Acute Mesenteric Ischemia in Adolescents: Diagnosis and Management

Definition and Pathophysiology

Acute mesenteric ischemia (AMI) in adolescents is an extremely rare but life-threatening vascular emergency caused by sudden interruption of blood supply to the intestine, leading to bowel necrosis and death if untreated, with mortality rates of 50-80% 1, 2
AMI is characterized by sudden interruption of blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes that progress to intestinal necrosis if untreated 1

Arterial emboli are less common in adolescents compared to adults, as this age group typically lacks atrial fibrillation or other embolic sources 3
Non-occlusive mesenteric ischemia (NOMI) can occur in critically ill adolescents with sepsis, multi-organ dysfunction, or those requiring high-dose vasopressor support 4
Mesenteric venous thrombosis may occur in adolescents with inherited hypercoagulable states or acquired conditions 3

Classic presentation: Severe abdominal pain out of proportion to physical examination findings, which should be assumed to be AMI until disproven 5, 3
Chronic presentations: Postprandial abdominal pain, progressive weight loss, food avoidance, nausea, vomiting, and early satiety may precede acute decompensation 6

Computed tomography angiography (CTA) should be performed as soon as possible for any adolescent with suspicion for AMI, as it is the first-line imaging technique 6, 5
Conventional angiography remains the reference standard with sensitivity of 74-100% and specificity of 100%, and allows for therapeutic intervention 6
Plain radiography has limited diagnostic value, though signs of intestinal perforation may be seen in advanced cases 5

Immediate fluid resuscitation to enhance visceral perfusion, correction of electrolyte abnormalities, and nasogastric decompression 5
Broad-spectrum antibiotics should be administered immediately, though evidence specifically for AMI is limited 5
Anticoagulation with intravenous unfractionated heparin unless contraindicated 5
Endovascular approaches have shown improved outcomes with lower mortality rates, decreased bowel resection, and reduced renal and respiratory failure compared to traditional open surgery 2
Prompt laparotomy is mandatory for patients with overt peritonitis 5
Damage control surgery with planned re-laparotomy 24-48 hours later is essential to reassess bowel viability and avoid unnecessary resection 5
The goal is to conserve as much bowel as possible, resecting only obviously necrotic segments 5

Delayed diagnosis is the most significant contributor to the 50-80% mortality rate 2

The mortality rate remains extremely high at 50-80% if untreated, despite advances in diagnostic and treatment modalities 2