Mesenteric ischemia is a lack of blood flow to the intestines, most often from an embolus or clot in the superior mesenteric artery. Acute cases are emergencies with high mortality, while chronic cases cause pain after meals and weight loss from narrowed arteries.
Key symptoms
- Sudden, severe belly pain out of proportion to the exam
- Nausea, vomiting or a sudden urge to pass stool
- Bloody stool later in the course
- Chronic form: pain 30 to 60 minutes after eating, fear of food and weight loss
What you find on exam
- Soft abdomen with little tenderness early despite severe pain
- Irregular pulse from atrial fibrillation
- Later: distension, guarding and rebound as the bowel dies
- Signs of shock: fast pulse, low pressure, confusion
Tests
- CT angiography of the abdomen right away
- Lactate, blood count, electrolytes and kidney function
- ECG for atrial fibrillation
- A normal lactate early does not rule it out
Treatment basics
- IV fluids, nothing by mouth, broad-spectrum antibiotics
- IV heparin as soon as the diagnosis is likely
- Urgent restoration of flow: embolectomy, endovascular stenting or thrombolysis
- Surgery to remove dead bowel, often with a second-look operation
- Chronic form: elective stenting or bypass
Red flags
- Severe pain out of proportion to the exam in an older patient with atrial fibrillation
- Peritoneal signs, bloody stools or rising lactate
- Low blood pressure or signs of sepsis
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Sources: NASEMSO National Model EMS Clinical Guidelines; NCCPA PANCE Content Blueprint; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.