Mesenteric ischemia medical therapy

Mesenteric ischemia is a medical emergency that requires prompt treatment. The mainstay of treatment is surgery if bowel necrosis or gangrene has occurred, whereas medical therapy is considered initially for hemodynamically stable patients.

The treatment of choice, medical versus surgical in mesenteric ischemia depends on the following key elements:

• Duration and severity of ischemia of the intestine
• Nature of the occlusive lesion
• Availability of the immediate surgical or interventional radiology facility in the emergency room
• Hemodyanamic stability of the patient

(A)Conservative management:

Mesenteric ischemia is an acute emergency condition that requires prompt intervention. The outline of initial medical management of all types of mesenteric ischemia includes:^{[1][2][3][4][3]}

• Supplemental oxygen

• Pain control
• Fluid resuscitation
• Hemodynamic support and monitoring

• Correction of electrolyte abnormalities
• Anticoagulation with heparin, to limit thrombus propagation^[5][1]

• Broad sprectrum antibiotics^[4][6]
• Gastrointestinal decompression
• Avoidance of vasopressors, which can exacerbate ischemia
• Proton pump inhibitors
• Measurement of electrolytes and acid base status
• Nutritional assessment and support

1.Pain control:

Parenteral opioids are used to control the pain.

2.Fluid resuscitation:

Patients suspected of having mesenteric ischemia should be resuscitated with crystalloids and blood products to prevent cardiovascular collapse.

3.Hemodynamic support and monitoring:

In order to guide effective resuscitation, effective hemodyanamic support and monitoring should be implemented.

4.Anticoagulation with heparin:^[7][8]

Early use of heparin is asscociated with improved survival especially in cases of mesenteric venous thrombosis.

5.Broad sprectrum antibiotics:

Broad spectrum antibiotics should be administered early in the course of treatment of mesenteric ischemia to prevent the risk of infection.

6.Avoidance of vasopressors:

Vasopressors should be used with caution. Dobutamine, low dose dopamine and milrinone can be used to improve cardiac function as they have less effect on mesenteric blood flow.

7.Measurement of electrolytes and acid base status:

8.Nutritional assessment and support:^[9][2]

For patients presenting with chronic mesenteric ischemia, nutritional assessment and support is an important factor as they usually present with malnutrition (BMI<20 and albumin <3).