no vein is suitable to harvest or a prosthetic graft is contraindicated (eg, massive fecal contamination). Endarterectomy is more time consuming than thrombectomy and bypass procedures.
- Reevaluate bowel viability after revascularization and thrombectomy.
- Mesenteric venous thrombosis
- As for any patient with AMI and signs of peritonitis, including diagnosed NOMI, exploratory laparotomy and resection of infarcted bowel is indicated.
- Thrombectomy has little use in MVT because it can only be performed if the thrombus is fresh (ie, 1-3 d). In MTV, thrombectomy has little proven effectiveness because the thrombus is usually too widespread and all the thrombi cannot be removed completely.
- Spontaneous dissection of the SMA: When diagnosed before the onset of intestinal infarction, percutaneous stent placement has been successful.2,3,4,5
- Embolic AMI
Consultations
- Vascular surgery: Consult a vascular surgeon to evaluate the patient and to perform a revascularization procedure if required.
- Interventional radiology: Consult an interventional radiologist to perform any needed angiographic drug infusions or angioplasty.
- Critical care specialist: A critical care specialist should evaluate the patient for possible insertion of a Swan-Ganz catheter or admission to a critical care unit.
Diet
Patients must take nothing by mouth (NPO) in preparation for surgery and to reduce oxygen demand on the ischemic bowel.
Activity
Patients' activities are dictated by their conditions. Bed rest to allow for monitoring and to reduce demand on cardiac output is balanced against ambulation to prevent DVT.
Medication
Withhold therapeutic drugs (except analgesics and prophylactic antibiotics) until CT scan or angiogram determination of AMI type.
Vasodilators
Dilate mesenteric arterial system, reversing reactive arterial vasospasms in AMI.
Papaverine (Genabid, Pavabid, Pavatine)
Benzylisoquinoline derivative. Exerts direct nonspecific relaxant effect on vascular, cardiac, and other smooth muscle. In the absence of peritoneal signs, it is the DOC for AMI of arterial origin if angiogram indicates good distal perfusion. Advocated for treatment of widespread vasoconstriction that follows therapy for SMA emboli by other modalities.
Adult
30-60 mg/h IV
Pediatric
Not established
May decrease effectiveness of levodopa
Documented hypersensitivity; complete heart block
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in angina, recent MI, recent stroke, and glaucoma
Thrombolytics
Angiographically infused to lyse thrombi in selected patients with embolic AMI.
Alteplase, TPA (Activase)
Synthetic tissue plasminogen activator (t-PA) used to manage acute MI, ischemic stroke, and PE. Use in AMI is controversial and potentially dangerous. May be indicated in patients with embolic AMI if no signs of peritonitis are present. Safety and efficacy of concomitant administration with aspirin and heparin during first 24 h after onset of symptoms have not been investigated.
Adult
0.9 mg/kg IV infused over 60 min with 10% of total dose administrated as initial IV bolus over 1 min; not to exceed 90 mg; optimal dosing for AMI not yet established
Pediatric
Not established
Drugs that alter platelet function (eg, aspirin, dipyridamole, abciximab) may increase risk of bleeding before, during, or after alteplase therapy; heparin may be administered with and after alteplase infusions to reduce risk of rethrombosis; either heparin or alteplase may cause bleeding complications
Documented hypersensitivity; active internal bleeding; stroke within last 2 mo; intracranial or intraspinal surgery or trauma; intracranial hemorrhage on pretreatment evaluation; suspicion of subarachnoid hemorrhage; intracranial neoplasm; arteriovenous malformation or aneurysm; bleeding diathesis; severe uncontrolled hypertension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for bleeding, especially at arterial puncture sites, or with coadministration of vitamin K antagonists; control and monitor blood pressure frequently during and following alteplase administration (when managing acute ischemic stroke); doses >0.9 mg/kg may cause ICH
Anticoagulants
Indicated to prevent further extension of thrombus in MVT or postrevascularization in arterial occlusive AMI. In arterial occlusive AMI, whether anticoagulant therapy should be started immediately or after 48 hours when infarction is clearly absent is undetermined because of the risk of GI bleeding. Oral anticoagulants are used for maintenance therapy. They interfere with hepatic synthesis of vitamin K–dependent coagulation factors.
Heparin
Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. This drug does not actively lyse but is able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis.
Adult
Initial dose: 80 U/kg IV
Maintenance infusion: 18 U/kg/h IV; alternatively, 50 U/kg/h IV initially, followed by continuous infusion of 15-25 U/kg/h and increase dose by 5 U/kg/h q4h prn using aPTT
SMVT: heparin is continued for about 7 d, then maintenance on warfarin is instituted for 3-6 mo
Pediatric
Initial dose: 50 U/kg IV
Maintenance infusion: 15-25 U/kg/h IV; increase dose by 2-4 U/kg/h q6-8h prn using aPTT results
Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, aspirin, dextran, dipyridamole, and hydroxychloroquine may increase heparin toxicity
Documented hypersensitivity; subacute bacterial endocarditis; active bleeding; history of heparin-induced thrombocytopenia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In neonates, preservative-free heparin is recommended to avoid possible toxicity (gasping syndrome) by benzyl alcohol, which is used as preservative; caution in severe hypotension and shock
Warfarin (Coumadin)
Convert patients with MVT from heparin to warfarin when possible. Continue for 6 mo if no contraindication or identifiable hypercoagulable state exists. Maintain patients on warfarin for life if hypercoagulable state exists. Also indicated to prevent further embolization in patients with atrial fibrillation. Used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders. Tailor dose to maintain INR in 2-3 range.
Adult
5-15 mg PO qd for 2-5 d; adjust dose according to desired INR
Pediatric
0.05-0.34 mg/kg/d PO as weight-based dose; adjust dose according to desired INR
Drugs that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate; medications that may increase anticoagulant effects of warfarin include oral antibiotics, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen, and sulindac
Documented hypersensitivity; severe liver or kidney disease; open wounds or GI ulcers
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis
Antibiotics
To prevent or treat sepsis caused by breakdown of mucosal barrier in bowel necrosis or perforation.
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
150-450 mg PO q6-8h; not to exceed 1.8 g/d
600-900 mg IV/IM q8h alternatively
Pediatric
8-20 mg/kg/d PO as hydrochloride and 8-25 mg/kg/d as palmitate divided tid/qid
20-40 mg/kg/d IV/IM divided tid/qid alternatively
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; Clostridium difficile toxin–mediated diarrhea; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal pseudomembranous colitis by allowing overgrowth of C difficile
Metronidazole (Flagyl)
Imidazole ring–based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis).
Adult
Loading dose: 15 mg/kg (1 g for 70-kg adult) IV over 1 h for life-threatening conditions
Maintenance infusion: 7.5 mg/kg (500 mg for 70-kg adult) IV over 1 h q6-8h starting 6 h following loading dose; not to exceed 4 g/d
500 mg PO q6h alternatively
Pediatric
Administer IV as in adults using body weight
35-50 mg/kg/d PO divided tid alternatively
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiramlike reaction may occur during and 48 h after orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution if CNS disorder exists; adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Ticarcillin and clavulanate (Timentin)
Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive organisms, most gram-negative organisms, and most anaerobes.
Adult
3.1 g (0.1 g clavulanic acid) IV q4-6h
Pediatric
>3 months or <60 kilograms: 50 mg/kg (ticarcillin component) IV q6h; increase to q4h for severe infections
>60 kilograms: Administer as in adults
Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity; treating severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pseudomembranous colitis has been reported with nearly all antibacterial agents and may range in severity from mild to life threatening; consider pseudomembranous colitis in patients who present with diarrhea subsequent to the administration of antibacterial agents; perform CBCs before initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; caution with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions (seizures)
Cefotetan (Cefotan)
Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. Dose and route of administration depends on condition of patient, severity of infection, and susceptibility of causative organism.
Adult
1-2 g IV/IM q12h for 5-10 d; not to exceed 6 g/d
Pediatric
20-40 mg/kg IV/IM q12h for 5-10 d
Consumption of alcohol within 72 h may produce disulfiramlike reactions; cefotetan may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor renal function when used with an aminoglycoside; reduce dosage by one half if CrCl is 10-30 mL/min and by one fourth if CrCl <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Cefoxitin (Mefoxin)
Second-generation cephalosporin indicated for infections with gram-positive cocci and gram-negative rods. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.
Adult
1-2 g IV q6-8h
Pediatric
<3 months: Not established
>3 months: 80-160 mg/kg/d IV divided q4-6h; may use higher doses for severe or serious infections; not to exceed 12 g/d
Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis
Meropenem (Merrem)
Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria.
Adult
1 g IV q8h
Pediatric
40 mg/kg IV q8h
Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication
Analgesics
For relief of pain caused by bowel ischemia.
Morphine (Duramorph)
DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used; commonly titrated until the desired effect is obtained.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose
Pediatric
0.1-0.2 mg/kg/dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway when establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
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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References
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Further Reading
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
