Acute Mesenteric Ischemia

Acute Mesenteric Ischemia
Overview and Recommendations
Background
● Acute mesenteric ischemia can be the result of thromboembolic occlusion of mesenteric arteries,
mesenteric venous thrombosis, aortic dissection, or nonocclusive mesenteric ischemia with
vasoconstriction due to low blood ow.
● Acute occlusive disease is characterized by sudden onset of abdominal cramps (may be postprandial)
for 3-6 hours with pain out of proportion to abdominal exam ndings, usually followed by a pain-free
interval, then development of peritoneal signs. Risk factors include or overlap with other
cardiovascular disease.
● Nonocclusive mesenteric ischemia (NOMI) results from mesenteric hypoperfusion with reactive
vasospasm with risk factors including long-term hemodialysis, recent cardiac surgery with
extracorporeal circulation, and vasoconstrictive medications such as digitalis.
● Acute mesenteric ischemia has a high rate of mortality with the most important determinant being
whether or not diagnosis is made before intestinal infarction.
Evaluation
● Suspect acute mesenteric ischemia in patients with abrupt onset of severe, crampy abdominal pain
(out of proportion to physical exam) persisting > 2-3 hours without alternate explanation.
⚬ Other symptoms may include forceful bowel evacuation, vomiting, and diarrhea; elderly patients
may present with mental status change.
⚬ Patients may develop abdominal distention and gastrointestinal bleeding.
● Assess for causes of abdominal pain such as pancreatitis, peritonitis, sepsis, and small bowel
obstruction as directed by patient’s presentation. Initial workup may include complete blood count
with di erential, comprehensive metabolic panel, amylase, lipase, blood cultures, blood gas, and
arterial lactate.
● Blood test ndings are nonspeci c and may include elevated white blood cell count, elevated
hematocrit, and metabolic acidosis. Normal lab values do not exclude acute mesenteric ischemia.
● Consider abdominal x-ray, especially if acute abdomen, to detect free air from perforation. Abdominal
plain lm radiographs with supine and upright views may be normal in many cases. Findings are not
speci c to mesenteric ischemia but may include ileus, bowel wall thickening, pneumatosis intestinalis,
necrosis, or perforation.
● Perform urgent computed tomography angiography (CTA) for most patents with suspected
mesenteric ischemia (Strong recommendation). CTA can detect intramural gas, portal venous gas, and
liver or spleen infarcts. CTA can show a pattern of arterial narrowing or occlusion, changes in bowel
wall thickness, pneumatosis, and mucosal or bowel wall enhancement or aortic dissection.
● Consider angiography for suspected nonocclusive mesenteric ischemia and/or preparing for
endovascular treatment.
Management
● If the patient has persistent peritoneal signs of acute abdomen, perform emergency laparoscopy or
laparotomy with consideration of revascularization.
● Treatment of shock is most important initial step. Provide aggressive uid replacement and intensive
monitoring as needed to stabilize hemodynamics (Strong recommendation).
● Start empiric antibiotics covering gram-positive, gram-negative, and anaerobic bacteria to treat
potential bacterial peritonitis.
● Consider anticoagulation with heparin to prevent further thrombosis.
● For arterial occlusive disease:
⚬ Perform revascularization before any bowel resection (Strong recommendation).

⚬ Revascularization may be done via embolectomy, thromboendarterectomy, or bypass surgery, or
may be done via endovascular treatment (transcatheter thrombolytics, balloon angioplasty, or
stenting) (Weak recommendation).
● For mesenteric venous thrombosis, consider catheter-directed thrombolysis to reduce thrombosis

and improve clinical symptoms.
● For nonocclusive disease, consider transcatheter delivery of vasodilators for patients with vasospasm
unresponsive to systemic treatment, and for patients with ischemia due to cocaine or ergot poisoning
(Weak recommendation).
● Perform bowel resection for necrotic bowel in patients unresponsive to medical treatment (Strong
recommendation). Delay until after revascularization and limit to overtly necrotic bowel to preserve as
much small bowel as possible.
● Consider second-look (or third-look) procedure 12-48 hours after initial surgery to assess bowel
viability (Weak recommendation).
Related Summaries
● Colon Ischemia
General Information
Description
● acute mesenteric ischemia is a potentially fatal vascular emergency due to sudden bowel ischemia
from blockage of venous or arterial blood ow 1 , 2 , 3
Types
● acute mesenteric ischemia may be due to various mechanisms 1 , 4
⚬ arterial occlusive ischemia - occurs in superior mesenteric artery via embolus or thrombus in
patients with pre-existing wall alterations
⚬ arterial nonocclusive ischemia - results from cardiac output reduction with reactive vessel spasm
mesenterically
⚬ venous ischemia - occurs due to thrombosis of mesenteric-portal axis
Epidemiology
Who is most affected
● more common in women and persons > 60 years old 2 , 3 , 4
Incidence/Prevalence
● acute mesenteric ischemia reported to account for 1
⚬ about 1% of patients presenting with acute abdomen

⚬ up to 10% of patients > 70 years old presenting with acute abdomen
● prevalence of reported underlying etiology 7
⚬ arterial occlusive disease is reported to account for 40%-50% of cases

⚬ nonocclusive mesenteric ischemia (typically due to prolonged state of hypotension) reported to
account for 20%-35% of cases
⚬ mesenteric venous thrombosis reported to account for < 5% of cases
STUDY
● SUMMARY
10 per 100,000 annual incidence for acute mesenteric ischemia reported in patients admitted to
hospital in Maryland, United States from 2009-2013
COHORT STUDY: Front Surg 2016 Apr 14;3:22 | Full Text
Details
⚬ based on retrospective cohort study
⚬ 3,157,499 adult hospital admissions in Maryland, United States from 2009-2013 were assessed for
diagnoses and outcomes
⚬ 2,255 patients (0.07%) were diagnosed with acute mesenteric ischemia (AMI) for admission rate
due to AMI of 10 per 100,000 persons
⚬ Reference - Front Surg 2016 Apr 14;3:22 full-text
● annual incidence of 5.3 per 100,000 population in Sweden (Eur J Vasc Endovasc Surg 2003
Aug;26(2):179 )
Risk factors
General risk factors for acute mesenteric ischemia
● general risk factors of acute mesenteric ischemia (AMI) include older age and history of
⚬ cardiovascular disease including atherosclerotic disease, heart failure and other low-output states,
arrhythmias, valvular disease, recent myocardial infarction, peripheral artery disease, and
hypotension; mesenteric ischemia is also reported to occur after aortic surgical procedures
⚬ previous arterial embolization
⚬ vasculitis - common cause in younger patients with autoimmune disease such as polyarteritis
nodosa
⚬ deep vein thrombosis
⚬ hypercoagulable states including protein C and S de ciencies, anti-thrombin III de ciency, and
activated protein C resistance
⚬ underlying vasculitides
⚬ intra-abdominal malignancy
⚬ chronic postprandial pain
⚬ connective tissue disorder
⚬ portal hypertension
⚬ medications including vasopressors, digoxin, or dopamine
⚬ signs of chronic mesenteric ischemia
⚬ References - 4 , 7 , World J Gastroenterol 2013 Mar 7;19(9):1338 full-text , Aliment Pharmacol
Ther 2005 Feb 1;21(3):201 full-text , Tech Vasc Interv Radiol 2015 Mar;18(1):24
STUDY
⚬ SUMMARY
typical cardiovascular risk factors (nicotine use, hypertension, dyslipidemia, and diabetes)
common in patients with mesenteric ischemia
CROSS-SECTIONAL STUDY: Catheter Cardiovasc Interv 2011 Nov 15;78(6):948
Details
– based on cross-sectional study
– 31 patients (mean age 65 years) with acute or chronic mesenteric ischemia were evaluated
– prevalence of cardiovascular risk factors in population
● nicotine use in 14 patients (45.2%)

● hypertension in 14 patients (45.2%)
● dyslipidemia in 12 patients (38.7%)
● diabetes in 8 patients (25.8%)
– Reference - Catheter Cardiovasc Interv 2011 Nov 15;78(6):948
● factors associated with hospital admission due to acute mesenteric ischemia in retrospective cohort
study with 3,157,499 adult hospital admissions in Maryland, United States from 2009-2013
⚬ 2,255 patients (0.07%) were diagnosed with acute mesenteric ischemia
⚬ comparing admitted patients with acute mesenteric ischemia vs. those without acute mesenteric
ischemia (p ≥ 0.0001 each)
– mean age 67 vs. 57 years (age > 65 years in 59% vs. 38%)
– white ethnicity in 72% vs. 60%
– emergent clinical presentation in 90% vs. 72%
– emergency department presentation in 81% vs. 63%
– hypercoagulable state in 9% vs. 2%
– cardiac dysrhythmia in 27% vs. 20%
– chronic kidney disease in 38% vs. 16%
⚬ acute mesenteric ischemia associated with reduced prevalence of diabetes mellitus (p < 0.0001),
hypertension (p < 0.0001), and ischemic heart disease (p = 0.01)
⚬ Reference - Front Surg 2016 Apr 14;3:22 full-text
STUDY
● SUMMARY
risk factors for ischemic colitis may differ from risk factors for acute mesenteric ischemia
CASE-CONTROL STUDY: Aliment Pharmacol Ther 2011 Apr;33(8):969

Details
⚬ based on case-control study
⚬ general practice population aged 18-84 years in United Kingdom evaluated including 6,494,044
person-years of general population follow-up and 155,745 person-years of cohort with irritable
bowel syndrome (IBS) or chronic constipation (CC)
⚬ 78 con rmed cases of intestinal ischemia identi ed including 44 cases of acute mesenteric
ischemia and 31 cases of ischemic colitis
⚬ incidence rate of ischemic colitis 0.43 per 100,000 person-years in general population and 1.93 per
100,000 person-years in patients with IBS and/or CC
⚬ cases matched to 2,000 randomly selected matched controls
⚬ risk factors for ischemic colitis in case-control study were
– body mass index < 20 kg/m2

– peripheral arterial vascular disease
– chronic renal disease
– heart failure
– in ammatory bowel disease
– proton pump inhibitor use
⚬ risk factors for acute mesenteric ischemia in case-control study were
– coagulation disease
– rheumatoid arthritis
– diabetes
– cardiovascular surgery in prior year
– antispasmodic drug use
– proton pump inhibitor use
– antidepressant use
⚬ Reference - Aliment Pharmacol Ther 2011 Apr;33(8):969
Risk factors by etiology

Arterial occlusive disease
● arterial occlusive disease is reported to account for 40%-50% AMI cases 1 , 2 , 3 , 7
⚬ cardiovascular diseases associated with increased risk for embolic occlusive disease
– arrhythmia including atrial brillation

– recent myocardial ischemia or infarction
– peripheral arterial emboli
– low ejection fraction due to cardiomyopathy or heart failure
– peripheral arterial occlusive disease (PAOD)
– aortic dissection involving abdominal aorta (Tech Vasc Interv Radiol 2015 Mar;18(1):24 )
STUDY
– SUMMARY
atrial fibrillation reported in 60%-95% of patients with embolism
COHORT STUDY: J Emerg Med 2012 Jun;42(6):635

COHORT STUDY: Acta Chir Belg 2004 Apr;104(2):184
COHORT STUDY: Eur J Vasc Endovasc Surg 2003 Aug;26(2):179
Details
● based on 3 retrospective cohort studies
● 55 patients (median age 76 years) with acute superior mesenteric artery occlusion evaluated
⚬ atrial brillation in 22 of 29 patients (76%) with embolism vs. 4 of 24 patients (17%) with
thrombosis (p < 0.001)
⚬ Reference - J Emerg Med 2012 Jun;42(6):635
● 15 patients with acute mesenteric ischemia were evaluated
⚬ atrial brillation in 9 patients (60%)

⚬ Reference - Acta Chir Belg 2004 Apr;104(2):184
● 24 patients with acute mesenteric ischemia were evaluated
⚬ atrial brillation in 19 of 20 patients with embolism (95%)

⚬ Reference - Eur J Vasc Endovasc Surg 2003 Aug;26(2):179
– case report of Takayasu arteritis manifesting as acute mesenteric ischemia in young man can be
found in Rheumatol Int 2017 Jan;37(1):169
⚬ cardiovascular conditions associated with increased risk for thrombotic occlusive disease 2
– ventricular aneurysms
– atherosclerosis
Nonocclusive mesenteric ischemia (NOMI)
● NOMI is reported to account for 20%-30% cases, and typically results from prolonged state of
hypotension such as 1 , 3 , 7
⚬ long-term hemodialysis
⚬ recent heart surgery with extracorporeal circulation
⚬ renal transplant (Saudi J Kidney Dis Transpl 2016 May;27(3):585 full-text )
⚬ vasoactive drugs causing splanchnic vasoconstriction including
– digitalis medications
– phenylephrine
– amphetamines
– vasopressin
– cocaine
– Reference - Aliment Pharmacol Ther 2005 Feb 1;21(3):201 full-text and Tech Vasc Interv
Radiol 2015 Mar;18(1):24
Mesenteric venous thrombosis (MVT)
● MVT is reported to account for < 5% AMI cases 1
⚬ thrombophilias of
– heritable origin
● de ciencies of antithrombin III, plasminogen, protein C, and protein S

● mutations including factor V Leiden mutation (activated protein C resistance phenotype),
JAK2V16F mutation without overt myeloproliferative disease, prothrombin 20210 mutation
(PTHR A20210)
● conditions including hereditary hemorrhagic telangiectasia, hyper brinogenemia, and sickle
cell disease
– acquired origin or systemic hypercoagulable states - antiphospholipid antibodies (including
anticardiolipin antibodies and beta-2 glycoprotein-1 antibodies), decompression illness,
disseminated intravascular coagulation (DIC), immune thrombocytopenia (ITP), heparin-induced
thrombocytopenia, hyperhomocysteinemia, malignancy (including hepatocellular carcinoma
with macrovascular invasion, neoplasia, or pancreatic carcinoma), monoclonal gammopathy,
myeloproliferative disease, nephrotic syndrome, oral contraceptive agents or other
medications, paroxysmal nocturnal hemoglobinuria, polycythemia vera, pregnancy
⚬ intra-abdominal issues such as cirrhosis (also associated with hypercoagulable state), in ammatory
bowel disease (also associated with hypercoagulable state), postoperative state (also associated
with hypercoagulable state), congenital venous anomaly, intestinal volvulus, intra-abdominal
infection, pancreatitis, trauma, prior surgery involving portal venous system
⚬ portal hypertension
⚬ References - 1 , Vasc Med 2010 Oct;15(5):407 , and Tech Vasc Interv Radiol 2015 Mar;18(1):24
Associated conditions
STUDY
● SUMMARY
lower limb ischemia requiring revascularization after treatment for acute aortic dissection
appears associated with mesenteric ischemia
COHORT STUDY: Ann Vasc Surg 2016 Oct;36:112
Details
⚬ 1,015 patients treated for acute aortic dissection (AAD) from 2000-2014 were assessed for
interventions, outcomes, and complications
⚬ 49.4% of patients had DeBakey I/II dissection (treated with urgent open repair of ascending aorta),
50.6% of patients had DeBakey III dissections and were treated with anti-impulse medical therapy
and either open aortic repair or thoracic endovascular aortic repair for malperfusion syndromes
⚬ 30-day mortality was 11.3%
⚬ 104 patients had lower limb ischemia (more common in DeBakey I/II dissections, p = 0.001); 40
patients required lower limb revascularization (no signi cant di erence comparing DeBakey
groups)
⚬ need for lower limb revascularization associated with mesenteric ischemia in both DeBakey I/II
group (p = 0.037) and DeBakey III group (p < 0.001)
⚬ Reference - Ann Vasc Surg 2016 Oct;36:112
STUDY
● SUMMARY
nonocclusive acute mesenteric ischemia is present in about one-fifth of patients with acute
aortic dissection
CROSS-SECTIONAL STUDY: J Vasc Surg 2002 Oct;36(4):738
Details
⚬ based on cross-sectional study
⚬ 371 patients with history of aortic dissection were evaluated for nonocclusive acute mesenteric
ischemia (NOMI)
⚬ 73 patients (19%) had NOMI
⚬ Reference - J Vasc Surg 2002 Oct;36(4):738
Etiology and Pathogenesis

Causes
● most common causes 1 , 2 , 3 , 5
⚬ occlusive mesenteric ischemia
– acute thromboembolic occlusion of superior mesenteric artery
● arterial embolism accounts for 40%-50% of cases

● arterial thrombosis (usually atherosclerotic) accounts for 25%-30% of cases
– mesenteric arterial thrombosis

– mesenteric venous thrombosis (MVT) 1 , 3 , 5 , 7
● accounts for about 10%-15% of cases

● thrombosis of mesenteric-portal axis due to Virchow classic triad for venous thrombosis -
stasis, epithelial injury, and hypercoagulability (Vasc Med 2010 Oct;15(5):407 )
● may be caused by primary or idiopathic thrombosis, but > 90% of cases are reported to be
associated with
⚬ thrombophilia
⚬ trauma
⚬ local in ammatory changes including pancreatitis, diverticulitis, or biliary system
in ammation or infection
⚬ nonocclusive mesenteric ischemia (NOMI) (including ischemic colitis)
– mesenteric underperfusion with reactive vascular spasm (vasoconstriction due to low ow)
– accounts for about 20% of cases
– most common clinical situations leading to NOMI
● long-term hemodialysis and hypovolemia

● heart surgery with extracorporeal circulation (NOMI occurs in 0.5%-1% heart operations)
● causes of altered mesenteric circulation include 7
⚬ vasculitis
⚬ traumatic injury
⚬ aortic dissection or in ammation
⚬ atherosclerosis
⚬ poor cardiac output leading to low mesenteric ow
⚬ in ammatory conditions such as pancreatitis, perforated ulcer, tumor, or other conditions that
a ect mesenteric vessels
⚬ cholesterol emboli (Tech Vasc Interv Radiol 2015 Mar;18(1):24 )
⚬ intestinal obstruction (Tech Vasc Interv Radiol 2015 Mar;18(1):24 )
Pathogenesis
● embolism involves superior mesenteric artery in up to 85% of cases of enteric ischemia due to oblique
angle of origin from visceral aortic segment 1 , 2

⚬ thromboemboli usually lodge in proximal superior mesenteric artery, distal to middle colic
artery 2 , 3
⚬ atheroemboli usually lodge in distal mesenteric circulation 2
● venous thrombosis usually only leads to permanent damage when centrally located and a ects > 1
downstream areas 1
● regardless of cause, within 6 hours disruption of blood ow leads to 1 , 2 , 3
⚬ irreversible ischemia and disintegration of intestinal mucosal barriers

⚬ morphological alterations of intestinal wall
⚬ bowel necrosis
History and Physical
History
Chief concern (CC)
● severe abdominal pain out of proportion to physical exam ndings (though may be absent in up to
25% of cases) 2 , 3 , 7
● typical symptoms may include 2
⚬ abdominal pain, which may be followed by forceful bowel evacuation

⚬ vomiting
⚬ diarrhea
⚬ distention
● if ischemia is due to embolus, onset and clinical decline may be more abrupt due to lack of
collaterals 2
History of present illness (HPI)
● occlusive disease characterized by sudden-onset abdominal cramps for 3-6 hours, usually followed by
pain-free interval, and then symptoms of peritonitis, 1 which may include

⚬ abdominal pain
⚬ fever
⚬ change in mental status (particularly in elderly patients)
⚬ chills
⚬ nausea or vomiting
● for nonocclusive disease 1
⚬ increasing abdominal pain in responsive patients

⚬ may occur following cardiac surgery with extracorporeal circulation, and symptoms may begin
when patients are in an unstable state and frequently receiving sedation, arti cial ventilation, or
analgesia
⚬ intubated patients may show
– abdominal distension
– increased in ammatory parameters
– signs of sepsis
– Reference - JAMA 2007 May 9;297(18):1985
● for thrombosis, subacute presentation may begin weeks before acute symptoms due to development
of collaterals 2
● for venous thrombosis 1

⚬ signs and symptoms depend on severity of thrombosis
⚬ usually, nonspeci c abdominal symptoms lasting for several days
⚬ may have venous infarction with peritonitis (rare)
● if pain onset is abrupt, suspect mesenteric venous thrombosis, as pain with acute arterial occlusion is
reported to usually be less abrupt 7
● mesenteric ischemic may progress to ischemic colitis, which is suggested by bloody or loose stools
(see also Ischemic colitis topic)
Medication history
● ask about use of vasoactive drugs which may cause splanchnic constriction including 1 , 3
⚬ digitalis medication
⚬ vasopressin
⚬ alpha agonists
Past medical history (PMH)
● ask about cardiovascular diseases or procedures 4
⚬ myocardial infarction
⚬ stroke
⚬ claudication
⚬ arterial intervention with catheter traversing visceral aorta or proximal arteries
⚬ arrhythmia
● ask about other vascular risk factors including smoking, diabetes, hypercholesterolemia
● about one-third of patients with superior mesenteric artery embolism have an antecedent embolic
event 2 , 3
● for acute thrombotic occlusion, history may include symptoms such as 2
⚬ postprandial abdominal pain

⚬ weight loss
⚬ food intolerance
● for nonocclusive disease, history may include 1
⚬ long-term hemodialysis ( uid loss may lead to vascular spasm)

⚬ heart surgery with extracorporeal circulation (reported after about 0.5%-1% of all heart operations)
● for venous thrombosis, history may include 1
⚬ paraneoplasia
⚬ pancreatitis or pancreatic carcinoma
⚬ congenital thrombophilia such as antithrombin (AT) II de ciency or protein C de ciency
⚬ hepatocellular carcinoma with macrovascular invasion
Physical
General physical
● few physical exam ndings, classic presentation is abdominal pain out of proportion to physical
ndings 2
● signs of sepsis (fever, tachycardia, tachypnea, and hypotension) may develop rapidly 1 , 2
● fever reported in 24% and altered mental status in 19% in cohort of 37 patients with acute
thromboembolic occlusion of the superior mesenteric artery (Hepatogastroenterology 2011 Nov-
Dec;58(112):1893 )
Abdomen
● minimal tenderness to palpation until transmural involvement of bowel 2
● patients with acute mesenteric ischemia may have distention 2
● acute abdomen present in 15 patients (40%) in cohort of 37 patients with thromboembolic occlusion
of the superior mesenteric artery (Hepatogastroenterology 2011 Nov-Dec;58(112):1893 )
Rectal
● patients with acute mesenteric ischemia may have gastrointestinal bleeding 2
Diagnosis
Making the diagnosis
● suspect acute mesenteric ischemia in patients with severe abdominal pain persisting > 2-3 hours
without alternate explanation 5
● suspect acute intestinal ischemia in patients with 4
⚬ history of cardiovascular disease presenting with acute abdominal pain out of proportion to
physical ndings (ACC/AHA Class I, Level B)
⚬ acute abdominal pain following either arterial intervention with catheter traversing visceral aorta
or proximal arteries, recent myocardial infarction, or recent arrhythmia (ACC/AHA Class I, Level C)
● suspect nonocclusive acute intestinal ischemia in patients who develop abdominal pain following 4
⚬ shock (especially cardiogenic shock) or low- ow states (ACC/AHA Class I, Level B)

⚬ use of vasoconstrictors such as cocaine, ergots, vasopressin, or norepinephrine (ACC/AHA Class I,
Level B)
⚬ coarctation repair or surgical revascularization of intestinal ischemia from arterial obstruction
(ACC/AHA Class I, Level B)
⚬ prolonged states of hypotension such as hemodialysis, renal transplant, or any recent heart
surgery with extracorporeal circulation (see Risk factors - NOMI section)
● diagnosis con rmed with computed tomography angiography showing pattern of arterial narrowing
or occlusion, changes in bowel wall thickness, pneumatosis, and mucosal or bowel wall
enhancement 1 , 2
Differential diagnosis
● pancreatitis 2 , 3
● diverticulitis 2 , 3
● cholecystitis 2
● appendicitis 2
● bowel obstruction 2
● ileus 3
● peritonitis 3
● perforated peptic ulcer
● gastric volvulus ( StatPearls 2018 Jan early online full-text )
● septic shock (Crit Care 2016 Nov 6;20(1):360 full-text )
● see also Acute abdominal pain in adults - approach to the patient
Testing overview
● initial evaluation is determined by clinical presentation 2 , 3 , 7
⚬ tests that may be helpful include
– complete blood count with di erential, comprehensive metabolic panel, amylase, lipase, blood
cultures, blood gas, and arterial lactate
– evaluation for infection
⚬ suspect mesenteric ischemia if abdominal pain and metabolic acidosis, but normal lab values do
not exclude acute mesenteric ischemia
● imaging for suspected acute mesenteric ischemia
⚬ perform urgent computed tomography angiography (CTA) for most patents with suspected
mesenteric ischemia (ACR Rating 9)
⚬ consider abdominal x-ray, especially if acute abdomen to detect free air from perforation (ACR
Rating 7)
⚬ consider angiography for suspected nonocclusive mesenteric ischemia and/or preparing for
endovascular treatment (ACR Rating 8)
Blood tests
● no serum marker is sensitive or speci c enough to diagnose or rule out acute mesenteric
ischemia 2 , 6 , 7
● common abnormalities include 2 , 3 , 7
⚬ hemoconcentration
⚬ leukocytosis
⚬ high anion gap
⚬ lactic acidosis
– common due to dehydration and decreased oral intake

– if present, indicates as least segmental, severe ischemia or irreversible bowel injury
● may also observe elevated levels of
⚬ aspartate aminotransferase 2 , 3
⚬ amylase 2 , 3
⚬ lactate dehydrogenase 2 , 3
⚬ lactate 2 , 3
⚬ creatine phosphokinase 2 , 3
⚬ troponin I (J Emerg Med 2012 Jun;42(6):635 )

⚬ amylase (J Emerg Med 2012 Jun;42(6):635 )
● hyperkalemia and hyperphosphatemia usually associated with bowel infarction 3
● left shift of ratio of immature to mature neutrophils or elevated white cell count may suggest either
full-thickness injury to bowel wall or ischemia with bacterial translocation 7
STUDY
● SUMMARY
serologic markers have limited ability to diagnose or rule out intestinal ischemia
DynaMed Level 2
SYSTEMATIC REVIEW: World J Surg 2009 Jul;33(7):1374
Details
⚬ based on systematic review of diagnostic cohort studies with methodologic limitations
⚬ systematic review of 14 prospective and 6 retrospective diagnostic cohort studies examining 18
di erent serologic markers for diagnosis of intestinal ischemia in 978 patients
⚬ only 3 small studies examined patients with suspected thromboembolic occlusion of mesenteric
vasculature, and there was clinical heterogeneity between studies included varying cuto values
used for diagnosis
⚬ 4 markers were tested in ≥ 3 studies (D-lactate, glutathione S-transferase, intestinal fatty-acid
binding protein, and D-dimer)
⚬ intestinal ischemia diagnosed in 28% by reference standard of surgery or autopsy
⚬ for diagnosis of intestinal ischemia, D-lactate had pooled
– sensitivity 82% (95% CI 65%-93%)

– speci city 48% (95% CI 38%-58%)
– positive likelihood ratio 3.04 (95% CI 0.73-12.59)
– negative likelihood ratio 0.35 (95% CI 0.18-0.7)
⚬ for diagnosis of intestinal ischemia, intestinal fatty-acid binding protein had pooled
– sensitivity 72% (95% CI 51%-88%)

– speci city 73% (95% CI 62%-83%)
⚬ for diagnosis of intestinal ischemia, glutathione S-transferase had pooled

– sensitivity 68% (95% CI 54%-80%)
– speci city 85% (95% CI 76%-92%)
⚬ for diagnosis of intestinal ischemia, D-dimer had pooled
– sensitivity 89% (95% CI 77%-96%)

– speci city 40% (95% CI 33%-47%)
⚬ Reference - World J Surg 2009 Jul;33(7):1374
STUDY
● SUMMARY
low D-dimer may help rule out acute mesenteric ischemia, but no validated optimal cutoff value
DynaMed Level 2
DIAGNOSTIC COHORT STUDY: Am J Emerg Med 2009 Oct;27(8):975

DIAGNOSTIC COHORT STUDY: Am J Surg 2009 Apr;197(4):429
Details
⚬ based on 2 diagnostic cohort studies, 1 without independent validation and 1 with reference test
not applied to all patients
⚬ 67 patients with suspected acute mesenteric ischemia had D-dimer levels measured
– surgery was used as reference standard

– acute mesenteric ischemia diagnosed in 23 patients (34.3%) by reference standard
– median D-dimer at admission in patients with acute mesenteric ischemia 6.24 mcg units/mL vs.
patients without acute mesenteric ischemia 3.45 mcg units/mL (p = 0.064)
– for diagnosing acute mesenteric ischemia, D-dimer with cuto value 1 mcg brinogen
equivalent units/mL had
● sensitivity 96%
● speci city 18%
● positive likelihood ratio 1.17
● negative likelihood ratio 0.24
– no signi cant di erence in D-dimer levels were observed between resectable and unresectable
bowel necrosis
– Reference - Am J Emerg Med 2009 Oct;27(8):975
⚬ 47 patients with suspected acute mesenteric ischemia had D-dimer levels tested
– surgery was used as reference standard in 40 patients and clinical and laboratory ndings were
used as reference standard in 7 patients
– 28 patients diagnosed with acute mesenteric ischemia by surgery reference standard
– for diagnosing acute mesenteric ischemia, D-dimer with cuto value > 3.17 mcg brinogen
equivalent units/mL had
● sensitivity 94.7%
● speci city 78.6%
● positive predictive value 75%
● negative predictive value 95.7%
– Reference - Am J Surg 2009 Apr;197(4):429

Imaging studies
Imaging options
Table 1. ACR Appropriateness Criteria for Imaging of Mesenteric Ischemia
Acute Mesenteric Chronic Mesenteric

Ischemia Ischemia
CTA abdomen with Usually appropriate (ACR Usually appropriate (ACR

contrast Rating 9) Rating 9)
Arteriography abdomen Usually appropriate (ACR Usually appropriate (ACR

Rating 8) Rating 7)
MRA abdomen without Usually appropriate (ACR Usually appropriate (ACR

and with contrast Rating 7) Rating 7)
US abdomen May be appropriate (ACR Usually appropriate (ACR

Rating 6) Rating 7)
X-ray abdomen Usually appropriate (ACR Usually not appropriate

Rating 7) (ACR Rating 3)
MRA abdomen without Usually not appropriate Usually not appropriate

contrast (ACR Rating 3) (ACR Rating 3)
Acute Mesenteric Chronic Mesenteric
Ischemia Ischemia
Abbreviations: ACR, American College of Radiology; CTA,

computed tomographic angiography; MRA, magnetic resonance angiography; US,
ultrasonography.
Reference -
Abdom Imaging 2013 Aug;38(4):714 .
X-ray
● abdominal x-ray
⚬ normal in up to 25% of patients 2
⚬ used to detect free air from bowel perforation 1
⚬ may help rule out of other causes of abdominal pain 2
⚬ early cases may show ileus 2
⚬ advanced cases may show evidence of bowel wall edema ("thumbprinting") or pneumatosis, but
either reported in less than 40% of patients 2 , 3
Duplex ultrasound
● not recommended for diagnosis of acute mesenteric ischemia due to technical demands and time
required to perform test (ACC/AHA Class III, Level C) 4
● highly speci c for occlusions or severe stenosis of splanchnic vessels but sensitivity only 70%-89%,
and not useful for detecting emboli beyond proximal main vessels or nonocclusive mesenteric
ischemia 6
Computed tomographic angiography (CTA)
● perform urgent CTA for suspected mesenteric ischemia, preferably using biphasic 3-dimensional
multiplanar reconstruction CTA of whole abdomen 1
● CTA has reported 95%-100% accuracy for detection of visceral ischemic syndromes 7
● typical CTA procedure for suspected ischemia involves 7
⚬ use of IV contrast material

⚬ image reconstruction with thin axial images (1-3 mm)
● CTA is useful for 2 , 6
⚬ con rming embolism or thrombotic occlusion with concomitant evaluation of bowel

⚬ detection of arterial narrowing (non-occlusive causes) or occlusion
⚬ ruling out other causes of abdominal pain
⚬ initial assessment of bowel perfusion
⚬ detection of mesenteric vein thrombosis (see typical ndings of venous occlusion)
● appearance of occlusions
⚬ embolism typically appears as oval-shaped clot surrounded by contrast in non-calci ed part of

middle of distal main stem of superior mesenteric artery
⚬ thrombus usually appears as clot superimposed on heavily calci ed lesion at ostium of superior
mesenteric artery
⚬ Reference - World J Gastroenterol 2014 Aug 7;20(29):9936 full-text
● highly suggestive ndings on standard CT (portal venous gas, pneumatosis intestinalis), only occur
after gangrene has developed 6
● typical CT ndings by etiology of mesenteric ischemia

⚬ arterial occlusion
– bowel wall
● appearance is variable; there may be thinning, have no change, or thickening with

reperfusion
● attenuation on unenhanced CT not characteristic
● enhancement on contrast-enhanced CT will be diminished, absent, target appearance, or
high with reperfusion
– bowel dilatation not apparent
– mesenteric arteries will show
● defect(s) and occlusion

● superior mesenteric artery diameter larger than superior mesenteric vein
– mesentery will not be hazy until mesenteric infarction occurs

– Reference - AJR Am J Roentgenol 2009 Feb;192(2):408
⚬ venous occlusion - for mesenteric vein thrombosis, contrast-enhanced CTA is diagnostic for most
patients
– mesenteric vein lling defect is most common nding; vein may also show engorgement
– bowel wall
● may be thickened
● attenuation on unenhanced CT will be low with edema, or high with hemorrhage
● may be persistently enhanced
– bowel dilatation is moderate to prominent

– mesentery will be hazy with ascites
– pneumatosis intestinalis, and/or portal vein gas may also be present
– References - 6 , J Clin Exp Hepatol 2014 Sep;4(3):257 full-text , AJR Am J Roentgenol 2009
Feb;192(2):408
⚬ nonocclusive ischemia
– bowel wall
● will have no change or thickening with reperfusion

● attenuation on unenhanced CT not characteristic
● enhancement on contrast-enhanced CT will be diminished, absent, or heterogeneous in
distribution
– bowel dilatation not apparent
– mesentery vessels will not have defect(s), but may show arterial constriction
– mesentery will not be hazy until mesenteric infarction occurs
– Reference - AJR Am J Roentgenol 2009 Feb;192(2):408
● ndings of mesenteric ischemia on multi-detector row CT in a ected bowel loops

⚬ circumferential bowel wall thickening (most common)
⚬ attenuation
– low indicates in ammation and submucosal edema

– high indicates submucosal hemorrhage
⚬ enhancement
– decrease due to compromised blood ow

– increase due to hyperemia
⚬ mesenteric stranding due to diminished blood ow

⚬ signs of more serious damage include
– pneumatosis (indicates permanent damage)

– free intra-abdominal air
– portal venous gas
⚬ bowel may also
– appear homogeneous or have a "halo"-like appearance

– have delayed and persistent enhancement
⚬ References - 7 and Radiographics 2001 Nov-Dec;21(6):1463
● traditional oral contrast agents produce poor quality images, so consider
⚬ IV contrast substance to both save time and for better visualization of alterations in intestinal
wall 1
⚬ negative oral contrast (such as water 500-750 mL) immediately before scan to prevent image
artifact from pooled areas of high opaci cation within the intestinal tract and enhance visualization
of bowel wall enhancement 2
⚬ low-attenuation contrast agents
– allow for better visualization of enhancing bowel wall

– do not interfere with manipulation of 3-dimensional volume sets
– Reference - Radiographics 2001 Nov-Dec;21(6):1463
● multidetector CTA allows good visualization of both celiac and superior mesenteric arteries 2
STUDY
● SUMMARY
contrast agent-enhanced multidetector computed tomography angiography may be sensitive
and specific for acute mesenteric ischemia DynaMed Level 2
SYSTEMATIC REVIEW: Radiology 2010 Jul;256(1):93

DIAGNOSTIC COHORT STUDY: Eur J Radiol 2011 Nov;80(2):297
DIAGNOSTIC COHORT STUDY: Eur J Radiol 2011 Dec;80(3):e582
Details
⚬ based on 1 systematic review of diagnostic cohort studies without blinding of reference standard
and 2 subsequent studies with limitations
⚬ systematic review of 3 prospective and 3 retrospective cohort studies evaluating diagnostic
accuracy of contrast agent-enhanced multidetector CTA for detecting acute mesenteric ischemia
and surgery or clinical outcome as reference standard in 619 patients
– 22.9% had acute mesenteric ischemia
– for diagnosis of acute mesenteric ischemia contrast agent-enhanced multidetector CTA had
pooled
● sensitivity 93.3% (95% CI 82.8%-97.6%)
● speci city 95.9% (95% CI 91.2%-98.2%)
– Reference - Radiology 2010 Jul;256(1):93
⚬ subsequent diagnostic cohort study with reference test not applied to all patients
– 200 adults aged 20-92 years with suspected acute mesenteric ischemia had multislice CT in both
arterial and venous phases
– reference standard used was surgery
– among 94 patients who had surgery, 49 patients (52%) had acute mesenteric ischemia
– for diagnosing acute mesenteric ischemia, multislice CT had
● sensitivity 100%
● speci city 100%
– Reference - Eur J Radiol 2011 Nov;80(2):297
⚬ subsequent small diagnostic cohort study
– 31 patients aged 16-73 years (25 male) with suspected acute mesenteric ischemia had
multidetector CT angiography (MDCTA)
– reference standard used was surgical, clinical, or histopathologic ndings
– 16 patients diagnosed with acute mesenteric ischemia (9 con rmed with surgery, 1 patient died
awaiting surgery, 5 patients diagnosed by clinical and lab ndings)
– reconstructed and axial images reviewed by 2 independent radiologists for bowel wall
thickening, mesenteric stranding, ascites, bowel dilatation or obstruction, solid organ infarcts,
pneumatosis intestinalis or portomesenteric gas, abnormal mucosal enhancement, and
mesenteric arterial or venous occlusion
– for diagnosing acute mesenteric ischemia, MDCTA had
● sensitivity 100%
● speci city 100%
– Reference - Eur J Radiol 2011 Dec;80(3):e582
STUDY
● SUMMARY
biphasic computed tomography with mesenteric CT angiography may diagnose or may rule out
acute mesenteric ischemia DynaMed Level 2
DIAGNOSTIC COHORT STUDY: Am J Surg 2009 Apr;197(4):429
Details
⚬ based on small diagnostic cohort study
⚬ 47 patients with suspected acute mesenteric ischemia had biphasic CT with mesenteric CTA
⚬ surgery was used for reference standard in 40 patients and clinical and laboratory ndings were
used as reference standard for 7 patients
⚬ acute mesenteric ischemia diagnosed in 28 patients (60%) by surgery reference standard
⚬ for diagnosing acute mesenteric ischemia, biphasic CT with CTA had
– sensitivity 93%
– speci city 89.5%
– positive predictive value 93%
– negative predictive value 89.5%
⚬ Reference - Am J Surg 2009 Apr;197(4):429
Magnetic resonance angiography (MRA)
● magnetic resonance angiography is limited by poor resolution of distal sites and secondary signs of
acute mesenteric ischemia (such as indurated fat and bowel wall thickening) 2
● MRA 7
⚬ may be useful to avoid radiation associated with contrast material used in computed tomography
angiography (CTA)
⚬ limitations compared to CTA include
– longer duration
– insu cient resolution of image
– may overestimate degree of stenosis
● MRA abdomen (without and with contrast) takes longer when compared to CT, limited utility in distal
thrombosis/embolism or nonocclusive mesenteric ischemia (Abdom Imaging 2013 Aug;38(4):714
PDF )
Angiography
● arteriography indicated for patients with suspected nonocclusive mesenteric ischemia who do not
improve rapidly with treatment of underlying disease (ACC/AHA Class I, Level B) 4

⚬ catheter angiography is currently used as component of initial intervention, but may also be used
to con rm diagnosis prior to open abdominal exploration 4 , 7

⚬ initial arteriography is considered reasonable in patients without indications for immediate
laparotomy such as very acute presentation, high likelihood of arterial obstruction, and/or
suspected bowel infarction 4
● angiography useful for di erentiating between embolic and thrombotic occlusions 2 , 3
● if used for diagnosis, keep catheter in superior mesenteric artery (if possible) for injection of intra-
arterial vasodilators, thrombolytics, or angioplasty with or without stenting 2 , 3

● ndings for nonocclusive mesenteric ischemia include di use, normal venous runo with narrowing
irregularities of major superior mesenteric artery branches ("string of sausages" sign) 2 , 3
● ndings for mesenteric venous thrombosis include generalized slowing and vasoconstriction of
arterial ow with no opaci cation of corresponding mesenteric or portal vein out ow tracts (usually
segmental) 2 , 3
Diagnostic laparoscopy
● laparoscopy has limited ability to assess bowel viability 2
● diagnostic laparoscopy used for early detection of acute mesenteric ischemia in case series of 9
patients with aortic dissection (Eur J Vasc Endovasc Surg 2012 Jun;43(6):690 )
● review of laparoscopy in acute abdomen can be found in Best Pract Res Clin Gastroenterol 2014
Feb;28(1):3
Management
Management overview
● goal is rapid restoration of blood ow but emergency exploratory laparoscopy or laparotomy
indicated if suspicion of 3 , 7
⚬ peritoneal signs of acute abdomen
⚬ stricture
⚬ gastrointestinal bleeding
● initial medical management
⚬ aggressive uid replacement to stabilize hemodynamics; treatment of shock is most important

initial step (ACC/AHA Class I, Level C)
⚬ monitoring should include hourly urine output, plus arterial and continuous central pressure
monitoring
⚬ avoid oral intake, which may exacerbate intestinal ischemia 7
⚬ broad-spectrum antibiotics (such as either a second-generation cephalosporin or levo oxacin, plus

metronidazole) for coverage of gram-positive, gram-negative, and anaerobic bacteria
⚬ anticoagulation with heparin may be started; continuation with warfarin indicated if mesenteric
vein thrombosis, but experts disagree on timing and use of heparin in arterial thromboembolism
● for arterial occlusive disease - revascularization recommended (before any bowel resection) (ACC/AHA
Class I, Level B)
⚬ systemic anticoagulation is usually appropriate ( ACR Rating 8); may be sole therapy depending on
patient status, but more typically serves as bridge to transcatheter or surgical evaluation of clot
⚬ surgical revascularization may be done via embolectomy, thromboendarterectomy, or bypass
surgery
⚬ revascularization associated with better survival in patients with acute superior mesenteric artery
occlusion DynaMed Level 2
⚬ endovascular treatment may provide revascularization via transcatheter thrombolytics, balloon

angioplasty, or stenting, but laparotomy may still be needed to manage nonviable intestine
(ACC/AHA Class IIb, Level C)
⚬ endovascular revascularization for acute mesenteric ischemia is associated with better survival
than surgical revascularization DynaMed Level 2
● for mesenteric venous thrombosis
⚬ anticoagulation is rst-line intervention; reported about 5% of patients will need further

intervention, options include thrombectomy or thrombolysis
⚬ catheter-directed thrombolysis reported to reduce thrombosis and improve clinical symptoms
DynaMed Level 3
● for nonocclusive intestinal ischemia unresponsive to systemic treatment (or due to cocaine or ergot
poisoning), consider transcatheter delivery of vasodilators (ACC/AHA Class IIa, Level B)
● bowel resection indicated for patients with nonocclusive intestinal ischemia unresponsive to medical
treatment (ACC/AHA Class I, Level B)
⚬ delay until after revascularization to save as much small bowel as possible
⚬ overtly necrotic bowel should be resected, but goal is to keep minimum length of intestine to
prevent short bowel syndrome
● second-look (or third-look) procedure 12-48 hours after initial surgery may be required to assess
bowel viability (ACC/AHA Class I, Level B)
● post-treatment monitoring and long-term management involves managing coexisting conditions and
risk factors to prevent recurrence
Fluid and electrolytes
● treatment of underlying shock is most important initial step in treatment of nonocclusive intestinal
ischemia (ACC/AHA Class I, Level C); management may include 2 , 3 , 4 , 7

⚬ uid resuscitation with isotonic crystalloid uids and blood products; aggressive rehydration with
lactated Ringer solution is an option (caution if cardiac insu ciency and pulmonary edema)
⚬ serial monitoring should include
– hourly urine output, plus arterial and continuous central pressure monitoring
– electrolyte levels
– acid-base status
– invasive hemodynamic monitoring, which should be initiated early
⚬ in patients with hemodynamic instability
– avoid uid overload while adjusting uid volume

– vasopressor agents may be last resort
– uid volume requirement
● may be high after revascularization due to capillary leakage
● up to 10-20 L of crystalloid uid may be required in 24 hours post-intervention
● correct electrolyte imbalances prior to IV contrast or surgical exploration 2
Medications
Antibiotics
● broad-spectrum antibiotics
⚬ provide coverage of gram-positive, gram-negative, and anaerobic bacteria to protect against
translocation of bacteria from ischemic bowel 1 , 2 , 3

⚬ some experts advise immediate administration of broad-spectrum antibiotics in patients with
acute mesenteric ischemia due high risk of infection, which outweighs concerns of antibiotic use 7
● options include
⚬ second-generation cephalosporin plus metronidazole 1
⚬ levo oxacin plus (metronidazole or piperacillin/tazobactam) 3
– levo oxacin 500 mg IV every 24 hours PLUS

– metronidazole OR
● loading dose 15 mg/kg IV over 1 hour (for life-threatening conditions)

● maintenance dose 7.5 mg/kg IV over 1 hour every 6-8 hours starting 6 hours after loading
dose, or 500 mg IV every 6 hours
● total dose not to exceed 4 g/day
● alternative dosing 500 mg IV every 6 hours
– piperacillin/tazobactam 3.375 mg IV every 6 hours
Anticoagulation
● ACR Appropriateness Criteria for Radiologic Management of Mesenteric Ischemia
⚬ anticoagulation is usually appropriate in all patients with mesenteric ischemia, though role may
vary by etiology
⚬ for occlusive arterial mesenteric ischemia in patients with known atrial brillation and
computed tomography angiography (CTA) results showing
– lling defect in proximal superior mesenteric artery consistent with embolus, systemic
anticoagulation is usually appropriate ( ACR Rating 8), and may be sole therapy depending on
patient status, but more typically serves as bridge to transcatheter or surgical evaluation of clot
– calci ed atherosclerotic plaque involving aorta and its major branches, plus proximal short-
segment occlusion of the proximal superior mesenteric artery, systemic anticoagulation is
usually appropriate ( ACR Rating 8), and is typically used as adjunct to surgical or transcatheter
treatment
⚬ for nonocclusive mesenteric ischemia, system anticoagulation is usually appropriate ( ACR
Rating 7)
⚬ for venous mesenteric ischemia, systemic anticoagulation in usually appropriate ( ACR Rating 9),
and may be primary therapy or adjunctive to thrombolysis depending on patient age and condition
⚬ Reference - J Am Coll Radiol 2017 May;14(5S):S266 or in ACR 2016 PDF
● anticoagulation with heparin suggested to reduce chance of progressive thrombosis and
thromboembolic occlusion 1 , 3 , 7
⚬ suggested dosing
– initial dosing 5,000-10,000 units bolus (or 100 units/kg) followed by 833-1,250 units/hour
– then titrate to partial thromboplastin time of 50-70 seconds or > 2 times normal
⚬ contraindications include hypersensitivity, active bleeding, severe thrombocytopenia, history of

heparin-induced thrombocytopenia, and subacute bacterial endocarditis
● some experts have suggested delaying heparin for 48 hours due to risk of intraluminal bleeding from
bowel injury 6
● suggested anticoagulation for superior mesenteric vein thrombosis 6 , 7
⚬ systemic heparin for 7-10 days

⚬ oral warfarin 24-48 hours after stabilization, continued for 3-6 months
● conservative management including systemic heparin reported to successfully resolve intestinal

ischemic injury in 60-year old man with extensive distal thrombosis in case report DynaMed Level 3
(N Engl J Med 2016 Oct 13;375(15):e31 full-text )
Glucagon
● glucagon hydrochloride may be used postrevascularization as a splanchnic vasodilator to reduce
oxygen demand 2 , 3
⚬ standard dose 1 mcg/kg/minute IV titrated up to 10 mcg/kg/minute as tolerated
⚬ couple glucagon with additional volume resuscitation to avoid vasodilatation-mediated
hypotension
Cilostazol
● cilostazol 100 mg orally twice daily reported for treatment of nonocclusive mesenteric ischemia in
case report of 2 patients (J Pharmacol Pharmacother 2012 Jan;3(1):68 full-text )
Surgery and procedures
Revascularization for arterial obstruction
Surgical treatment of arterial obstruction
● revascularization should precede bowel resection 1 , 2 , 3
● recommendations
⚬ surgical treatment of acute obstructive intestinal ischemia includes (ACC/AHA Class I, Level B) 4
– revascularization
– resection of necrotic bowel
– when appropriate, "second look" surgery 24-48 hours after revascularization
⚬ ACR Appropriateness Criteria for Radiologic Management of Mesenteric Ischemia
– for patients with occlusive arterial mesenteric ischemia and signs of bowel infarction such as
peritoneal symptoms, pneumoperitoneum, or intramural air on CT, urgent surgery rather than
thrombolysis is advised
– for occlusive arterial mesenteric ischemia in patients with known atrial brillation and
computed tomography angiography results showing
● lling defect in proximal superior mesenteric artery consistent with embolus, surgical
embolectomy may be appropriate ( ACR Rating 5); may be rst-line treatment over
thrombolytic therapy based on physician preference and clinical presentation
● showing calci ed atherosclerotic plaque involving aorta and its major branches, plus
proximal short-segment occlusion of the proximal superior mesenteric artery, surgical
endarterectomy or bypass may be appropriate ( ACR Rating 6)
– Reference - J Am Coll Radiol 2017 May;14(5S):S266 or in ACR 2016 PDF
● open revascularization is reported to have 26%-65% short-term mortality 7

● open surgical options include
⚬ standard embolectomy 1 , 2 , 3 , 7
⚬ thromboendarterectomy for arterial thrombosis of proximal mesenteric vasculature, with bypass
surgery as alternative if adequate in ow cannot be established 2 , 3 , 7

⚬ mesenteric artery bypass surgery 3 , 7
– grafts may be antegrade (supraceliac aorta) or retrograde (infrarenal aorta or iliac artery)
– saphenous vein may also be used, reported to be less prone to infection but slower to harvest
– consider prosthetic bypass graft, requires no time to harvest but is reported to be prone to
infection and additional cost
– should be performed with autologous grafting, usually of single vessel distal to occlusion
– if distal perfusion persistently impaired, consider local intra-arterial thrombolytic agents
● retrograde open mesenteric stenting is an uncommon hybrid option to reduce extent of surgery while
allowing for bowel assessment 7

⚬ involves local thromboendarterectomy and angioplasty, followed by retrograde stenting
STUDY
⚬ SUMMARY
retrograde open mesenteric stenting (ROMS) reported to achieve primary patency and relief
from symptoms at 1 year in most patients with acute mesenteric ischemia DynaMed Level 3
CASE SERIES: J Vasc Surg 2014 Sep;60(3):726 | Full Text
Details
– based on case series
– 15 patients with acute mesenteric ischemia received ROMS for superior mesenteric artery
revascularization
– 4 patients received ROMS after failed percutaneous mesenteric artery stenting, and 11 patients
received ROMS as initial treatment
– clinical success de ned as relief or improvement of presenting symptoms
– 1 patient had failed procedure, 1 patient required partial bowel resection at ROMS due to
irreversible transmural ischemia
– 10 patients required unplanned relaparotomy
– at 30 days
● mortality was 20%

● primary patency in 92%
● clinical success in 73%
– at 12 months
● mortality was 20%

● primary patency was 83% (primary assisted patency was 91% and secondary patency was
100%)
● clinical success in 67%
– Reference - J Vasc Surg 2014 Sep;60(3):726 full-text
STUDY
● SUMMARY
revascularization associated with better survival in patients with acute superior mesenteric
artery occlusion DynaMed Level 2
Details
⚬ 55 patients (median age 76 years) with acute superior mesenteric artery occlusion (53% embolic)
evaluated
⚬ 33% overall in-hospital mortality rate
⚬ attempting intestinal revascularization associated with improved survival (p < 0.001)
⚬ presence of ischemia on electrocardiogram associated with increased mortality (p = 0.042)
⚬ Reference - J Emerg Med 2012 Jun;42(6):635
Endovascular treatment of arterial obstruction
● recommendations from professional organizations
⚬ percutaneous interventions (including transcatheter lytic therapy, balloon angioplasty, and

stenting) are appropriate in selected patients with acute intestinal ischemia caused by arterial
obstructions, but laparotomy may still be needed to manage nonviable intestine (ACC/AHA Class
IIb, Level C) 4
⚬ ACR Appropriateness Criteria for Radiologic Management of Mesenteric Ischemia
– for occlusive arterial mesenteric ischemia in patients with known atrial brillation and
computed tomography angiography (CTA) results showing
● lling defect in proximal superior mesenteric artery consistent with embolus,
⚬ transcatheter thrombolysis is usually appropriate ( ACR Rating 7); procedure depends on
thrombus burden seen distally during angiography - organized thrombus in setting of
atrial brillation may not respond to thrombolysis
⚬ angiography and aspiration embolectomy is usually appropriate ( ACR Rating 7)
● calci ed atherosclerotic plaque involving aorta and its major branches, plus proximal short-
segment occlusion of the proximal superior mesenteric artery, angiography and
transcatheter thrombolysis followed by percutaneous transluminal angioplasty and stent
placement is usually appropriate( ACR Rating 8)
– for patients with occlusive arterial mesenteric ischemia and signs of bowel infarction such as
peritoneal symptoms, pneumoperitoneum, or intramural air on CT, urgent surgery rather than
thrombolysis is advised
– Reference - J Am Coll Radiol 2017 May;14(5S):S266 or ACR 2016 PDF
● endovascular treatment may be contraindicated with direct indications for open surgery if 1 , 7
⚬ clinical manifestations of peritonitis

⚬ evidence of intestinal gangrene, such as gas in wall of intestine or portal venous system on
computed tomography
⚬ any sign of clinical decompensation
● endovascular management with angioplasty or stenting may be performed during initial mesenteric
angiography 3
● transfemoral aspiration embolectomy may be indicated for large embolus close to outlet 1
EVIDENCE SYNOPSIS
Endovascular revascularization for acute mesenteric ischemia associated with improved

survivalcompared to surgical revascularization.
STUDY
⚬ SUMMARY
endovascular treatment associated with decreased mortality compared to open surgery for
COHORT STUDY: J Vasc Surg 2014 Jan;59(1):159
Details
– based on retrospective cohort study
– 4,665 patients (mean age 70 years, 57% female) with acute mesenteric ischemia had
interventional treatment from 2005 to 2009
● 24.3% had endovascular treatment
● 75.7% had open surgery
– comparing endovascular treatment vs. open surgery
● mortality 24.9% vs. 39.3% (p = 0.01, NNT 8)

● length of stay 12.9 days vs. 17.1 days (p = 0.006)
● bowel resection in 14.4% vs. 33.4% (p < 0.001, NNT 6)
● total parenteral nutrition (TPN) support in 13.7% vs. 24.4%, (p = 0.025, NNT 10)
– Reference - J Vasc Surg 2014 Jan;59(1):159
STUDY
⚬ SUMMARY
successful endovascular revascularization associated with less need for extensive bowel
resection and lower mortality rate compared to surgical therapy in patients with occlusive
COHORT STUDY: J Vasc Surg 2011 Mar;53(3):698
Details
– 70 patients (mean age 64 years) with thrombotic or embolic acute mesenteric ischemia had
endovascular revascularization or surgical therapy
● 57 patients had endovascular therapy (50 successful)
● 13 patients had traditional surgical therapy
– comparing endovascular therapy vs. surgery
● laparotomy required in 69% vs. 100% (p < 0.05)

● median necrotic bowel resection 52 cm vs. 160 cm (p < 0.05)
● acute renal failure in 27% vs. 50% (p < 0.05)
● pulmonary failure in 27% vs. 64% (p < 0.05)
– mortality 36% following successful endovascular therapy vs. 50% following surgery (p < 0.05)
– 50% mortality following unsuccessful endovascular therapy
– endovascular therapy associated with improved mortality for thrombotic cases (odds ratio 0.1,
95% CI 0.1-0.76)
– Reference - J Vasc Surg 2011 Mar;53(3):698
STUDY
⚬ SUMMARY
endovascular revascularization may improve survival compared with open surgery for acute
occlusion of superior mesenteric artery DynaMed Level 2
COHORT STUDY: J Vasc Surg 2010 Oct;52(4):959
Details
– 42 endovascular and 121 open revascularizations evaluated
– comparing endovascular revascularization vs. open surgery
● 30-day mortality rate 28% vs. 42% (p = 0.03)

● 1-year mortality rate 39% vs. 58% (p = 0.02)
– open surgery associated with higher rate of bowel resection (p < 0.001) and short bowel
syndrome (p = 0.009)
– Reference - J Vasc Surg 2010 Oct;52(4):959
● catheter-directed thrombolysis
⚬ catheter-directed thrombolytics - tissue plasminogen activator initial dose 2-5 mg intra-arterially
followed by 1-2 mg/hour intra-arterially 3
STUDY
⚬ SUMMARY
in patients with acute superior mesenteric artery occlusion, successful local thrombolysis
with tissue plasminogen activator may be associated with increased survival
DynaMed Level 2
COHORT STUDY: J Vasc Surg 2011 Dec;54(6):1734
Details
– 34 patients (median age 78 years) with acute superior mesenteric artery occlusion had local
thrombolysis with alteplase (median dose 20 mg)
– successful thrombolysis in 30 patients
– patients had
● 13 exploratory laparotomies
● 10 repeat laparotomies
● 8 bowel resections
– in-hospital mortality rate 26% (9 patients)

– successful thrombolysis was associated with increased survival (p = 0.048)
– Reference - J Vasc Surg 2011 Dec;54(6):1734
● papaverine infusion into superior mesenteric artery has been in highly selected patients for treatment
of superior mesenteric artery emboli 6
Procedures for venous thrombosis
● up to 5% of patients are reported to require further intervention beyond anticoagulation 7
● ACR Appropriateness Criteria for Radiologic Management of Mesenteric Ischemia for venous
mesenteric ischemia
⚬ transhepatic superior mesenteric vein catheterization and thrombolytic infusion is usually
appropriate ( ACR Rating 7)
– procedure depends on symptom severity, patient condition, and response to systemic
anticoagulation
– consider adjunct transjugular intrahepatic portosystemic shunt (TIPS) creation for out ow
improvement
⚬ superior mesenteric artery angiography followed by thrombolytic infusion may be appropriate (
ACR Rating 4); reported to have minimal proven e cacy in literature
⚬ surgical thrombectomy is usually not appropriate ( ACR Rating 3), due to thrombus typically
involving multiple branches
⚬ Reference - J Am Coll Radiol 2017 May;14(5S):S266 or in ACR 2016 PDF
● catheter-directed thrombolysis
⚬ thrombolysis for acute superior mesenteric vein thrombosis have been administered 6
– antegrade via superior mesenteric artery

– retrograde via internal jugular vein
– transhepatically via portal vein
⚬ tissue plasminogen activator 2 mg/hour may be used for 2-3 days following lysis for patients with
venous thrombosis who had peritonitis requiring laparotomy 1

⚬ for portal-vein thrombosis, use local thrombolysis with transhepatic catheter within 3-4 hours of
symptom onset 1
STUDY
⚬ SUMMARY
in patients with acute thrombosis of superior mesenteric vein, catheter-directed
thrombolysis reported to reduce thrombosis and improve clinical symptoms
DynaMed Level 3
CASE SERIES: Abdom Imaging 2011 Aug;36(4):390 | Full Text
Details
– 12 patients (mean age 41 years) with acute thrombosis of superior mesenteric vein had
transjugular intrahepatic catheter-directed thrombolysis
– thrombolysis included pigtail catheter thrombus fragmentation, urokinase injection, and
aspiration thrombectomy followed by continuous thrombolytic medication infused via
indwelling catheter for mean 4.2 days
– intervention associated with
● signi cant improvement in abdominal pain, nausea, and distension in all patients
● near-complete disappearance of thrombosis in all patients on contrast-enhanced computed
tomography
● no recurrence at mean 37.7-month follow-up
– Reference - Abdom Imaging 2011 Aug;36(4):390 full-text
● endovascular portal venous (transjugular transhepatic) treatment may include 1
⚬ portal venous rechanneling for ischemia of wall of intestine in cases of mesenteric or portal venous
thrombosis, may prevent portal hypertension
⚬ portal decompression via transjugular intrahepatic portosystemic stent shunt (TIPS) in portal
hypertension with venous ischemia of intestinal wall due to congestion
● give systemic antibiotics prior to surgery for cases of septic thromboses to prevent release of
microbes into blood 1
● laparotomy
⚬ exploratory laparotomy to assess for bowel necrosis indicated if suspicion of peritonitis, stricture,
or gastrointestinal bleeding 7
⚬ with peritonitis requiring laparotomy, consider placement of transmesenteric catheter
intraoperatively, for subsequent local lysis 1

⚬ resection of ischemic jejunal loop on postoperative day 2 after pancreatoduodenectomy, with re-
anastomoses of biliary and pancreatic ducts, reported successful in 77-year-old man receiving
treatment for pancreatic cancer DynaMed Level 3 in case report (Surg Case Rep 2016 Dec;2(1):24
full-text )
● surgical thrombectomy rarely performed due to endothelial in ammation and high-repeat
thrombosis rate 1
Transcatheter vasodilators for nonocclusive intestinal ischemia
● recommendations
⚬ consider transcatheter delivery of vasodilators into area of vasospasm for patients with
nonocclusive mesenteric ischemia (NOMI) unresponsive to systemic treatment and patients with
intestinal ischemia due to cocaine or ergot poisoning (ACC/AHA Class IIa, Level B) 4 , 7
⚬ ACR Appropriateness Criteria for Radiologic Management of Mesenteric Ischemia in patients with
nonocclusive mesenteric ischemia
– angiography with infusion of vasodilator is usually appropriate ( ACR Rating 8); procedure may
lead to hypotension
– systemic infusion of prostaglandin E1 is usually appropriate ( ACR Rating 7); procedure may lead
to hypotension
– Reference - J Am Coll Radiol 2017 May;14(5S):S266 or in ACR 2016 PDF
● vasodilator choices (with selective administration of vasodilators into superior mesenteric artery)
include
⚬ prostaglandin E1 (PGE1) alprostadil 20 mcg bolus followed by perfusion-directed alprostadil 60-80
mcg/day 1
⚬ PGI2 epoprostenol 5-6 ng/kg/minute 1
⚬ papaverine hydrochloride is reported be most commonly used agent 2 , 6 , 7

– standard dose 30-60 mg/hour via angiography catheter 2
– use with caution in patients with angina, recent stoke or myocardial infarction, or glaucoma 2
● open abdominal exploration suggested is peritonitis is suspected 7
● case series
⚬ 3 elderly patients with NOMI successfully treated with alprostadil 0.01 mcg/kg/minute in case
report (Intern Med 2008;47(22):2001 full-text )
STUDY
⚬ SUMMARY
papaverine reported to improve ileus symptoms in more than half of patients with
nonocclusive mesenteric ischemia after cardiac surgery DynaMed Level 3
CASE SERIES: Ann Thorac Surg 2001 Nov;72(5):1583
Details
– 14 patients with nonocclusive mesenteric ischemia identi ed during evaluation for ileus after
cardiac surgery were treated with papaverine continuous intra-arterial infusion via angiography
catheter
– symptoms improved in 9 (64%) within hours and 5 (36%) deteriorated
– of the 5 who deteriorated
● laparotomy required in 4 patients

● death in 3 patients
– Reference - Ann Thorac Surg 2001 Nov;72(5):1583
⚬ intra-arterial tolazoline and glycerol trinitrate for treatment of nonocclusive mesenteric ischemia
with severe cardiovascular complications in case report (Catheter Cardiovasc Interv 2009 Feb
1;73(2):152 )
Bowel resection
● laparotomy and resection of nonviable bowel indicated for patients with nonocclusive intestinal
ischemia unresponsive to medical treatment (ACC/AHA Class I, Level B) 4
● perform after revascularization to save as much small bowel as possible 1 , 2 , 3
● goal of surgery is arterial reperfusion, repair of bowel perforation, and removal of dead bowel 1 , 2 , 3
● overtly necrotic bowel should be resected, but goal is to keep minimum length of intestine to prevent
short bowel syndrome 1

⚬ 100 cm for terminal jejunostomy (removing colon)
⚬ 65 cm for jejunocolic anastomosis (keeping colon)
⚬ 35 cm for jejunoileal anastomosis (keeping ileocecal region)
● assess bowel viability using combined clinical and adjunct approach 2
⚬ if possible, allow for 20-30 minutes of reperfusion time prior to making decision about viability
⚬ in clinical assessment, look for
– visible, palpable pulses in mesenteric arcade

– normal appearance and color of bowel serosa
– peristalsis
– bleeding at cut surfaces
⚬ consider continuous-wave 9-10 megahertz (MHz) Doppler ultrasound probe - absence of pulsatile
signals on antimesenteric border indicates nonviable bowel
● consider placing ends of intestine deemed as worth preserving outside of abdominal wall to prevent
failed anastomosis 1
● review of emergency laparoscopic surgery can be found in World J Emerg Surg 2006 Aug 31;1:24
full-text
Second-look procedure
● second-look (or third-look) procedure 12-48 hours after initial surgery may be required in sections of
bowel that suggest possible presence of ischemia (decision made following reperfusion following
initial surgery) (ACC/AHA Class I, Level B) 1 , 2 , 4 , 7
⚬ up to 57% of patients ultimately require further bowel resection, which includes 40% of patients
who receive second-look procedure
⚬ bowel resection and/or reanastomosis may occur during second-look operation
⚬ additional exploration also indicated if patient does not stabilize following primary surgery
Consultation and referral
● cooperation between visceral and vascular surgeons usually required for surgery of central occlusion
of superior mesenteric artery, peritonitis, or failure of endovascular treatment 1
● 89% 2-year survival rate reported with multidisciplinary medical management involving
revascularization of viable small bowel and/or resection of nonviable small bowel, and arterial
revascularization as indicated in uncontrolled trial of 18 patients with occlusive acute mesenteric
ischemia (Clin Gastroenterol Hepatol 2013 Feb;11(2):158 )
Follow-up
● 28%-59% of patients who receive endovascular-only interventions ultimately require bowel resection;
monitor closely for 7

⚬ clinical deterioration
⚬ peritonitis
● following surgery, monitor abdominal, cardiac, pulmonary, and renal function due to risk of secondary
organ failure 1
● monitor patients for abdominal compartment syndrome with serial exams and bladder pressure
monitoring
● in patients with nonocclusive disease, use angiography to check e ciency of vasodilation 1

● post-treatment monitoring and long-term management 7
⚬ to manage coexisting conditions and risk factors, consider
– aggressive smoking cessation measures

– blood pressure control
– statin therapy
⚬ to prevent recurrence in patients who receive endovascular or open repair, consider lifelong
aspirin
⚬ consider clopidogrel for 1-3 months for patients who received endovascular repair
⚬ consider oral anticoagulation therapy inde nitely, or anticoagulation until underlying cause of
embolism or thrombosis is resolved in patients with
– atrial brillation
– mesenteric venous thrombosis
– inherited or acquired thrombophilia
⚬ monitor nutritional status and body weight post-intervention, as patients may have prolonged ileus
and food fear
– patients may require full parenteral nutrition until full oral intake is possible
– in patients with persistent short-gut syndrome, extensive nutritional support, lifelong total
parenteral nutrition, or evaluation for small bowel transplant may be required
⚬ monitor vascular patency in patients with history of mesenteric ischemia, as recurrence of
symptoms is reported to be common
– consider duplex ultrasound every 6 months in rst year after repair, then annually
– advise patients how to recognize warning signs of stenosis, occlusion, and recurrent ischemia
– if symptoms recur,
● diagnostic imaging is indicated

● if evidence of recurrent stenosis or occlusion, consider preemptive revascularization
Complications and Prognosis
Complications
● mesenteric ischemia may lead to infarction, which leads to severe metabolic acidosis and
hyperkalemia, which in turn may cause rapid decompensation and sepsis 7
● other complications may include 1 , 2 , 3 , 7
⚬ bacterial in ltration
⚬ ileus
⚬ gangrene
⚬ multiorgan failure
⚬ short bowel syndrome, which may lead to
– parenteral nutrition
– small intestine transplant
⚬ ischemic colitis or bowel infarction - suggested by red or maroon stools within 12-24 hours of
onset of crampy, localized abdominal pain and urgency to defecate
IMAGE 1 OF 1
Necrotic bowel
Acute mesenteric ischemia causing partial small bowel

infarction.
Prognosis
Prognosis summary
● overall reported mortality rate 50%-93% 1 , 2 , 5 , 7
⚬ for occlusive disease, reported mortality
– 0%-10% if treatment received within 6 hours

– 50%-60% if treatment delayed 6-12 hours
– 80%-100% if treatment delayed > 24 hours after symptom onset
⚬ diagnosis before intestinal infarction is single most important factor to reduce mortality
⚬ nonocclusive ischemia reported to have increased mortality (reported about 50%-83%) compared
to occlusive ischemia, perhaps due to delay of diagnosis following presentation
⚬ long-term mortality for venous mesenteric thrombosis depends on underlying etiology; 30-day
survival is reported to be 80%, and 5-year survival 70% based on case series of 51 patients (Br J
Surg 2008 Oct;95(10):1245 )
⚬ peripheral ischemia reported to have better survival compared to central occlusion (likely due to
collateral growth capacity)
⚬ factors associated with higher mortality include
– renal insu ciency

– older age
– metabolic acidosis
– longer duration of symptoms
– bowel resection at second-look procedure
● among survivors, short bowel syndrome reported in 20%-60%; bowel resection ultimately required in
reported 28%-59% of patients with acute mesenteric ischemia 3 , 7
● predictive factors reported to in uence disease progression 1
⚬ time to diagnosis
⚬ time to enteric revascularization
⚬ location and etiology of acute mesenteric ischemia
⚬ age of patient
⚬ comorbidities
Risk factors for mortality
● delayed treatment is associated with increased mortality
STUDY
⚬ SUMMARY
surgical consultation > 24 hours after symptom onset associated with increased mortality
DynaMed Level 2
COHORT STUDY: Am Surg 2009 Mar;75(3):212
Details
– 72 adults (mean age 63 years) with acute mesenteric ischemia were evaluated
– 26 patients (36%) died (12 patients died with full support and 14 patients had care withdrawn)
– for patients with full support, surgical consult > 24 hours after symptom onset was associated
with increased mortality (adjusted odds ratio 9.4, 90% CI 1.3-65)
– Reference - Am Surg 2009 Mar;75(3):212
STUDY
⚬ SUMMARY
referral to multiple specialists at admission may be associated with increased mortality in
patients with acute superior mesenteric artery occlusion DynaMed Level 2
Details
– 55 patients (median age 76 years) with acute superior mesenteric artery occlusion were
evaluated
– 33% overall in-hospital mortality rate
– 23 patients referred to internal medicine specialist, of whom 9 died
– 10 patients referred to cardiologist, of whom 6 died
– referral to cardiologist associated with increased mortality (p = 0.018)
– authors conclude that consecutive referral pattern (internal medicine specialist followed by
cardiology consult) resulted in diagnostic delays that may have increased mortality
– Reference - J Emerg Med 2012 Jun;42(6):635
● older age (and other factors) associated with increased mortality
STUDY
⚬ SUMMARY
increase in age, impaired functional status, and postoperative septic shock each likely to be
predictors of mortality in patients with revascularized acute arterial mesenteric ischemia
COHORT STUDY: Am Surg 2011 Jul;77(7):832
Details
– 142 patients (mean age 66 years) with acute arterial mesenteric ischemia had revascularization
– 71 patients with embolism and 71 patients with thrombosis
– unadjusted morbidity and mortality for
● embolism 78% and 38%

● thrombosis 61% and 23%
– multivariate predictors of mortality include
● impaired functional status (odds ratio [OR] 4, 95% CI 1.8-9)

● 5-year increase in age (OR 1.2, 95% CI 1.2-1.5)
● postoperative septic shock (OR 3.1, 95% CI 1.2-7.8)
– Reference - Am Surg 2011 Jul;77(7):832
STUDY
⚬ SUMMARY
older age, bandemia, elevated serum aspartate aminotransferase, increased blood urea
nitrogen, and increased metabolic acidosis are each associated with increased risk of
mortality in patients with acute mesenteric ischemia
COHORT STUDY: J Chin Med Assoc 2005 Jul;68(7):299
Details
– charts from 124 adults (mean age 71 years) with acute mesenteric ischemia were evaluated
– 50% mortality overall
– independent predictors of mortality include
● older age (odds ratio [OR] 1.08, 95% CI 1.01-1.15)

● bandemia (OR 3.89, 95% CI 1.16-13.07)
● elevated serum aspartate aminotransferase (OR 4.53, 95% CI 1.27-16.12)
● increased blood urea nitrogen (OR 7.22, 95% CI 1.17-44.7)
● metabolic acidosis (OR 6.6, 95% CI 1.8-24.17)
– Reference - J Chin Med Assoc 2005 Jul;68(7):299
STUDY
⚬ SUMMARY
age < 60 years and bowel resection each associated with improved survival following surgery
for acute mesenteric ischemia
COHORT STUDY: J Vasc Surg 2002 Mar;35(3):445
Details
– 58 patients (mean age 67 years) had surgical exploration for acute mesenteric ischemia
– surgical procedures included
● open mesenteric revascularization in 43 patients

● bowel resection required at rst operation in 31 patients
● second-look procedures in 23 patients (with 11 bowel resections)
● exploration only in 3 patients
– 30-day overall mortality rate 32%
● 31% in patients with embolism

● 32% in patients with thrombosis
● 80% in patients with nonocclusive mesenteric ischemia
– cumulative survival rate at
● 90 days 59%
● 1 year 43%
● 3 years 32%
– < 60 years old (p < 0.003) and bowel resection (p = 0.03) each associated with improved survival
rates
– Reference - J Vasc Surg 2002 Mar;35(3):445
● bowel and blood vessel features associated with increased mortality
STUDY
⚬ SUMMARY
extensive bowel necrosis requiring surgery associated with high mortality rate in patients
with acute mesenteric ischemia DynaMed Level 2
COHORT STUDY: Tunis Med 2012 Jul;90(7):533 | Full Text
Details
– based on retrospective cohort study published in French
– 26 patients (mean age 60 years) with acute mesenteric ischemia were evaluated
– 25 patients had surgery, including 15 patients with bowel resection
– overall mortality rate 69%
– factors associated with increased mortality
● preoperative collapse (p = 0.02)

● extensive bowel necrosis (p = 0.0001)
– all 4 patients with venous thrombosis lived

– no signi cant e ect of age or gender on mortality rate
– Reference - Tunis Med 2012 Jul;90(7):533 full-text [French]
STUDY
⚬ SUMMARY
short length of remnant small bowel following surgery and presence of renal insufficiency
may increase risk of death in patients with acute thromboembolic occlusion of superior
mesenteric artery DynaMed Level 2
COHORT STUDY: Hepatogastroenterology 2011 Nov-Dec;58(112):1893
Details
– based on cohort study
– 37 adults (mean age 59 years) with acute thromboembolic occlusion of superior mesenteric
artery were evaluated
– 17 patients had surgery and 15 patients were managed medically
– mortality rate 43% (16 patients)
– 32 patients (86%) overall were misdiagnosed
– comparing patients who died vs. patients who survived
● length of small bowel after surgery 80 cm vs. 175 cm (p = 0.013)

● renal insu ciency in 14 patients vs. 10 patients (p = 0.017)
– Reference - Hepatogastroenterology 2011 Nov-Dec;58(112):1893
STUDY
⚬ SUMMARY
reduced number of venous vessels and mesenteric pneumatosis on computed tomography
each associated with in-hospital mortality
COHORT STUDY: J Comput Assist Tomogr 2012 Jan-Feb;36(1):1
Details
– 34 adults (mean age 75 years) with con rmed acute mesenteric ischemia had computed
tomography
– in-hospital mortality 62% (21 patients)
– ndings on computed tomography associated with in-hospital mortality included
● reduced number of venous vessels (p = 0.042)
● mesenteric pneumatosis (p = 0.027)
● reduced number of arterial vessels (p = 0.089)
– Reference - J Comput Assist Tomogr 2012 Jan-Feb;36(1):1
STUDY
● SUMMARY
elevated cell-free plasma DNA concentration may predict increased mortality risk in patients
with acute mesenteric ischemia
COHORT STUDY: Clin Chim Acta 2010 Sep 6;411(17-18):1269
Details
⚬ based on prospective cohort study without clinical outcomes
⚬ 130 patients with suspected acute mesenteric ischemia had real-time polymerase chain reaction
for beta-globin gene
⚬ 99 patients (76%) diagnosed with acute mesenteric ischemia in surgery
⚬ 46 patients (46.6%) with acute mesenteric ischemia died within 30 days
⚬ median beta-globin concentration in patients
– 7,340 genome-equivalent (GE)/mL with acute mesenteric ischemia vs. 2,735 GE/mL without
acute mesenteric ischemia (p < 0.01)
– with acute mesenteric ischemia who died 8,830 GE/mL vs. with acute mesenteric ischemia who
lived 4,970 GE/mL (p < 0.05)
⚬ risk of hospital mortality increased 1.52-fold for every 1,000 GE/mL increase in plasma beta-globin
⚬ Reference - Clin Chim Acta 2010 Sep 6;411(17-18):1269
STUDY
● SUMMARY
nonocclusive acute mesenteric ischemia following acute aortic dissection associated with high
mortality rate DynaMed Level 2
COHORT STUDY: J Vasc Surg 2002 Oct;36(4):738
Details
⚬ 371 patients with acute aortic dissection were evaluated for nonocclusive acute mesenteric
ischemia (NOMI)
⚬ 73 patients (19%) had NOMI
⚬ among 73 patients with NOMI, 63 patients (86%) died, all from sepsis or multiorgan failure
⚬ Reference - J Vasc Surg 2002 Oct;36(4):738
STUDY
● SUMMARY
cyclooxygenase inhibitors might be associated with increased mortality from nonocclusive
mesenteric ischemia in dialysis patients
COHORT STUDY: Ren Fail 2009;31(9):802

Details
⚬ based on cohort study
⚬ 12 patients (mean age 72 years) on dialysis developed nonocclusive mesenteric ischemia and were
followed for 2 years
⚬ 4 patients died
⚬ 10 patients had chronic hypotension
⚬ comparing 4 patients who died vs. 8 patients who survived
– cyclooxygenase inhibitors in 3 patients vs. 0 patients (p = 0.018)

– serum bicarbonate 9.4 mm/L vs. 16.7 mm/L (p = 0.034)
⚬ Reference - Ren Fail 2009;31(9):802
Risk scores and calculators
STUDY
● SUMMARY
Acute Mesenteric Ischemia Perioperative Risk Calculator may predict postoperative morbidity
and mortality after bowel resection for acute mesenteric ischemia DynaMed Level 2
DIAGNOSTIC COHORT STUDY: Surgery 2011 Oct;150(4):779
Details
⚬ based on derivation cohort study without validation
⚬ 861 adults (median age 69 years) with acute mesenteric ischemia had bowel resection
⚬ 30-day postoperative morbidity 56.6% and mortality 27.9%
⚬ risk factors signi cantly associated with postoperative morbidity
– preoperative do not resuscitate order

– open wound
– low albumin
– dirty vs. clean-contaminated case
– poor functional status
– preoperative renal failure
– admission from chronic care facility
– previous cardiac surgery
– myocardial infarction within 6 months
– chronic obstructive pulmonary disease
– prolonged operative time
– requiring preoperative ventilator support
⚬ risk calculator can be downloaded from Surgical Risk Calculator
⚬ Reference - Surgery 2011 Oct;150(4):779
STUDY
● SUMMARY
risk score may predict in-hospital mortality with acute mesenteric ischemia DynaMed Level 2
DIAGNOSTIC COHORT STUDY: Digestion 2009;80(2):104
Details
⚬ based on derivation cohort study without validation
⚬ 110 patients (median age 75 years) with acute mesenteric ischemia were evaluated
⚬ 51% in-hospital mortality rate
⚬ assigned points for risk score
– 1 point if ≥ 70 years old

– 2 points if atrial brillation with rate 60-90/minute
– 2 points if shock index ≥ 0.7
– 4 points if any of the following electrocardiogram ndings
● any other abnormal rhythm

● ectopic beats > 4/minute
● Q waves and ST/T changes
Table 2. Mortality Rate in Derivation Cohort:
Risk Score Mortality Rate
≤2 19%
3 or 4 37%
≥5 91%
Unknown 52%
⚬ Reference - Digestion 2009;80(2):104
Prevention and Screening
Prevention
● cardiovascular disease prevention
⚬ strategies generally recommended for all persons
– proper diet - see Dietary Considerations for Cardiovascular Disease Risk Reduction
– aerobic exercise (or at least physical activity) - see Physical activity for cardiovascular disease
prevention
– smoking cessation - see Tobacco use
⚬ strategies recommended for speci c populations
– weight loss if obese - see Obesity in adults

– treatment of diabetes
– treatment of hypertension
– treatment of hyperlipidemia (list of topics)
– aspirin for primary prevention of cardiovascular disease
● see Cardiovascular disease prevention overview for more information
Guidelines and Resources
Guidelines
International guidelines
● World Society of Emergency Surgery (WSES) guideline on acute mesenteric ischemia can be found in
World J Emerg Surg 2017;12:38 full-text
United States guidelines
● American College of Gastroenterology (ACG) guideline on disorders of hepatic and mesenteric

circulation can be found in Am J Gastroenterol 2020 Jan;115(1):18
● American College of Radiology (ACR) Appropriateness Criteria for radiologic management of

mesenteric ischemia can be found in J Am Coll Radiol 2017 May;14(5S):S266
● American Gastrointestinal Association (AGA) guidelines on intestinal ischemia can be found in

Gastroenterology 2000 May;118(5):951 PDF , supporting literature review can be found in
Gastroenterology 2000 May;118(5):954 PDF
● American College of Radiology (ACR) Appropriateness Criteria for imaging of mesenteric ischemia can
be found at ACR 2016 PDF or in J Am Coll Radiol 2017 May;14(5S):S266
● American College of Cardiology/American Heart Association (ACC/AHA) guidelines on
⚬ management of patients with lower extremity peripheral artery disease can be found in Circulation
2017 Mar 21;135(12):e726 full-text
⚬ management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and
abdominal aortic) can be found in J Am Coll Cardiol 2006 Mar 21;47(6):1239 full-text , also
published in Circulation 2006 Mar 21;113(11):e463 PDF
⚬ 2011 focused update on management of patients with peripheral artery disease can be found in
Circulation 2011 Nov 1;124(18):2020 full-text , also published in J Am Coll Cardiol 2011 Nov
1;58(19):2020 , Catheter Cardiovasc Interv 2012 Mar 1;79(4):501 , J Vasc Surg 2011
Nov;54(5):e32 , or in Vasc Med 2011 Dec;16(6):452
⚬ compilation of 2005 and 2011 ACCF/AHA guideline recommendations can be found in J Am Coll
Cardiol 2013 Apr 9;61(14):1555
European guidelines
● European Society of Cardiology/ European Society for Vascular Surgery (ESC/ESVS) guideline on
diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of
extracranial carotid and vertebral, mesenteric, renal, upper, and lower extremity arteries can be found
in Eur Heart J 2018 Mar 1;39(9):763 full-text
Review articles
● review can be found in Best Pract Res Clin Gastroenterol 2017 Feb;31(1):15
● review can be found in Surg Clin North Am 2014 Feb;94(1):165
● review can be found in JAAPA 2011 Jul;24(7):44
● review of acute mesenteric ischemia in elderly patients can be found in Expert Rev Gastroenterol
Hepatol 2016 Sep;10(9):985
● review of mesenteric ischemia can be found in Curr Opin Crit Care 2015 Apr;21(2):171
● review of treatment of acute mesenteric ischemia can be found in Br J Surg 2014 Jan;101(1):e100
● review of acute mesenteric ischemia following cardiopulmonary bypass surgery can be found in World
J Gastroenterol 2008 Sep 21;14(35):5361 full-text
● reviews of intestinal ischemia can be found in
⚬ Int J Colorectal Dis 2011 Sep;26(9):1087

⚬ Langenbecks Arch Surg 2011 Jan;396(1):3
● review of multidetector row computed tomography for diagnosis can be found in Radiol Clin North
Am 2012 Jan;50(1):173
● reviews of mesenteric venous thrombosis can be found in
⚬ J Vasc Surg Venous Lymphat Disord 2016 Oct;4(4):501

⚬ J Clin Exp Hepatol 2014 Sep;4(3):257
● review of surgical management of peritonitis secondary to acute superior mesenteric artery occlusion
can be found in World J Gastroenterol 2014 Aug 7;20(29):9936 full-text
● case presentation of acute intestinal ischemia in elderly woman can be found in Annals of Long-Term
Care 2008 Mar;16(3):34 full-text
● case report of acute mesenteric ischemia due to chronic mesenteric ischemia with chronic occlusion
of the celiac axis, and long acute-on-chronic occlusion of the superior mesenteric artery can be found
in Acta Chir Belg 2016 Jun 21;1
MEDLINE search
● to search MEDLINE for (Mesenteric ischemia) with targeted search (Clinical Queries), click therapy ,
diagnosis , or prognosis
Patient Information
● handout on mesenteric ischemia from Society for Vascular Surgery
ICD Codes
ICD-10 codes
● K55.0 acute vascular disorders of intestine
● K55.1 chronic vascular disorders of intestine
● K55.9 vascular disorder of intestine, unspeci ed
References
General references used

1. Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B. Acute mesenteric ischemia: a
vascular emergency. Dtsch Arztebl Int. 2012 Apr;109(14):249-56 full-text , commentary can be
found in Dtsch Arztebl Int 2012 Oct;109(42):709 full-text , Dtsch Arztebl Int 2012 Oct;109(42):710
full-text
2. Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg.
2010 Mar;23(1):9-20
3. Berland T, Oldenburg WA. Acute mesenteric ischemia. Curr Gastroenterol Rep. 2008 Jun;10(3):341-6
4. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with
peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive
summary a collaborative report from the American Association for Vascular Surgery/Society for
Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular
Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice
Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral
Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary
Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic
Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol. 2006 Mar 21;47(6):1239-
312 , also published in Circulation 2006 Mar 21;113(11):e463 full-text (updated in 2016 with no
changes to mesenteric ischemia recommendations in Vasc Med 2017 Jun;22(3):NP1 [executive
summary])
5. American Gastroenterological Association Medical Position Statement: guidelines on intestinal

ischemia. Gastroenterology. 2000 May;118(5):951-3 PDF , correction can be found in
Gastroenterology 2000 Jul;119(1):280-1
6. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association.
Gastroenterology. 2000 May;118(5):954-68 PDF
7. Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016 Mar 10;374(10):959-68
Recommendation grading systems used
● American College of Radiology (ACR) rating scale
⚬ Rating 1, 2, and 3 - usually not appropriate

⚬ Rating 4, 5, and 6 - may be appropriate
⚬ Rating 7, 8, and 9 - usually appropriate
⚬ Reference - ACR Appropriateness Criteria on imaging of mesenteric ischemia (ACR 2012 PDF )
● American College of Cardiology/American Heart Association (ACC/AHA) grading system for

recommendations
⚬ classi cations of recommendations
– Class I - procedure or treatment should be performed or administered

– Class IIa - reasonable to perform procedure or administer treatment, but additional studies with
focused objectives needed
– Class IIb - procedure or treatment may be considered; additional studies with broad objectives
needed, additional registry data would be useful
– Class III - procedure or treatment should not be performed or administered because it is not
helpful or may be harmful
● Class III ratings may be subclassi ed as Class III No Bene t or Class III Harm
⚬ levels of evidence
– Level A - data derived from multiple randomized clinical trials or meta-analyses

– Level B - data derived from single randomized trial or nonrandomized studies
– Level C - only expert opinion, case studies, or standard of care
⚬ Reference - ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral
arterial disease (lower extremity, renal, mesenteric, and abdominal aortic) (J Am Coll Cardiol 2006
Mar 21;47(6):1239 ), also published in Circulation 2006 Mar 21;113(11):e463 full-text
Synthesized Recommendation Grading System for DynaMed Content
● The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of
the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based
Methodology ).
● Guideline recommendations summarized in the body of a DynaMed topic are provided with the
recommendation grading system used in the original guideline(s), and allow users to quickly see
where guidelines agree and where guidelines di er from each other and from the current evidence.
● In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities,
and clinical expertise to provide recommendations to support clinical decision-making in the Overview
& Recommendations section.
● We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to

classify synthesized recommendations as Strong or Weak.
⚬ Strong recommendations are used when, based on the available evidence, clinicians (without
con icts of interest) consistently have a high degree of con dence that the desirable consequences
(health bene ts, decreased costs and burdens) outweigh the undesirable consequences (harms,
costs, burdens).
⚬ Weak recommendations are used when, based on the available evidence, clinicians believe that
desirable and undesirable consequences are nely balanced, or appreciable uncertainty exists
about the magnitude of expected consequences (bene ts and harms). Weak recommendations are
used when clinicians disagree in judgments of relative bene t and harm, or have limited
con dence in their judgments. Weak recommendations are also used when the range of patient
values and preferences suggests that informed patients are likely to make di erent choices.
● DynaMed synthesized recommendations (in the Overview & Recommendations section) are
determined with a systematic methodology:
⚬ Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological
expertise and ≥ 1 with content domain expertise) aware of the best current evidence for bene ts
and harms, and the recommendations from guidelines.
⚬ Recommendations are phrased to match the strength of recommendation. Strong
recommendations use "should do" phrasing, or phrasing implying an expectation to perform the
recommended action for most patients. Weak recommendations use "consider" or "suggested"
phrasing.
⚬ Recommendations are explicitly labeled as Strong recommendations or Weak
recommendations when a quali ed group has explicitly deliberated on making such a
recommendation. Group deliberation may occur during guideline development. When group
deliberation occurs through DynaMed Team-initiated groups:
– Clinical questions will be formulated using the PICO (Population, Intervention, Comparison,
Outcome) framework for all outcomes of interest speci c to the recommendation to be
developed.
– Systematic searches will be conducted for any clinical questions where systematic searches
were not already completed through DynaMed content development.
– Evidence will be summarized for recommendation panel review including for each outcome, the
relative importance of the outcome, the estimated e ects comparing intervention and
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Acute Mesenteric Ischemia

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Acute Mesenteric Ischemia

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Acute Mesenteric Ischemia

Overview and Recommendations

● Consider anticoagulation with heparin to prevent further thrombosis.

● For arterial occlusive disease:

⚬ Perform revascularization before any bowel resection (Strong recommendation).

● For mesenteric venous thrombosis, consider catheter-directed thrombolysis to reduce thrombosis

from blockage of venous or arterial blood ow 1 , 2 , 3

● acute mesenteric ischemia may be due to various mechanisms 1 , 4

Who is most affected

● more common in women and persons > 60 years old 2 , 3 , 4

● acute mesenteric ischemia reported to account for 1

⚬ about 1% of patients presenting with acute abdomen

● prevalence of reported underlying etiology 7

⚬ arterial occlusive disease is reported to account for 40%-50% of cases

COHORT STUDY: Front Surg 2016 Apr 14;3:22 | Full Text

General risk factors for acute mesenteric ischemia

CROSS-SECTIONAL STUDY: Catheter Cardiovasc Interv 2011 Nov 15;78(6):948

● nicotine use in 14 patients (45.2%)

– Reference - Catheter Cardiovasc Interv 2011 Nov 15;78(6):948

CASE-CONTROL STUDY: Aliment Pharmacol Ther 2011 Apr;33(8):969

– body mass index < 20 kg/m2

⚬ risk factors for acute mesenteric ischemia in case-control study were

⚬ Reference - Aliment Pharmacol Ther 2011 Apr;33(8):969

Risk factors by etiology

● arterial occlusive disease is reported to account for 40%-50% AMI cases 1 , 2 , 3 , 7

– arrhythmia including atrial brillation

COHORT STUDY: J Emerg Med 2012 Jun;42(6):635

● 15 patients with acute mesenteric ischemia were evaluated

⚬ atrial brillation in 9 patients (60%)

● 24 patients with acute mesenteric ischemia were evaluated

⚬ atrial brillation in 19 of 20 patients with embolism (95%)

Nonocclusive mesenteric ischemia (NOMI)

Mesenteric venous thrombosis (MVT)

● MVT is reported to account for < 5% AMI cases 1

● de ciencies of antithrombin III, plasminogen, protein C, and protein S

COHORT STUDY: Ann Vasc Surg 2016 Oct;36:112

CROSS-SECTIONAL STUDY: J Vasc Surg 2002 Oct;36(4):738

Etiology and Pathogenesis

● most common causes 1 , 2 , 3 , 5

⚬ occlusive mesenteric ischemia

– acute thromboembolic occlusion of superior mesenteric artery

● arterial embolism accounts for 40%-50% of cases

– mesenteric arterial thrombosis

● accounts for about 10%-15% of cases

● long-term hemodialysis and hypovolemia

● causes of altered mesenteric circulation include 7

angle of origin from visceral aortic segment 1 , 2

⚬ irreversible ischemia and disintegration of intestinal mucosal barriers

History and Physical

Chief concern (CC)

● typical symptoms may include 2

⚬ abdominal pain, which may be followed by forceful bowel evacuation

History of present illness (HPI)

pain-free interval, and then symptoms of peritonitis, 1 which may include

● for nonocclusive disease 1

⚬ increasing abdominal pain in responsive patients

● for venous thrombosis 1

reported to usually be less abrupt 7

Past medical history (PMH)

● ask about cardiovascular diseases or procedures 4

● for acute thrombotic occlusion, history may include symptoms such as 2

⚬ postprandial abdominal pain

● for nonocclusive disease, history may include 1

⚬ long-term hemodialysis ( uid loss may lead to vascular spasm)