Acute Mesenteric Ischemia — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Suspected AMI?
   Pain out of proportion to findings — suspected acute mesenteric ischemia? (Sudden severe abdominal pain with mild findings (pain out of proportion) → treat as AMI until excluded. Causes: arterial embolism (~50%), arterial thrombosis (15–25%), venous thrombosis (5–15%), non-occlusive (NOMI, in the critically ill / on vasopressors). Raised lactate/CK appears late and is non-specific.)
   • Suspected AMI → Confirm & initial management
   • Does not fit → Does not fit
2. [End] Does not fit
   Evaluate other causes of an acute abdomen and manage along the appropriate pathway; reassess dynamically in high-risk patients (AF, atherosclerosis, hypoperfusion).
3. [Decision] Confirm & initial management
   Are there signs of peritonitis / bowel necrosis? (Confirm with CTA as soon as possible (not plain film). Concurrently start fluid resuscitation (limited crystalloid to prevent abdominal compartment syndrome), correct electrolytes, gastric decompression, broad-spectrum antibiotics, and IV unfractionated heparin anticoagulation (if no contraindication).)
   • Peritonitis / bowel necrosis present → Peritonitis → emergency laparotomy
   • None (assess revascularization) → No peritonitis → revascularization
4. [End] Peritonitis → emergency laparotomy
   Emergency laparotomy: embolectomy/revascularization, resect necrotic bowel, with damage control and a second-look to assess bowel viability before anastomosis if needed. Continue resuscitation, antibiotics and anticoagulation perioperatively.
5. [End] No peritonitis → revascularization
   On top of resuscitation + anticoagulation + antibiotics, revascularize as early as possible: embolism/thrombosis by surgical embolectomy or endovascular therapy (partial occlusion is more suited to endovascular); NOMI by intra-arterial papaverine and correcting hypoperfusion, stopping vasoconstrictors. Reassess closely; convert to laparotomy if peritonitis develops.

Source guidelines & references

• WSES 2022 Guidelines on acute mesenteric ischemia. World J Emerg Surg 2022

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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