Acute Mesenteric Ischemia Diagnosis and Management

Clinical Presentation and Diagnosis

The American College of Surgeons recommends considering acute mesenteric ischemia (AMI) in patients with severe abdominal pain out of proportion to physical findings, as this is the hallmark of AMI 1
The World Journal of Emergency Surgery suggests that a 48-hour progression from epigastric pain and projectile vomiting to cardiovascular collapse fits the typical timeline of arterial occlusion evolving to transmural bowel necrosis 1
The presence of pre-transfer bradycardia preceding complete cardiovascular collapse suggests profound metabolic derangement from bowel necrosis, likely severe lactic acidosis and hyperkalemia, according to the World Journal of Emergency Surgery 1
Refractory asystole despite maximal resuscitation indicates irreversible metabolic catastrophe, consistent with massive bowel infarction and overwhelming septic shock, as reported by the World Journal of Emergency Surgery 1, 3

Acute mesenteric arterial embolism or thrombosis causes sudden-onset severe abdominal pain with vomiting, according to the World Journal of Emergency Surgery 1
Without prompt diagnosis and intervention, ischemia progresses to transmural necrosis within 6-12 hours, as stated by the World Journal of Emergency Surgery 1
Elevated lactate >2 mmol/L indicates irreversible intestinal ischemia (hazard ratio 4.1) and is associated with metabolic acidosis in 88% of AMI patients, according to the World Journal of Emergency Surgery 1

Perforated peptic ulcer presents with sudden severe epigastric pain, vomiting, and signs of peritonitis, as described by Clinical Infectious Diseases 4
Progression to septic shock occurs when peritoneal contamination leads to overwhelming sepsis, according to the World Journal of Emergency Surgery 3
Mortality in septic shock from intra-abdominal infection is 67.8%, explaining the refractory arrest, as reported by the World Journal of Emergency Surgery 3

CT angiography should be performed without delay in any patient with suspicion for AMI, as every 6 hours of delay doubles mortality, according to the World Journal of Emergency Surgery 1
Lactate, D-dimer, and leukocyte count would have supported the diagnosis, with lactate >2 mmol/L indicating irreversible ischemia, as stated by the World Journal of Emergency Surgery 1