Diagnosis and Management of Acute Mesenteric Ischemia in the Emergency Department

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Publication Date: December 2024 (Volume 26, Number 12)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 12/01/2027.

Author

Peer Reviewers

Abstract

Acute mesenteric ischemia is a rare but potentially catastrophic condition, and survival is highly dependent on timely diagnosis in the emergency department. Symptoms can be both variable and subtle. Laboratory studies may be misleading and may provide either false reassurance or misdirection. This review includes evidence-based recommendations on the recognition of the 4 separate types of acute mesenteric ischemia, current guidelines on the diagnostic approach, and essential resuscitative steps that should be initiated in the emergency department.

Case Presentations

A 55-year-old woman presents via EMS with vomiting and diarrhea in the setting of new, severe abdominal pain for the past 30 minutes…

• The patient states that she was previously diagnosed with atrial fibrillation, but she never established care due to concerns about the cost of anticoagulation medication.
• Her temperature is 37˚C; blood pressure, 156/90 mm Hg; heart rate, 110 beats/min; respiratory rate, 20 breaths/min; and oxygen saturation, 96% on room air.
• On physical examination, you note that despite the patient reporting severe abdominal pain, she does not seem to have any significant tenderness or guarding. Her laboratory test results are notable for mild acute kidney injury but no leukocytosis or lactic acidosis.
• You wonder whether these laboratory tests have sufficiently ruled out acute mesenteric ischemia. If not, is it still reasonable to move forward with CT imaging?

A 75-year-old man presents to the ED with his family, who are concerned about his health…

• The family informs you that he has been experiencing abdominal pain and losing weight for at least the past 6 months, although it seems to have worsened over the past few days, and he has simultaneously become quite ill.
• His temperature is 38.5˚C; blood pressure, 84/52 mm Hg; heart rate, 100 beats/min; respiratory rate, 24 breaths/min; and oxygen saturation, 93% on room air. On examination, he is ill-appearing and oriented to name only. His abdomen appears moderately distended and is tender to palpation.
• You wonder whether this could represent acute mesenteric ischemia, and what treatment you should implement immediately…

A 60-year-old man intubated for pneumonia is boarding in the ED, waiting on transfer to an available ICU bed…

• The patient became hypotensive a couple of hours ago, and he was started on peripheral norepinephrine. The patient’s recent lactate measurements have been increasing.
• On examination, you note that he is sedated and unable to provide significant history. His abdomen appears to be mildly distended, with hypoactive bowel sounds and possibly some tenderness.
• You wonder what additional resuscitative measures you could take in the ED, and whether any advanced therapies might benefit this patient…

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