What are the guideline sources, guidelines and references for Acute mesenteric ischemia ?
Guideline sources The following summarized guidelines for the evaluation and management of acute mesenteric ischemia (AMI) are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2022), the American Association for the Study of Liver Diseases (AASLD 2021), the American College of Gastroenterology (ACG 2020), the European Society of Cardiology (ESC/ESVS 2018), the American College of Radiology (ACR 2018), the European Society for Vascular Surgery (ESVS 2017), the European Society for Trauma and Emergency Surgery (ESTES 2016), and the European Association for the Study of the Liver (EASL 2016). 1 2 3 4 5 6 7 8 https://web.pathway.md/diseases/receyfRKUHyVy6myP 1/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway Guidelines 1. Screening and diagnosis Diagnosis: As per WSES 2022 guidelines: Suspect AMI in patients with severe abdominal pain out of proportion to physical examination until disproven. B Suspect non-occlusive mesenteric ischemia in critically ill patients with abdominal pain or distension requiring vasopressor support and evidence of multiorgan dysfunction. B As per ESVS 2017 guidelines, diagnose non-occlusive mesenteric ischemia based on clinical suspicion. B Do not obtain biomarkers to diagnose or rule out the condition in patients with suspected non-occlusive mesenteric ischemia. B As per ESTES 2016 guidelines, suspect the diagnosis of AMI in patients with acute abdominal pain without clear diagnosis, particularly when the pain is disproportionate to the physical examination findings, and in elderly patients with a history of cardiovascular comorbidities. B Show 2 more 2. Classification and risk stratification Classification: Differentiate AMI into the following types based on the clinical scenario and risk factors: mesenteric arterial embolism mesenteric arterial thrombosis non-occlusive mesenteric ischemia mesenteric venous thrombosis. B 3. Diagnostic investigations Diagnostic imaging: As per WSES 2022 guidelines: Obtain CT angiography without delay in any patient with suspected AMI. A Do not obtain plain radiographs for the evaluation of intestinal ischemia. D As per ACR 2018 guidelines, obtain CT angiography as initial imaging in patients with suspected AMI. B As per ESC 2018 guidelines, obtain urgent CT angiography in patients with suspected AMI. B As per ESVS 2017 guidelines: Obtain triphasic CT angiography with 1 mm slices (or thinner) to detect mesenteric arterial occlusion in patients with suspected AMI. B https://web.pathway.md/diseases/receyfRKUHyVy6myP 2/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway Consider obtaining CT angiography, accepting the risk of contrast-induced renal failure, in patients with suspected AMI and elevated creatinine values. C As per ESTES 2016 guidelines: Obtain immediate multidetector CT with IV contrast in patients with suspected AMI. Avoid using oral contrast as it significantly delays the investigation. B Do not obtain percutaneous angiography for initial diagnosis of AMI, unless non-occlusive mesenteric ischemia is suspected. D Laboratory tests: As per WSES 2022 guidelines, recognize that there are no sufficiently accurate laboratory parameters to conclusively identify the presence or absence of ischemic or necrotic bowel, although assessments for elevated L-lactate, leukocytosis, and D-dimer may assist. B As per ESC 2018 guidelines, consider obtaining D-dimer in patients with suspected AMI to rule out the diagnosis. C As per ESVS 2017 guidelines: Obtain D-dimer measurement to exclude AMI in patients with acute abdominal pain. B Do not obtain L-lactate measurement to diagnose or rule out acute occlusive mesenteric ischemia. D As per ESTES 2016 guidelines: Do not use serum lactate levels for the diagnosis of AMI, as its normal value does not exclude the diagnosis. D Do not use routine laboratory tests for the diagnosis of AMI, instead they reflect disease progression. D 4. Diagnostic procedures Laparoscopy: insufficient evidence to support routine use of laparoscopy in patients with AMI. I 5. Respiratory support Oxygen therapy: administer immediate supplementary oxygen in patients with AMI. B 6. Medical management General principles: As per WSES 2022 guidelines: Manage patients with AMI in dedicated centers using a focused care bundle and a multidisciplinary team. B Treat the underlying cause and improve mesenteric perfusion in patients with suspected non- occlusive mesenteric ischemia. B https://web.pathway.md/diseases/receyfRKUHyVy6myP 3/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway As per ESC 2018 guidelines, obtain strict glycemic control in patients with diabetes mellitus and PAD. B As per ESTES 2016 guidelines, perform revascularization within 12 hours from the onset of symptoms in patients with AMI. B Show 2 more Supportive therapy: As per WSES 2022 guidelines: Initiate immediate fluid resuscitation to enhance visceral perfusion once the diagnosis of AMI is made. Correct electrolyte abnormalities. B Provide postoperative intensive care in patients with AMI for improved intestinal perfusion and prevention of multiple organ failure. B As per ESTES 2016 guidelines, obtain quick assessment of fluid volume status and initiate prompt fluid replacement in patients with AMI, but do not delay the diagnosis and interventions. B Show 5 more Antibiotic therapy: As per WSES 2022 guidelines, administer broad-spectrum antibiotics immediately in patients with AMI. B As per ESVS 2017 guidelines, administer antibiotics in patients requiring bowel resection for intestinal infarction. A As per ESTES 2016 guidelines, administer broad-spectrum antibiotics early in the course in patients with AMI. B Antithrombotic therapy: As per WSES 2022 guidelines: Consider administering a continuous infusion of UFH for the treatment of patients with mesenteric venous thrombosis. B Initiate long-term anticoagulation in patients after revascularization. B As per ESTES 2016 guidelines, initiate systemic anticoagulation as soon as possible in patients with acute mesenteric venous thrombosis. B Show 2 more Antihypertensive therapy: Target controlling BP at < 140/90 mmHg in patients with PAD and hypertension. A Consider offering ACEIs or ARBs as first-line therapy in patients with PAD and hypertension. C Lipid-lowering therapy: Offer statins in all patients with PADs. A Target reducing LDL-C to < 1.8 mmol/L (< 70 mg/dL) or decreasing it by 50% if baseline values are 1.8-3.5 mmol/L (70-135 mg/dL). B Palliative care: https://web.pathway.md/diseases/receyfRKUHyVy6myP 4/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway As per WSES 2022 guidelines, obtain a careful assessment of underlying comorbidities and use advanced directives to find the optimal therapeutic strategy (including palliation) in patients with massive gut necrosis. B As per ESTES 2016 guidelines: Offer palliative care in patients with AMI considered unsalvageable. B Consider offering palliative care alone in patients with advanced age, late presentation, peritonitis and signs of organ failure, as they are unlikely to benefit from invasive procedures. C 7. Inpatient care Intra-abdominal pressure monitoring: Obtain intra-abdominal pressure monitoring to prevent non-occlusive mesenteric ischemia in patients with known risk factors for intraabdominal hypertension/abdominal compartment syndrome. B Initiate medical treatment in patients with intraabdominal pressure > 12 mmHg to prevent abdominal compartment syndrome and non-occlusive mesenteric ischemia. B 8. Nonpharmacologic interventions Lifestyle modifications: As per ESC 2018 guidelines, advise smoking cessation B , healthy diet and physical activity in all patients with PADs. B As per ESTES 2016 guidelines, advise making appropriate lifestyle changes to reduce the consequences of vascular disease in all patients with AMI. B 9. Therapeutic procedures Nasogastric decompression: perform nasogastric decompression in patients with AMI. B Endovascular revascularization: As per WSES 2022 guidelines, perform endovascular revascularization, if sufficient expertise is available, as the primary procedure in patients with arterial occlusion. B As per ESC 2018 guidelines: Consider performing endovascular revascularization in patients with acute mesenteric arterial embolism. C Consider performing endovascular revascularization as first-line therapy in patients with acute mesenteric arterial thrombosis. C As per ESVS 2017 guidelines, consider performing endovascular therapy as first-line therapy in patients with acute thrombotic superior mesenteric artery occlusion. C https://web.pathway.md/diseases/receyfRKUHyVy6myP 5/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway As per ESTES 2016 guidelines, decide on performing endovascular intervention or open surgery in patients with acute mesenteric arterial embolism based on personal experience and technical capabilities of the surgeon and the available resources, if immediate surgical intervention is not required. B Show 2 more 10. Surgical interventions Indications for open surgery: As per WSES 2022 guidelines, perform prompt laparoscopy/laparotomy in patients with overt peritonitis. B As per ESC 2018 guidelines, consider performing open surgical revascularization in patients with acute mesenteric arterial embolism. C As per ESVS 2017 guidelines: Perform decompression laparotomy to prevent non-occlusive mesenteric ischemia in patients with abdominal compartment syndrome (defined as an intraabdominal pressure > 20 mmHg and newly developed organ dysfunction or failure). B Transfer patients with life-threatening non-occlusive mesenteric ischemia to an operating room with the capacity for open and endovascular surgery where angiography (with stenting in the case of stenosis) and/or intra-arterial administration of vasodilators and/or laparotomy for bowel resection can be performed. B As per ESTES 2016 guidelines, decide on performing open surgery or endovascular intervention in patients with acute mesenteric arterial embolism based on personal experience and technical capabilities of the surgeon and the available resources, if immediate surgical intervention is not required. B Show 3 more Bowel resection: As per WSES 2022 guidelines: Perform prompt resection of infarcted bowel in patients with non-occlusive mesenteric ischemia. B Restore digestive continuity in association with hormonal therapy to optimize absorptive function and achieve nutritional autonomy in patients with short bowel syndrome following extensive bowel resection. B As per ESVS 2017 guidelines: Consider performing open or endovascular revascularization before bowel surgery in patients with acute mesenteric arterial ischemia. C Assess bowel viability during laparotomy based on clinical judgment. B As per ESTES 2016 guidelines, perform excision of non-viable, necrotic bowel without delay in patients with AMI considered salvageable. B Show 5 more https://web.pathway.md/diseases/receyfRKUHyVy6myP 6/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway Damage control surgery: As per WSES 2022 guidelines, perform damage control surgery with temporary abdominal closure as an adjunct to allow reassessment of bowel viability in patients requiring intestinal resection and in patients with severe abdominal sepsis. B As per ESTES 2016 guidelines, perform life-saving damage control surgery in patients with AMI and severe sepsis or septic shock. B 11. Specific circumstances Patients with isolated mesenteric artery dissection: consider offering conservative management with antiplatelet therapy and control of hypertension in patients with asymptomatic isolated mesenteric artery dissection. C Show 3 more Patients with mesenteric vein thrombosis, diagnostic imaging: As per ACG 2020 guidelines, obtain contrast-enhanced CT or MRI to assess the extension of thrombus into the mesenteric veins and to exclude tumor thrombus in patients with cirrhosis developing new portal and/or mesenteric vein thrombus. B As per ESVS 2017 guidelines: Obtain CT angiography with arterial and portal phases in patients with suspected mesenteric vein thrombosis. B Rule out the possibility of intestinal infarction until the resolution of pain in patients with mesenteric vein thrombosis. B Patients with mesenteric vein thrombosis, evaluation for etiology: As per ESVS 2017 guidelines, evaluate for abdominal cancer, inflammatory disease, and myeloproliferative neoplasms in patients with mesenteric vein thrombosis. B Show 2 more As per ESTES 2016 guidelines, evaluate for thrombophilia in patients with mesenteric vein thrombosis. B Patients with mesenteric vein thrombosis, anticoagulation therapy, indications: As per WSES 2022 guidelines, consider administering a continuous infusion of UFH for the management of patients with mesenteric venous thrombosis. B As per AASLD 2021 guidelines, consider initiating antithrombotic therapy in patients with cirrhosis with recent occlusive or partially occlusive (> 50% obstruction of the lumen) thrombosis of the main portal vein or mesenteric veins, in order to avoid thrombosis progression possibly hindering future liver transplantation or causing progression of portal hypertension. E As per ESVS 2017 guidelines, administer heparin as first-line therapy in patients with acute mesenteric vein thrombosis without peritonitis. B Patients with mesenteric vein thrombosis, anticoagulation therapy, duration: As per ACG 2020 guidelines: https://web.pathway.md/diseases/receyfRKUHyVy6myP 7/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway Consider continuing anticoagulation for at least 6 months in patients with non-cirrhotic mesenteric vein thrombosis without thrombophilia and when the etiology of the thrombosis is reversible. Continue anticoagulation indefinitely in patients with non-cirrhotic mesenteric vein thrombosis with thrombophilia. C Consider continuing anticoagulation for 6 months in patients with cirrhotic mesenteric vein thrombosis. Continue anticoagulation beyond this period in patients with cirrhotic mesenteric vein thrombosis awaiting a liver transplant. C As per ESVS 2017 guidelines: Continue anticoagulation for 3-6 months in patients with mesenteric vein thrombosis with reversible causes (such as trauma, infection, or pancreatitis). B Continue anticoagulation lifelong in patients with mesenteric vein thrombosis with any of the following: proven thrombophilia recurrent venous thrombosis progression or recurrence of thrombosis would have severe clinical consequences. B As per EASL 2016 guidelines, consider continuing anticoagulation lifelong in patients with superior mesenteric venous thrombosis with a past history suggestive of intestinal ischemia or being liver transplant candidates. C As per ESTES 2016 guidelines, continue anticoagulation therapy, when indicated, for a minimum of 6 months in patients with mesenteric vein thrombosis. B Patients with mesenteric vein thrombosis (prevention of variceal bleeding): Initiate nonselective -blockers for the prevention of variceal bleeding in patients with high-risk varices and portal and/or mesenteric venous thrombosis requiring anticoagulation. B Consider performing endoscopic variceal ligation if there are contraindications or intolerance to -blockers. Consider interrupting anticoagulation in the periprocedural period. B 12. Preventative measures Secondary prevention: As per ESVS 2017 guidelines, offer secondary medical prevention including smoking cessation, statin therapy, and antiplatelet or anticoagulation therapy in patients surviving AMI. B As per ESTES 2016 guidelines, initiate life-long anticoagulation, if not contraindicated, in patients with emboli to reduce the risk of recurrence. B 13. Follow-up and surveillance Second-look procedures: As per ESVS 2017 guidelines, consider performing second-look laparotomy and damage control surgery in patients undergoing acute intestinal revascularization. C https://web.pathway.md/diseases/receyfRKUHyVy6myP 8/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway As per ESTES 2016 guidelines, reassess ischemic bowel after adequate fluid resuscitation and revascularization. Perform a second-look procedure to assess the viability of the bowel if any doubt remains. B Show 4 more Follow-up imaging: As per WSES 2022 guidelines, obtain surveillance imaging after revascularization. B As per ESVS 2017 guidelines: Consider obtaining completion imaging with angiography or transit time flow measurements in patients undergoing mesenteric revascularization. C Consider obtaining imaging follow-up in patients with AMI and stented mesenteric arteries. C As per ESTES 2016 guidelines, obtain duplex ultrasound or CT angiography for graft surveillance or stent follow-up for early detection and management of stenosis and occlusion in patients with vascular stents or bypass procedures. B 14. Quality improvement Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs. B References 1. Miklosh Bala, Fausto Catena, Jeffry Kashuk et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. WSES. 2022 Oct;. Open 2. Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E L Bartelink et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery ESVS Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization ESO The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology ESC and of the European Society for Vascular Surgery ESVS . Eur Heart J. 2018 Mar 1;39 9 763 816. Open 3. M Bj rck, M Koelemay, S Acosta et al. Editor's Choice Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery ESVS . Eur J Vasc Endovasc Surg. 2017 Apr;53 4 460 510. Open 4. Tilsed JV, Casamassima A, Kurihara H et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016 Apr;42 2 253 70. Open 5. Douglas A Simonetto, Ashwani K Singal, Guadalupe Garcia-Tsao et al. ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation. Am J Gastroenterol. 2020 Jan;115 1 18 40. Open 6. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Vascular diseases of the liver. J Hepatol. 2016 Jan;64 1 179 202. Open https://web.pathway.md/diseases/receyfRKUHyVy6myP 9/10 6/23/23, 1:58 AM Acute mesenteric ischemia Pathway 7. Patrick G Northup, Juan Carlos Garcia-Pagan, Guadalupe Garcia-Tsao et al. Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Jan;73 1 366 413. Open 8. Expert Panels on Vascular Imaging and Gastrointestinal Imaging:, Michael Ginsburg, Piotr Obara et al. ACR Appropriateness Criteria Imaging of Mesenteric Ischemia. J Am Coll Radiol. 2018 Nov;15 11S S332 S340. Open 9. Bala M, Kashuk J, Moore EE et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2017 Aug 7;12 38. Open 10. Expert Panel on Interventional Radiology, Alexander Lam, Yoon-Jin Kim et al. ACR Appropriateness Criteria Radiologic Management of Mesenteric Ischemia: 2022 Update. J Am Coll Radiol. 2022 Nov;19 11S S433 S444. Open https://web.pathway.md/diseases/receyfRKUHyVy6myP 10/10