[ ] [CK] mesenteric ischemia

Conservative care — In general, patients with an incidental diagnosis of mesenteric occlusive disease who do not have overt clinical manifestations are managed with smoking cessation and secondary prevention measures to limit the progression of atherosclerotic disease [2,21]. Interestingly, compared with patients with a typical risk profile for peripheral artery disease, 376 patients with chronic mesenteric ischemia were more likely be female, have lower incidences of hypertension and hypercholesterolemia, and have a lower-than-expected incidence of obesity and diabetes [14]. Reduced caloric intake, related to the postprandial pain, likely explains the observed differences. (See "Overview of the prevention of cardiovascular disease events in those with established disease (secondary prevention) or at high risk".)

Secondary prevention in patients with atherosclerotic disease typically includes antiplatelet therapy, which also has a role in the treatment of patients with spontaneous mesenteric artery dissection [46]. (See "Spontaneous mesenteric arterial dissection".)

Systemic anticoagulation is indicated in the setting of acute thrombus (ie, acute-on-chronic mesenteric ischemia). (See "Overview of intestinal ischemia in adults", section on 'Anticoagulation' and "Acute mesenteric arterial occlusion".)

In the absence of symptoms, there is little role for prophylactic intervention. An exception may be in patients with atherosclerotic occlusive disease of the mesenteric vessels who require aortic reconstruction for other indications (aneurysm, aortoiliac occlusive disease) or extensive foregut surgery (eg, pancreaticoduodenectomy), but such a decision depends on other factors as well. (See "Endovascular repair of abdominal aortic aneurysm", section on 'Anatomic considerations'.)

Nutritional assessment and support — Due to the often delayed diagnosis, patients may exhibit malnutrition (eg, body mass index [BMI] <20, albumin <3.0). Thus, nutritional status should be evaluated in all patients [47,48]. The severity of nutritional deficiency has a bearing on the approach to treatment [49]. (See "Overview of perioperative nutritional support", section on 'Consequences of malnutrition in surgical patients' and "Overview of perioperative nutritional support", section on 'Nutritional assessment in the surgical patient' and "Overview of perioperative nutritional support", section on 'Preoperative nutritional support'.)

Revascularization — The indication for revascularization (open or endovascular) is the presence of symptoms, including abdominal pain and weight loss, in the setting of documented severe splanchnic artery stenoses. The aim of intervention is to prevent future bowel infarction [2]. For patients with acute symptoms (ie, acute-on-chronic mesenteric ischemia), revascularization options in the acute setting are discussed separately. (See "Acute mesenteric arterial occlusion", section on 'Management'.)

Options for revascularization include open surgical reconstruction and percutaneous transluminal angioplasty (PTA) with or without placement of a stent (bare or covered). Traditionally, open surgical revascularization, which is durable, was the standard and only available treatment. As catheter-based techniques improved, percutaneous angioplasty, with or without stenting, was offered initially to those who were not candidates for surgery due to the presence of multiple and severe comorbidities, and later as a primary therapy, but has evolved to become the preferred initial therapy. In practice, in patients with severe renal impairment for whom intravenous radiocontrast may be contraindicated, a surgical rather than percutaneous intervention may need to be considered, provided the patient has an acceptable risk for surgery. An alternative method may be to use carbon dioxide (CO2) as a contrast agent, but this may cause severe cramping. Another option is to guide intervention using intravascular ultrasound (IVUS).

The extent of revascularization (number of vessels revascularized) may depend upon the approach chosen, but this varies from institution to institution [50,51]. In a systematic review comparing approaches, significantly more mesenteric vessels were revascularized with open surgery compared with the endovascular approach [2]. The celiac artery was more often treated with open surgery, typically in conjunction with superior mesenteric artery revascularization. Although not commonly revascularized in isolation, the inferior mesenteric artery may be the only suitable vessel [52]. In some cases, advanced percutaneous techniques, such as crossing total occlusions, may be attempted to avoid an open surgical approach [53-56]. In the setting of acute mesenteric ischemia, isolated revascularization of the superior mesenteric artery is more commonly performed either using an open or hybrid approach [57]. (See "Acute mesenteric arterial occlusion".)

cf>

acute mesenteric ischemia

Diagnosis and initial management of intestinal ischemia

CT: computed tomography.
* Patients ultimately identified with nonocclusive mesenteric ischemia will not benefit from anticoagulation, at which point it can be discontinued.
¶ Imaging signs associated with mesenteric ischemia include focal or segmental bowel wall thickening, intestinal pneumatosis, portal vein gas, portomesenteric thrombosis, mesenteric arterial calcification, and mesenteric artery occlusion.
Δ Medically fit patients.
◊ Refer to associated UpToDate algorithms on mesenteric ischemia (acute or chronic, occlusive or nonocclusive, arterial or venous).

Graphic 62760 Version 6.0

MANAGEMENT — Initial medical management for all patients with acute mesenteric ischemia includes the following, which are discussed in detail separately (algorithm 1) (see "Overview of intestinal ischemia in adults", section on 'Initial management'):

●Nothing by mouth, nasogastric decompression.

●Fluid therapy to maintain adequate intravascular volume and visceral perfusion and monitored as normal urine output.

●Avoidance of vasopressors, which can exacerbate ischemia.

●Antithrombotic therapy consists of anticoagulation (unfractionated heparin, weight-based protocol) to limit thrombus propagation and help alleviate associated arteriolar vasoconstriction with or without antiplatelet therapy [32].=> Heparin infusion + ASA. 

●Empiric broad-spectrum antibiotic therapy.= VANC AND ZOSYN.

●Proton pump inhibitors [33].

●Supplemental oxygen [33].

IVF+ABx(SEPSIS) + PPI, O2 

CTA?yes => Heparin infusion

SEPSIS: ABX+ PPI  RESUSCITATION + KUB

=> IF IT's PERFORATON => OP.

=> IF IT's not perforation => Stablization => CTA(abdomen) with treatment. 

-Heparin infusion
-true ischemia = consult, IR or General surgeon to decide it !!!