However, this is a mid to late finding and is seen in

only 40% of patients. Nonspecific findings s uch as ileus are

seen in up to 60% of patients. Pneumatosis intestinalis,

portal venous air, andfreeairare latefindings (Figure 32-lA).

Computed tomography (CT) angiography is much

more sensitive and frequently shows bowel edema, lack of

arterial flow, or venous thrombus with ischemia. It has

become the imaging study of choice in suspected acute

mesenteric ischemia (Figure 32-lB).

MEDICAL DECISION MAKING

Any patient who is part of the "at risk" population who

presents with moderate to severe abdominal pain should

be considered at risk for mesenteric ischemia (Figure 32-2).

A lactic acid level should be obtained as soon as possible

and the stool should be tested for blood. Involve your surgical consultant early. If the diagnosis is in question, a CT

angiogram should be performed.

B

.A. Figure 32-1. A. Porta l venous air, a late finding of

mesenteric ischemia, is seen in this patient (arrows).

B. Pneumatosis intesti nalis demonstrated in a loop of

bowel on CT sca n (arrow).

TREATMENT

In the emergency department, aggressive fluid therapy to

correct hypotension and hypovolemia is instituted. Central

venous access and monitoring may be necessary. Administer

broad-spectrum antibiotics in the setting of suspected

perforation.

MESENTERIC ISCHEMIA

C Abdominal pain�

Severe pain, out of proportion to

exam, elderly + j- risk factors

for mesenteric ischemia

Pa in medications

order labs, lactate, upright CXR

order CTA Abd/Pelvis

Figure 32-2. Mesenteric ischemia diagnostic algorithm. CTA,

com puted tomography angiogram; CXR, chest x-ray.

Surgery is the mainstay of treatment for mesenteric

ischemia due to embolus or thrombosis. Early surgical

consultation has been shown to improve outcomes even in

patients ultimately treated nonsurgically. Patients with

ischemia due to nonocclusive disease or venous thrombosis

are not amenable to surgery, but surgery may be necessary

to remove necrotic bowel. There are several nonsurgical

management options involving angiography. Infusion of

papaverine into the SMA for vasodilation has been reported

to improve survival rate. Venous thrombosis is treated with

anticoagulation.

DISPOSITION

All patients with mesenteric ischemia need rapid surgical

consult and admission.

SUGGESTED READINGS

Deehan DJ, Heys SD, Brittenden J. Mesenteric ischemia: prog ­

nostic factors and Influence of delay upon outcome. J R Coli

Surg Edinb. 1 995;40:1 1 2-1 15.

Edwards MS, Cherr GS, Craven TE. Acute occlusive mesenteric

ischemia: surgical management and outcomes. Ann Vase Surg.

2003;17:72-79.

O'Brien MC. Acute abdominal pain. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.