The Next Step · Emergency General Surgery
Severe abdominal pain with few early examination findings should raise concern for acute mesenteric ischemia, especially in patients with embolic risk, vascular disease, or a low-flow state.
The next step: urgent CT angiography
When suspicion is high, obtain CT angiography without delay while starting resuscitation and engaging the surgical and vascular teams. A normal lactate does not exclude early ischemia.
Identify the mechanism
- Arterial embolism
- Arterial thrombosis
- Non-occlusive mesenteric ischemia
- Mesenteric venous thrombosis
Treat the patient and the cause
Early priorities include restoring perfusion, broad-spectrum antibiotics, and considering anticoagulation unless contraindicated. Revascularization, bowel assessment, and resection of nonviable bowel depend on the mechanism and physiology. Peritonitis requires urgent operative assessment.
Do not wait for advanced examination findings before investigating threatened bowel.
Further reading
Bala M, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2022;17:54. Read the guideline.