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Hépato-Gastro & Oncologie Digestive

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Acute mesenteric ischemia in 2013: a multimodal and multidisciplinary management coordinated by the gastroenterologist Volume 20, issue 6, Juin 2013

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Authors
Hôpital Beaujon, pôle des maladies de l’appareil digestif, service de gastroentérologie, MICI, assistance nutritive, 100 Boulevard du Général Leclerc, 92110 Clichy, France

Acute mesenteric ischemia is the most misunderstood of abdominal emergencies. It may occur with or without mesenteric vascular occlusion, involving arteria and/or vein. The incidence is increasing and the prognosis could be improved by an innovative multimodal and multidisciplinary management initiated at early presentation. Diagnosis must be suspected regarding any sudden, continuous and unusual abdominal pain, contrasting with normal physical examination at the initial stage. Risk factors are often unknown at presentation and no biochemical test is specific. Absence of individual risk factor or normal biology might not deny or delay the diagnosis which is confirmed by abdominal computed tomography angiography objectifying intestinal injury, associated or not with vascular occlusion. Gastroenterologist has a major role in the management, in order to avoid death and large intestinal resections, by initiating and coordinating the multidisciplinary management which is based on the combination of a medical protocol, revascularisation of viable small bowel and resection of non viable small bowel. Therapeutic strategy depends on the presence of at least one of three criteria (surgical complication, organ failure, elevated serum lactate). In this case, surgery must be performed first for revascularisation and intestinal resection. In early stages, patients do not present surgical complication nor organ failure and lactates are normal; they should be treated by endovascular revascularisation. Any factor that may have contributed to this ischemic stroke (i.e. atherosclerosis, cardiac embolism or thrombophilia) should be sought for and treated. A pre-existing malnutrition, short bowel syndromes and oral intolerance require parenteral nutrition, better conducted in a referral center. Creating local intestinal stroke centers is able to modify the prognosis of acute mesenteric ischemia.