Ischemic bowel disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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

ACUTE

evidence of infarction, perforation, or peritonitis

1st line – resuscitation and supportive measures

Plus – empiric antibiotics

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Plus –

empiric antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotics suitable for enteric coverage (e.g., third-generation cephalosporin or a fluoroquinolone plus metronidazole) should be given to all patients, as bacterial translocation may be significant due to the loss of the normal intestinal mucosal barrier.[11]

Antibiotics should be prescribed according to local antimicrobial guidelines that are targeted against local sensitivities.

Systemic fluoroquinolone antibiotics, such as levofloxacin, 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; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[47] 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 information source for more information on suitability, contraindications, and precautions.

Primary options

ceftriaxone: 1 g intravenously every 24 hours

levofloxacin: 500 mg intravenously every 24 hours

-- AND --

metronidazole: 500 mg intravenously every 8 hours

Plus – exploratory laparotomy or laparoscopy

superior mesenteric artery (SMA) embolus

Plus – surgical revascularization or endovascular therapy ± bowel resection

Back

Plus –

surgical revascularization or endovascular therapy ± bowel resection

Treatment recommended for ALL patients in selected patient group

Responsible for approximately 50% of acute mesenteric ischemia events. Emboli typically originate from the heart and lodge at points of normal anatomic tapering, usually just distal to the origin of a major branch.

An embolus in the superior SMA causes severe vasoconstriction of both the obstructed and unobstructed branches of the SMA. If not corrected promptly this vasoconstriction can become irreversible and persist following removal of the embolus.

The American College of Radiology recommends surgical revascularization for most patients, with endovascular revascularization used as an adjunct to surgery in patients who are clinically unstable and need urgent intervention.[17] However, if available and the clinical condition of the patient permits, endovascular treatment may be considered as a first-line option.[11][12][24]

Any infarcted bowel should be resected.

Transcatheter thrombolysis may be an option for patients where residual clot remains in the arterial bed following embolectomy.[17] The risk of hemorrhage should be carefully considered.[17]

Plus – postoperative anticoagulation

acute superior mesenteric artery (SMA) thrombosis

Plus – endovascular therapy ± endarterectomy or bypass ± bowel resection

Plus – postoperative anticoagulation

nonocclusive mesenteric ischemia

Plus – correct underlying medical cause ± vasodilator infusion ± bowel resection

Back

Plus –

correct underlying medical cause ± vasodilator infusion ± bowel resection

Treatment recommended for ALL patients in selected patient group

Responsible for 20% to 30% of cases of acute mesenteric ischemia and results from mesenteric vasoconstriction following hypoperfusion of the gut.

Hypoperfusion may be precipitated by congestive heart failure, cardiac arrhythmia, shock, or by large volume shifts such as occur during hemodialysis.

Correcting any underlying medical cause of hypoperfusion (e.g., heart failure) is of paramount importance to restore perfusion.

Endovascular therapy with selective mesenteric angiography and intra-arterial infusion of vasodilators (e.g., papaverine, alprostadil) may be considered. In practice, vasodilators may be given if a repeat angiogram shows evidence of vasospasm. Papaverine is not available as a Food and Drug Administration (FDA)-approved proprietary formulation in the US. Alprostadil (prostaglandin E1) may be considered. The American College of Radiology recommends alprostadil for patients without evidence of peritoneal signs.[17] However, in practice it is also used for those with evidence of infarction, perforation, or peritonitis. The evidence for alprostadil is limited.[17] However, one large retrospective study showed significant improvement in organ function after 24 hours of treatment, although no overall survival benefit.[83] Other vasodilatory agents to be considered in the treatment of nonocclusive mesenteric ischemia include nitroglycerin.[54][55][56] Consult a specialist for guidance on the choice of a suitable vasodilator and the dose.

Infarcted bowel should be resected following infusion of vasodilators.[24] Bowel of questionable viability should be preserved unless necrosis is clear; borderline viable bowel often responds to vasodilators and, by using frequent re-explorations, intestinal resection can be kept to a minimum.

Back

Plus –

empiric antibiotics

Treatment recommended for ALL patients in selected patient group

Patients with colonic ischemia routinely receive antibiotic therapy suitable for enteric coverage to protect against bacterial translocation, although good evidence of benefit is lacking. The practice is based on a number of old studies and the theoretical protection it gives against the bacterial translocation that occurs with loss of mucosal integrity.[11]

Antibiotics should be prescribed according to local antimicrobial guidelines that are targeted against local sensitivities.

Primary options

ceftriaxone: 1 g intravenously every 24 hours

levofloxacin: 500 mg intravenously every 24 hours

-- AND --

metronidazole: 500 mg intravenously every 8 hours

superior mesenteric artery (SMA) embolus

Plus – endovascular therapy ± open embolectomy ± bowel resection

Back

Plus –

endovascular therapy ± open embolectomy ± bowel resection

Treatment recommended for ALL patients in selected patient group

If available and the clinical condition of the patient permits, endovascular treatment should be considered as the first-line option.[17] Endovascular intervention includes aspiration embolectomy and transcatheter thrombolysis; choice of intervention is guided by local preference.[17] Transcatheter thrombolysis may be used instead of, or in addition to, aspiration embolectomy.[12][17][59][60][61]

If endovascular intervention is unsuccessful, patients should undergo surgical embolectomy.[17] Indications that endovascular intervention has been unsuccessful include lysis of the embolus not demonstrated within 4 hours, and evidence of ischemia progression.

Any infarcted bowel should be resected.

Plus – anticoagulation

superior mesenteric artery (SMA) thrombosis

Plus – endovascular therapy ± endarterectomy or bypass ± bowel resection

Plus – anticoagulation

nonocclusive mesenteric ischemia

Plus – correct underlying medical cause + vasodilator infusion + observation

Back

Plus –

correct underlying medical cause + vasodilator infusion + observation

Treatment recommended for ALL patients in selected patient group

Responsible for 20% to 30% of cases of acute mesenteric ischemia and results from mesenteric vasoconstriction following hypoperfusion of the gut.

Hypoperfusion may be precipitated by congestive heart failure, cardiac arrhythmia, shock, or by large volume shifts such as occur during hemodialysis.

After correction of the underlying medical condition, endovascular therapy is the first-line option with selective mesenteric angiography and intra-arterial infusion of vasodilators (e.g., papaverine or alprostadil). In practice, vasodilators may be given if a repeat angiogram shows evidence of vasospasm. Papaverine is not available as a Food and Drug Administration (FDA)-approved proprietary formulation in the US. Alprostadil (prostaglandin E1) may be considered. The American College of Radiology recommends alprostadil for patients without evidence of peritoneal signs.[17] The evidence for alprostadil is limited.[17] However, one large retrospective study showed significant improvement in organ function after 24 hours of treatment, although no overall survival benefit.[83] Other vasodilatory agents to be considered in the treatment of nonocclusive mesenteric ischemia include nitroglycerin.[54][55][56] Consult a specialist for guidance on the choice of a suitable vasodilator and the dose.

mesenteric vein thrombosis

Plus – anticoagulation + observation

Back

Plus –

anticoagulation + observation

Treatment recommended for ALL patients in selected patient group

Systemic anticoagulation is the first-line treatment option for venous mesenteric ischemia when the clinical condition permits.[17] 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.

In patients who receive heparin the recurrence rate is lowered from 25% to 13% and mortality is reduced from 50% to 13%.[32] 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.

If patients remain stable and symptom-free, they may be converted to warfarin 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, or a further extended duration if a predisposing hypercoagulable state or concomitant deep vein thrombosis can be identified.[58]

Primary options

heparin: see local protocol for dosing guidelines

warfarin: see local protocol for dosing guidelines

Consider – endovascular management

vasculitis associated mesenteric ischemia

Plus – immunosuppressant therapy

ONGOING

chronic mesenteric ischemia

due to atherosclerotic disease

1st line – endovascular revascularization

Back

1st line –

endovascular revascularization

If chronic mesenteric disease is due to atherosclerotic disease, endovascular revascularization is the primary treatment of choice.[17] Endovascular revascularization has largely replaced open surgical revascularization in patients with chronic mesenteric ischemia, due to lower perioperative risk, especially in patients with severe malnutrition.[17][62][63][64][65] However, endovascular management is associated with higher risk of peripheral vascular complications, restenosis, recurrent symptoms, and requirement for additional interventions.[17]

Consider – surgical revascularization

Consider – systemic anticoagulation

due to celiac compression syndrome: surgical candidate

1st line – surgical release of the median arcuate ligament (MAL)

Consider – endovascular stent placement or surgical bypass

due to celiac compression syndrome: nonsurgical candidate

1st line – supportive measures

Ischemic bowel disease

Treatment algorithm

evidence of infarction, perforation, or peritonitis

resuscitation and supportive measures

empiric antibiotics

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

exploratory laparotomy or laparoscopy

surgical revascularization or endovascular therapy ± bowel resection

postoperative anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

endovascular therapy ± endarterectomy or bypass ± bowel resection

postoperative anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

correct underlying medical cause ± vasodilator infusion ± bowel resection

anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

endovascular management

subtotal or total colectomy

no evidence of infarction, perforation, or peritonitis

supportive measures

empiric antibiotics

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

endovascular therapy ± open embolectomy ± bowel resection

anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

endovascular therapy ± endarterectomy or bypass ± bowel resection

anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

correct underlying medical cause + vasodilator infusion + observation

anticoagulation + observation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

endovascular management

immunosuppressant therapy

chronic mesenteric ischemia

endovascular revascularization

surgical revascularization

systemic anticoagulation

Primary options

surgical release of the median arcuate ligament (MAL)

endovascular stent placement or surgical bypass

supportive measures

nonacute colonic ischemia

segmental colectomy

segmental colectomy

endoscopic dilation of stricture or segmental resection