eMedicine Specialties > Emergency Medicine > Cardiovascular

Mesenteric Ischemia: Treatment & Medication

Author: Daniel K Nishijima, MD, Staff Physician, Department of Emergency Medicine, University of California Davis Medical Center
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
Contributor Information and Disclosures

Updated: Apr 8, 2009

Treatment

Prehospital Care

  • Cardiac monitor, intravenous access, oxygen
  • May require intravenous fluid resuscitation

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

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.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Antibiotic

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


Clindamycin (Cleocin)

Active against anaerobic gram-negative bacilli. Lincosamide useful in treating serious skin and soft tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci.
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.

Adult

400-900 mg IV q8h

Pediatric

9-16 mg/kg/d IV divided tid/qid

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; 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 colitis by allowing overgrowth of Clostridium difficile


Metronidazole (Flagyl)

Imidazole ring-based antibiotic that is active against anaerobes. Usually used in combination with other antimicrobial agents, except when used for C difficile enterocolitis, in which monotherapy is appropriate.

Adult

1 g IV loading dose followed by 0.5 g IV q6h or 1 g IV q12h

Pediatric

15-30 mg/kg/d IV divided bid/tid for 7 d, or 40 mg/kg once; not to exceed 2 g/d

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiramlike reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy


Aztreonam (Azactam)

Monobactam that inhibits cell wall synthesis during bacterial growth. Active against aerobic gram-negative bacilli.

Adult

2 g IV q8h

Pediatric

90-120 mg/kg/d IV divided q6-8h

Tetracyclines may reduce effects of this medication

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal insufficiency


Ticarcillin (Ticar, Synthetic Penicillin)

Active against aerobic gram-negative bacilli. Inhibits biosynthesis of cell wall mucopeptide, and effective during stage of active growth.

Adult

4 g IV q6h

Pediatric

200-300 mg/kg/d IV divided q4-6h

Tetracyclines decrease ticarcillin effects; ticarcillin decreases effect of oral contraceptives; large IV doses can increase risk of bleeding in patients receiving anticoagulants; ticarcillin increases duration of neuromuscular blockers; probenecid increases ticarcillin levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBCs before initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; urinalysis and BUN and creatinine determinations should be performed during therapy (adjust dose if values become elevated); if renal impairment is known or suspected, adjust dose and monitor blood levels


Cefoxitin (Mefoxin)

Active against aerobic and anaerobic gram-negative bacilli. Second-generation cephalosporin 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.

Adult

2 g IV q8h

Pediatric

<3 months: Not established
>3 months: 80-160 mg/kg/d IV divided q4-6h; use higher dosages for more 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)

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


Cefotetan (Cefotan)

Active against aerobic and anaerobic gram-negative bacilli. Second-generation cephalosporin indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods.
Determine proper dosage and route of administration by condition of the patient, severity of the infection, and susceptibility of the causative organism.

Adult

1-2 g IV q12h

Pediatric

20-40 mg/kg/dose IV q12h for 5-10 d

Consumption of alcohol within 72 h of cefotetan may produce disulfiramlike reactions; cefotetan may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce dosage by one half if CrCl is 10-30 mL/min and by one fourth if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy


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

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

Vasodilators

These agents can improve blood supply to ischemic areas.


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 acute mesenteric ischemia (AMI) of arterial origin if angiogram indicates good distal perfusion. Advocated for treatment of widespread vasoconstriction that follows therapy of superior mesenteric artery (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

More on Mesenteric Ischemia

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

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Keywords

acute mesenteric ischemia, AMI, chronic mesenteric ischemia, CMI, interruption of blood flow to small intestine, arterial mesenteric ischemia, venous mesenteric ischemia, superior mesenteric artery occlusion, nonocclusive infarction, inferior mesenteric artery occlusion, mesenteric venous thrombosis, arteritis

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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.

Medical Editor

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.

Pharmacy Editor

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

Managing Editor

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 and National Association of EMS Physicians
Disclosure: Intellicare Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

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, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, 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: Schering  Honoraria Speaking and teaching

 
 
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