Diagnosis and management of acute mesenteric ischemia: What you need to know.

Acute mesenteric ischemia (AMI) is associated with high mortality rates. There are multiple challenges to establishing an accurate early diagnosis and providing state-of-the-art care for AMI patients. A high index of suspicion is key for early diagnosis. Once suspicion is raised, a triphasic computed tomography angiography is the essential diagnostic tool. Avoiding delays, using hybrid operating rooms and contemporary revascularization techniques for arterial occlusive AMI, can significantly improve the prognosis. Regional health care systems should be developed to direct AMI patients into centers with sufficient capabilities for providing all aspects of care at all hours. The acute care surgeon has a central role in performing laparotomies and bowel resections when needed and coordinating the management flow in close collaboration with vascular surgeons and interventional radiologists for prompt and effective revascularization. A significant share of patients with an arterial occlusive AMI can be managed by endovascular revascularization without the need for a laparotomy. There are no reliable tools for predicting transmural bowel necrosis, and individual assessment and clinical experience are very important in decision-making when choosing between laparotomy and close observation. During laparotomy, an atherosclerotic occlusion at the root of the superior mesenteric artery can be stented by using a retrograde open mesenteric or percutaneous approach, and surgical bypass is seldom needed. Using hospital-specific management pathways is very useful for the standardization of care in arterial occlusive AMI. In venous AMI, systemic anticoagulation is sufficient in most cases. In patients whose symptoms do not resolve, there are various options for endovascular and surgical revascularization. In nonocclusive mesenteric ischemia, prevention by maintaining sufficient abdominal perfusion pressure is key. High-level evidence is scarce, but with current knowledge, the prognosis of AMI patients has plenty of room for improvement.