Mesenteric Ischemia in Emergency Medicine Treatment & Management

  • Author: Daniel K Nishijima, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: May 28, 2010
 

Prehospital Care

  • Cardiac monitor, intravenous access, oxygen
  • May require intravenous fluid resuscitation
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Emergency Department Care

  • Resuscitation
    • Resuscitation is often needed because patients with mesenteric ischemia are usually very toxic or rapidly become toxic.
    • Early intubation in unstable patients may improve oxygenation and allow for more aggressive fluid resuscitation.
    • Parenteral opioid analgesics
    • Parenteral broad-spectrum antibiotics
  • All cases of mesenteric ischemia with signs of peritonitis, regardless of the etiology, generally require immediate surgical intervention for the resection of ischemic or necrotic intestines.
  • Intra-arterial papaverine during angiography can be used regardless of the etiology of the intestinal ischemia. Papaverine is an opium derivative that functions as a phosphodiesterase inhibitor, which acts to relax vascular smooth muscle. It is usually infused directly into the superior mesenteric artery (SMA), thus improving intestinal blood flow.
  • Definitive treatment is generally withheld by the EP until an etiology is determined. In cases of mesenteric ischemia, time is of the utmost essence. Treatment options depend on the etiology of intestinal ischemia as well as the hemodynamic stability of the patient.
  • Definitive treatment
    • For acute arterial embolus, options include papaverine infusion, surgical embolectomy, and intra-arterial thrombolysis.
    • For acute arterial thrombosis, options include papaverine infusion and arterial reconstruction either through aortosuperior mesenteric arterial bypass grafting or reimplantation of the SMA to the aorta.[46]
    • For nonocclusive mesenteric ischemia, papaverine infusion is the mainstay of treatment. Papaverine has been shown to decrease mortality in nonocclusive mesenteric ischemia from 70-90% to 0-55% in a few small studies.[12, 32, 47]
    • For mesenteric venous thrombosis, anticoagulation with heparin/warfarin either alone or in combination with surgery. Immediate heparinization should be started even when surgical intervention is indicated, as it decreases progression of thrombosis and improves survival.[38, 19, 48, 33, 49]
    • For chronic mesenteric ischemia, management options include angioplasty with or without stent placement or surgical revascularization. Several studies have found a high rate of success with percutaneous stent revascularization for chronic mesenteric ischemia, although repeated interventions may be necessary.[50, 51, 52]
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Consultations

  • Vascular surgery - Given the need for early diagnosis and treatment, the EP should obtain surgical consultation as soon as the diagnosis is considered.
  • Interventional radiology - Angiography and adjunctive treatment
  • Intensivist - Patients diagnosed with mesenteric ischemia are often hemodynamically unstable or have a high probability to progress to instability, so most patients require hospitalization in an intensive care unit.
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Contributor Information and Disclosures
Author

Daniel K Nishijima, MD  Staff Physician, 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.

Coauthor(s)

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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

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: Nothing to disclose.

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Pneumatosis intestinalis is one of the few radiographic findings in patients with mesenteric ischemia.
Diagnosis and treatment of intestinal ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternate management plan. DVT, deep vein thrombosis; SMA, superior mesenteric artery. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
Diagnosis and treatment of intestinal ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternate management plan. DVT, deep vein thrombosis; SMA, superior mesenteric artery. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
Management of chronic mesenteric ischemia (CMI). Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. MRA, magnetic resonance angiography; CT, computerized tomography. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
Management of colon ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. BE, barium enema; NPO, nothing by mouth; PLC, protein-losing colopathy; IBD, inflammatory bowel disease. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
 
 
 
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