Ischaemic bowel disease
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
evidence of infarction, perforation, or peritonitis on diagnostic computed tomography scan
resuscitation and supportive measures
Acute mesenteric ischaemia is a medical emergency. Liaise early with surgery and intensive care unit colleagues.
Administer adequate fluid resuscitation and supplemental oxygen to optimise tissue perfusion and oxygenation.[20]Tilsed JV, Casamassima A, Kurihara H, et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016 Apr;42(2):253-70. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830881 http://www.ncbi.nlm.nih.gov/pubmed/26820988?tool=bestpractice.com
Check your local protocols for specific recommendations on fluid choice. There is debate, based on conflicting evidence, on whether there is a benefit in using normal saline or balanced crystalloid in critically ill patients.
Monitor controlled oxygen therapy. An upper SpO2 limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.
Evidence suggests that liberal use of supplemental oxygen (target SpO2 >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[48]Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-705. http://www.ncbi.nlm.nih.gov/pubmed/29726345?tool=bestpractice.com
A lower target SpO2 of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[49]O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com
Initial resuscitation should also aim to address any acute heart failure and correct any cardiac arrhythmias.
Involve the critical care team for further management as necessary.
Consider invasive monitoring as appropriate. Nil by mouth status should be enforced, with nasogastric tube decompression for symptomatic relief.[8]Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2022 Oct 19;17(1):54. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9580452 http://www.ncbi.nlm.nih.gov/pubmed/36261857?tool=bestpractice.com
More info: Sepsis
Think 'Could this be sepsis?' based on acute deterioration in an adult patient in whom there is clinical evidence or strong suspicion of infection.[50]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [51]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. December 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [52]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 See Sepsis in adults.
The patient may present with non-specific or non-localised symptoms (e.g., acutely unwell with a normal temperature) or there may be severe signs with evidence of multi-organ dysfunction and shock.[50]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [51]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. December 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [52]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Remember that sepsis represents the severe, life-threatening end of infection.[53]Inada-Kim M. Introducing the suspicion of sepsis insights dashboard. Royal College of Pathologists Bulletin. 2019 Apr;186;109.
Ischaemic bowel disease and bowel perforation can cause rapid deterioration into septic shock. For this reason, the assessment of severity status and subsequent action should be upgraded according to patient need, and at least to the next NEWS band. There should be no avoidable delay in giving antimicrobials and achieving source control.[54]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis V2.0. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 In practice, if computed tomography (CT) shows extensive ischaemia in a patient who is a very frail or has significant comorbidities, palliative care may be the treatment of choice (rather than antibiotics and source control) this decision should always be made in discussion with a consultant.
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[50]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [51]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. December 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [55]Nutbeam T, Daniels R; The UK Sepsis Trust. Professional resources: clinical [internet publication]. https://sepsistrust.org/professional-resources/clinical [56]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com [52]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST3 level doctor in the UK) if you suspect sepsis:[54]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis V2.0. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0
Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns).
A patient is also at high risk of severe illness or death from sepsis if they have a NEWS2 score below 7 and a single parameter contributes 3 points to their NEWS2 score and a medical review has confirmed that they are at high risk.
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6) or within 1 hour of any intervention for suspected sepsis (antibiotics/fluid resuscitation/oxygen) if there is no improvement in the patient’s condition.
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[54]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis V2.0. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [56]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
In the community and custodial settings: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[52]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
At risk of neutropenic sepsis.
If there are clinical signs of peritonitis, or radiographic or laboratory evidence suggesting infarction or perforation, proceed urgently with exploratory laparotomy and include resection of non-viable intestine. Ideally, revascularisation procedures should be completed prior to any bowel resection, as borderline ischaemic bowel may recover satisfactorily after revascularisation.
Patients with delayed presentation and abdominal signs of peritonitis or organ failure generally have a worse prognosis than patients without these clinical factors.[20]Tilsed JV, Casamassima A, Kurihara H, et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016 Apr;42(2):253-70. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830881 http://www.ncbi.nlm.nih.gov/pubmed/26820988?tool=bestpractice.com It may be appropriate to discuss palliative care options with the multidisciplinary team if the patient is unlikely to benefit from invasive procedures.[20]Tilsed JV, Casamassima A, Kurihara H, et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016 Apr;42(2):253-70. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830881 http://www.ncbi.nlm.nih.gov/pubmed/26820988?tool=bestpractice.com
empirical antibiotics
Treatment recommended for ALL patients in selected patient group
Consult your local antimicrobial guidelines to administer empirical antibiotics suitable for enteric coverage (e.g., a third-generation cephalosporin plus metronidazole in critically ill patients, or a fluoroquinolone-based regimen in patients with beta-lactam allergy such as ciprofloxacin plus metronidazole) to all patients who are being treated with curative intent. Ischaemia can lead to significant bacterial translocation due to damage to the normal intestinal mucosal barrier.[8]Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2022 Oct 19;17(1):54. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9580452 http://www.ncbi.nlm.nih.gov/pubmed/36261857?tool=bestpractice.com [57]Sartelli M, Coccolini F, Kluger Y, et al. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections. World J Emerg Surg. 2021 Sep 25;16(1):49. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8467193 http://www.ncbi.nlm.nih.gov/pubmed/34563232?tool=bestpractice.com Antibiotics may not be indicated if a palliative treatment pathway is being followed.
Practical tip
Drug safety alert
Systemic fluoroquinolone antibiotics may cause serious, disabling and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[58]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10056716 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Primary options
ceftriaxone: 1-2 g intravenously every 24 hours
and
metronidazole: 500 mg intravenously every 8 hours
Secondary options
ciprofloxacin: 400 mg intravenously every 8-12 hours
and
metronidazole: 500 mg intravenously every 8 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
ceftriaxone: 1-2 g intravenously every 24 hours
and
metronidazole: 500 mg intravenously every 8 hours
Secondary options
ciprofloxacin: 400 mg intravenously every 8-12 hours
and
metronidazole: 500 mg intravenously every 8 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ceftriaxone
and
metronidazole
Secondary options
ciprofloxacin
and
metronidazole
Plus – open embolectomy or arterial bypass ± bowel resection
open embolectomy or arterial bypass ± bowel resection
Treatment recommended for ALL patients in selected patient group
If there is evidence of ischaemia progression, patients should undergo urgent exploratory laparotomy with a view to conventional surgical embolectomy.
If not amenable to embolectomy, arterial bypass may be required.
postoperative anticoagulation
Treatment recommended for ALL patients in selected patient group
Timing of postoperative anticoagulation is controversial, although it is generally recognised as being beneficial.
Some authorities recommend a delay of 48 hours because of the risk of intraluminal bleeding from damaged bowel, while others advocate immediate anticoagulation. Another suggested approach has been immediate anticoagulation if no infarction is present, and delayed anticoagulation if intestinal infarction is present. Good data on these approaches are lacking.[32]Burns BJ, Brandt LJ. Intestinal ischemia. Gastroenterol Clin North Am. 2003 Dec;32(4):1127-43. http://www.ncbi.nlm.nih.gov/pubmed/14696300?tool=bestpractice.com
Primary options
heparin: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
heparin: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
heparin
Plus – arterial reconstruction or bypass ± bowel resection
arterial reconstruction or bypass ± bowel resection
Treatment recommended for ALL patients in selected patient group
The absence of collaterals on angiography suggests an acute SMA thrombosis has occurred and necessitates immediate intervention.
Surgical procedures that may be used in these circumstances include antegrade and retrograde bypass grafting, aortic re-implantation of the SMA, and transarterial and transaortic mesenteric endarterectomy.[31]American College of Radiology. ACR appropriateness criteria: radiologic management of mesenteric ischemia. 2022 [internet publication]. https://acsearch.acr.org/docs/69501/Narrative
Endovascular treatment is unlikely to be appropriate in a patient determined to have evidence of peritonitis.
postoperative anticoagulation
Treatment recommended for ALL patients in selected patient group
Timing of postoperative anticoagulation is controversial, although it is generally recognised as being beneficial.
Some authorities recommend a delay of 48 hours because of the risk of intraluminal bleeding from damaged bowel, while others advocate immediate anticoagulation. Another suggested approach has been immediate anticoagulation if no infarction is present, and delayed anticoagulation if intestinal infarction is present. Good data on these approaches are lacking.[32]Burns BJ, Brandt LJ. Intestinal ischemia. Gastroenterol Clin North Am. 2003 Dec;32(4):1127-43. http://www.ncbi.nlm.nih.gov/pubmed/14696300?tool=bestpractice.com
Primary options
heparin: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
heparin: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
heparin
correct underlying medical cause ± bowel resection
Treatment recommended for ALL patients in selected patient group
Splanchnic hypoperfusion may be precipitated by congestive heart failure, cardiac arrhythmia, or shock, or by large volume shifts, which can sometimes occur during haemodialysis.
Urgent correction of any underlying medical cause of hypoperfusion (e.g., heart failure) is of paramount importance to restore perfusion.
Laparotomy is indicated if there is evidence of peritonitis, perforation, or if the patient clinically declines.[20]Tilsed JV, Casamassima A, Kurihara H, et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016 Apr;42(2):253-70. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830881 http://www.ncbi.nlm.nih.gov/pubmed/26820988?tool=bestpractice.com Surgery should preserve bowel of questionable viability, unless necrosis is clear. With use of temporary abdominal closure and re-exploration at 24 to 48 hours after the first operation, intestinal resection can be kept to a minimum.
postoperative anticoagulation
Treatment recommended for ALL patients in selected patient group
Timing of postoperative anticoagulation is controversial, although it is generally recognised as being beneficial. Some authorities recommend a delay of 48 hours because of the risk of intraluminal bleeding from damaged bowel, while others advocate immediate anticoagulation. Another suggested approach has been immediate anticoagulation if no infarction is present, and delayed anticoagulation if intestinal infarction is present. Good data on these approaches are lacking.[32]Burns BJ, Brandt LJ. Intestinal ischemia. Gastroenterol Clin North Am. 2003 Dec;32(4):1127-43. http://www.ncbi.nlm.nih.gov/pubmed/14696300?tool=bestpractice.com
Primary options
heparin: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
heparin: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
heparin
anticoagulation
Treatment recommended for ALL patients in selected patient group
Anticoagulation is the first-line treatment option for venous mesenteric ischaemia when the clinical condition permits. This may be successful in up to 95% of cases. These patients need close clinical observation, and surgery is indicated if signs of peritonitis develop. Therapeutic anticoagulation with intravenous heparin should continue until bowel function normalises.[64]Acosta S, Salim S. Management of acute mesenteric venous thrombosis: a systematic review of contemporary studies. Scand J Surg. 2021 Jun;110(2):123-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258716 http://www.ncbi.nlm.nih.gov/pubmed/33118463?tool=bestpractice.com In patients who receive heparin, the recurrence rate is lowered from 25% to 13% and mortality is reduced from 50% to 13%.[32]Burns BJ, Brandt LJ. Intestinal ischemia. Gastroenterol Clin North Am. 2003 Dec;32(4):1127-43. http://www.ncbi.nlm.nih.gov/pubmed/14696300?tool=bestpractice.com Once patients are stable, and able to tolerate oral medication, they can be converted to warfarin, which should then be administered for 3 to 6 months.
Primary options
heparin: consult specialist for guidance on dose
OR
warfarin: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
heparin: consult specialist for guidance on dose
OR
warfarin: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
heparin
OR
warfarin
open surgery ± thrombectomy ± bowel resection
Treatment recommended for ALL patients in selected patient group
Surgery is indicated in patients with venous ischaemia when there are signs of infarction or peritonitis. Infarcted bowel should be resected.[64]Acosta S, Salim S. Management of acute mesenteric venous thrombosis: a systematic review of contemporary studies. Scand J Surg. 2021 Jun;110(2):123-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258716 http://www.ncbi.nlm.nih.gov/pubmed/33118463?tool=bestpractice.com A second-look procedure is a valuable tool to assess the recovery of any questionable segments of bowel that can be left in situ at the index surgery if potentially viable.[64]Acosta S, Salim S. Management of acute mesenteric venous thrombosis: a systematic review of contemporary studies. Scand J Surg. 2021 Jun;110(2):123-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258716 http://www.ncbi.nlm.nih.gov/pubmed/33118463?tool=bestpractice.com
subtotal or total colectomy
Treatment recommended for ALL patients in selected patient group
These patients usually appear acutely unwell and are unresponsive to medical therapy.
Ischaemia and necrosis of the right-side colon may be treated by right hemicolectomy with primary anastomosis, providing the remaining ileal and colonic ends are well perfused. If there is perforation and peritonitis, resection with terminal ileostomy and a colonic mucocutaneous fistula is indicated. Damage control surgery is another option; this involves resecting the ischaemic bowel and planning a second look with possible anastomosis 24 to 48 hours later.
Left-sided colonic involvement may require a proximal end stoma and distal mucous fistula or Hartmann's procedure.
If most of the colon is ischaemic, subtotal colectomy with terminal ileostomy is indicated.
Depending on the findings of the initial surgery, a second-look operation within around 24 hours to reassess bowel viability may be indicated.
no evidence of infarction, perforation, or peritonitis on diagnostic computed tomography scan
1st line – supportive measures and treatment of the underlying cause
supportive measures and treatment of the underlying cause
Patients with acute transient or mild ischaemia have physical findings with no evidence of peritonitis, intestinal perfusion, or full-thickness necrosis on a computed tomography scan or mesenteric angiography.
Use conservative measures if imaging suggests mucosal or submucosal involvement only. These include nil by mouth status; resuscitation with intravenous fluids; and nasogastric tube decompression for symptomatic relief. Also consider supplemental oxygen as needed; and correction of hypotension, heart failure, and arrhythmias.
The underlying cause should be treated promptly. This may include anticoagulation for mesenteric venous thrombosis, tailored antibiotic therapy when an infectious cause is identified, corticosteroids for vasculitis, and fluid resuscitation and cardiac optimisation for shock (see Shock).[64]Acosta S, Salim S. Management of acute mesenteric venous thrombosis: a systematic review of contemporary studies. Scand J Surg. 2021 Jun;110(2):123-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258716 http://www.ncbi.nlm.nih.gov/pubmed/33118463?tool=bestpractice.com
Frequently reassess vital signs, and repeat the physical examination and laboratory values to detect failure of non-surgical management that may then require operative intervention. These patients require close observation, and surgery is indicated should signs of peritonitis develop (e.g., rigid, distended abdomen; guarding and rebound; loss of bowel sounds).
Plus – endovascular therapy ± open embolectomy or arterial bypass ± bowel resection
endovascular therapy ± open embolectomy or arterial bypass ± bowel resection
Treatment recommended for ALL patients in selected patient group
An embolus in the superior SMA causes a critical reduction in flow of both the obstructed and unobstructed branches of the SMA. If not corrected promptly this will progress to infarction.
If available and the clinical condition of the patient permits, consider endovascular treatment as a first-line option. Refer to the vascular team and a vascular radiologist.
Consider local thrombolytic therapy if there is no evidence of infarction, perforation, or peritonitis requiring urgent surgical intervention (and there are no contraindications). If lysis of the embolus cannot be demonstrated within 4 hours, or there is evidence of ischaemia progression, patients should undergo exploratory laparotomy with a view to conventional surgical embolectomy.
The open alternative is SMA embolectomy or arterial bypass. If not amenable to embolectomy, arterial bypass may be required. Any infarcted bowel should be resected.
anticoagulation
Treatment recommended for ALL patients in selected patient group
Patients will generally be maintained on an intravenous heparin infusion once a diagnosis of SMA embolus is established.
A heparin infusion titrated to therapeutic dosing following partial thromboplastin time (PTT) prolongation to 1.5 to 2.5 times normal PTT levels is recommended.
Primary options
heparin: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
heparin: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
heparin
anticoagulation
Treatment recommended for ALL patients in selected patient group
Patients will generally be maintained on an intravenous heparin infusion once a diagnosis of SMA thrombosis is established.
A heparin infusion titrated to therapeutic dosing following partial thromboplastin time (PTT) prolongation to 1.5 to 2.5 times normal PTT levels is recommended.
Primary options
heparin: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
heparin: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
heparin
Plus – endovascular therapy ± arterial reconstruction or bypass ± bowel resection
endovascular therapy ± arterial reconstruction or bypass ± bowel resection
Treatment recommended for ALL patients in selected patient group
The presence of collaterals on angiography suggests a chronic thrombosis.
Endovascular treatment is the first-line therapy for chronic thrombotic mesenteric ischaemia. Options include angioplasty ± stenting, aspiration thrombectomy, or local drug instillation. If patients are unsuitable for endovascular intervention, surgery may be an option if the patient is fit enough. Refer to the vascular team and a vascular radiologist.
Surgical procedures that may be used in these circumstances include antegrade and retrograde bypass grafting, aortic reimplantation of the SMA, and transarterial and transaortic mesenteric endarterectomy.[31]American College of Radiology. ACR appropriateness criteria: radiologic management of mesenteric ischemia. 2022 [internet publication]. https://acsearch.acr.org/docs/69501/Narrative
endovascular therapy + observation
Treatment recommended for ALL patients in selected patient group
Splanchnic hypoperfusion may be precipitated by congestive heart failure, cardiac arrhythmia, or shock, or by large volume shifts, which can sometimes occur during haemodialysis.
Urgent correction of any underlying medical cause of hypoperfusion (e.g., heart failure) is of paramount importance to restore perfusion.
After correction of the underlying medical condition, endovascular therapy is the first-line option, with selective mesenteric angiography and local intra-arterial infusion of vasodilators.[66]Stahl K, Rittgerodt N, Busch M, et al. Nonocclusive mesenteric ischemia and interventional local vasodilatory therapy: a meta-analysis and systematic review of the literature. J Intensive Care Med. 2020 Feb;35(2):128-39. http://www.ncbi.nlm.nih.gov/pubmed/31645176?tool=bestpractice.com
The infusion should be continued until there is no angiographic or clinical evidence of persistent vasoconstriction.
anticoagulation + observation
Treatment recommended for ALL patients in selected patient group
Anticoagulation is the first-line treatment option for venous mesenteric ischaemia when the clinical condition permits. This may be successful in up to 95% of cases. These patients need close clinical observation, and surgery is indicated if signs of peritonitis develop.
Therapeutic anticoagulation with intravenous heparin should continue until bowel function normalises.[64]Acosta S, Salim S. Management of acute mesenteric venous thrombosis: a systematic review of contemporary studies. Scand J Surg. 2021 Jun;110(2):123-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258716 http://www.ncbi.nlm.nih.gov/pubmed/33118463?tool=bestpractice.com
In patients who receive heparin, the recurrence rate is lowered from 25% to 13% and mortality is reduced from 50% to 13%.[32]Burns BJ, Brandt LJ. Intestinal ischemia. Gastroenterol Clin North Am. 2003 Dec;32(4):1127-43. http://www.ncbi.nlm.nih.gov/pubmed/14696300?tool=bestpractice.com Once patients are stable, symptom-free, and able to tolerate oral medication, they can be converted to warfarin, which should then be administered for 3 to 6 months.
If a mesenteric vein thrombus is discovered incidentally in an asymptomatic patient who undergoes a computed tomography scan for another reason besides abdominal pain, a 3- to 6-month course of warfarin is recommended, especially if a predisposing hypercoagulable state or concomitant deep vein thrombosis can be identified.[67]Russell CE, Wadhera RK, Piazza G. Mesenteric venous thrombosis. Circulation. 2015 May 5;131(18):1599-603. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.114.012871?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/25940967?tool=bestpractice.com
Primary options
heparin: consult specialist for guidance on dose
OR
warfarin: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
heparin: consult specialist for guidance on dose
OR
warfarin: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
heparin
OR
warfarin
corticosteroid therapy
Treatment recommended for ALL patients in selected patient group
If vasculitis is identified as a contributory cause of the ischaemia (e.g., by thickened blood vessels on computed tomography scan, the presence of other vasculitic symptoms and serological markers, or a previous diagnosis), postoperative corticosteroid therapy may be considered.
Primary options
methylprednisolone: consult specialist for guidance on dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
methylprednisolone: consult specialist for guidance on dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
methylprednisolone
chronic mesenteric ischaemia
1st line – medical optimisation + surgical systemic-mesenteric bypass
medical optimisation + surgical systemic-mesenteric bypass
The treatment of chronic mesenteric ischaemia will depend on several factors, most notably whether or not the patient is a surgical candidate. Consider endovascular treatment, particularly in patients with severe malnutrition, as it is associated with less morbidity and mortality than open therapy.[68]Pecoraro F, Rancic Z, Lachat M, et al. Chronic mesenteric ischemia: critical review and guidelines for management. Ann Vasc Surg. 2013 Jan;27(1):113-22. http://www.ncbi.nlm.nih.gov/pubmed/23088809?tool=bestpractice.com [69]Huber TS, Björck M, Chandra A, et al. Chronic mesenteric ischemia: clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg. 2021 Jan;73(1s):87S-115S. https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(20)32286-2 http://www.ncbi.nlm.nih.gov/pubmed/33171195?tool=bestpractice.com
The National Institute for Health and Care Excellence in the UK defines malnutrition as:[70]National Institute for Health and Care Excellence. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. August 2017 [internet publication]. https://www.nice.org.uk/guidance/cg32
A body mass index (BMI) of less than 18.5 kg/m2
Unintentional weight loss greater than 10% within the last 3 to 6 months
A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3 to 6 months.
If the patient is assessed as suitable for open surgery after medical optimisation of any cardiovascular, respiratory, or other comorbidities, then surgical systemic-mesenteric bypass forms the mainstay of treatment.
Antegrade and retrograde bypass grafting, aortic re-implantation of the superior mesenteric artery, and transarterial and transaortic mesenteric endarterectomy may all have a role.[31]American College of Radiology. ACR appropriateness criteria: radiologic management of mesenteric ischemia. 2022 [internet publication]. https://acsearch.acr.org/docs/69501/Narrative Open surgery is better for long-term patency when compared with endovascular approaches for chronic mesenteric ischaemia.[68]Pecoraro F, Rancic Z, Lachat M, et al. Chronic mesenteric ischemia: critical review and guidelines for management. Ann Vasc Surg. 2013 Jan;27(1):113-22. http://www.ncbi.nlm.nih.gov/pubmed/23088809?tool=bestpractice.com [71]Gupta PK, Horan SM, Turaga KK, et al. Chronic mesenteric ischemia: endovascular versus open revascularization. J Endovasc Ther. 2010 Aug;17(4):540-9. http://www.ncbi.nlm.nih.gov/pubmed/20681773?tool=bestpractice.com
1st line – medical optimisation + percutaneous angioplasty and stenting
medical optimisation + percutaneous angioplasty and stenting
If the patient is assessed as unsuitable for open surgery despite medical optimisation of any cardiovascular, respiratory, or other comorbidities, then percutaneous transluminal mesenteric angioplasty alone or with stent insertion may be an option.[72]Assar AN, Abilez OJ, Zarins CK. Outcome of open versus endovascular revascularization for chronic mesenteric ischemia: review of comparative studies. J Cardiovasc Surg (Torino). 2009 Aug;50(4):509-14. http://www.ncbi.nlm.nih.gov/pubmed/19455085?tool=bestpractice.com
ischaemic colitis
conservative management
Patients with colonic ischaemia can develop chronic ulcerating ischaemic colitis.[37]Xu Y, Xiong L, Li Y, et al. Diagnostic methods and drug therapies in patients with ischemic colitis. Int J Colorectal Dis. 2021 Jan;36(1):47-56. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493065 http://www.ncbi.nlm.nih.gov/pubmed/32936393?tool=bestpractice.com Seek gastroenterological and surgical input for ischaemic colitis.[36]Hung A, Calderbank T, Samaan MA, et al. Ischaemic colitis: practical challenges and evidence-based recommendations for management. Frontline Gastroenterol. 2021;12(1):44-52. http://www.ncbi.nlm.nih.gov/pubmed/33489068?tool=bestpractice.com
In mild cases, trial conservative management, including intravenous antibiotics, fluids (and blood glucose control in patients with diabetes), and bowel rest.
Consider nutrition support in patients at risk of malnutrition who:[70]National Institute for Health and Care Excellence. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. August 2017 [internet publication]. https://www.nice.org.uk/guidance/cg32
Have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer
Have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.
Frequently review the patient, examining the abdomen and monitoring vital signs. Further investigations and imaging are required if symptoms do not resolve, symptoms worsen, or new symptoms appear.[36]Hung A, Calderbank T, Samaan MA, et al. Ischaemic colitis: practical challenges and evidence-based recommendations for management. Frontline Gastroenterol. 2021;12(1):44-52. http://www.ncbi.nlm.nih.gov/pubmed/33489068?tool=bestpractice.com
anticoagulation
Additional treatment recommended for SOME patients in selected patient group
Prophylactic low molecular weight heparin is generally used. Secondary prevention with anticoagulation should be considered at the point of discharge.[36]Hung A, Calderbank T, Samaan MA, et al. Ischaemic colitis: practical challenges and evidence-based recommendations for management. Frontline Gastroenterol. 2021;12(1):44-52. http://www.ncbi.nlm.nih.gov/pubmed/33489068?tool=bestpractice.com
Primary options
heparin: consult specialist for guidance on dose
OR
warfarin: consult specialist for guidance on dose
segmental resection and stoma
Additional treatment recommended for SOME patients in selected patient group
Surgical intervention for ischaemic colitis usually involves segmental resection and stoma formation.[36]Hung A, Calderbank T, Samaan MA, et al. Ischaemic colitis: practical challenges and evidence-based recommendations for management. Frontline Gastroenterol. 2021;12(1):44-52. http://www.ncbi.nlm.nih.gov/pubmed/33489068?tool=bestpractice.com
non-acute colonic ischaemia
segmental colectomy
Patients who have an acute episode of colonic ischaemia that evolves into a segmental colitis pattern with symptoms persisting for >2 weeks, or who develop a protein-losing colonopathy, are usually best treated by segmental colectomy.[4]Brandt LJ, Feuerstadt P, Longstreth GF, et al. ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol. 2015 Jan;110(1):18-44. https://journals.lww.com/ajg/fulltext/2015/01000/acg_clinical_guideline__epidemiology,_risk.8.aspx http://www.ncbi.nlm.nih.gov/pubmed/25559486?tool=bestpractice.com
segmental colectomy
Episodes of recurrent sepsis in a patient who has symptomatically recovered from an acute episode of colonic ischaemia may be an indication for surgery. These patients usually have a short segment of unhealed bowel that is the source of sepsis, and resection of the segment is usually curative.[4]Brandt LJ, Feuerstadt P, Longstreth GF, et al. ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol. 2015 Jan;110(1):18-44. https://journals.lww.com/ajg/fulltext/2015/01000/acg_clinical_guideline__epidemiology,_risk.8.aspx http://www.ncbi.nlm.nih.gov/pubmed/25559486?tool=bestpractice.com
See Sepsis in adults.
1st line – endoscopic dilation of stricture or segmental resection
endoscopic dilation of stricture or segmental resection
These interventions should only be used if strictures are symptomatic. Transendoscopic dilation may be successful in less severe cases. Alternatively, segmental resection can be used.[4]Brandt LJ, Feuerstadt P, Longstreth GF, et al. ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol. 2015 Jan;110(1):18-44. https://journals.lww.com/ajg/fulltext/2015/01000/acg_clinical_guideline__epidemiology,_risk.8.aspx http://www.ncbi.nlm.nih.gov/pubmed/25559486?tool=bestpractice.com
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