›Meropenem 1 g IV every 8 hours for critically ill or resistant organism risk
›Covers ESBL-producing organisms
›Ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours
›Alternative for less severely ill patients
›Duration guided by clinical response and operative findings
›Continue until bowel viability confirmed and clinical improvement
›De-escalate based on cultures and clinical course
Definitive treatment by subtype
›Arterial embolism treatment
›Endovascular approach — first-line when expertise available
›Aspiration thrombectomy or mechanical thrombectomy via SMA catheter
›Thrombolysis with tPA if thrombectomy not immediately feasible
›Open surgical embolectomy
›Transverse arteriotomy of SMA
›Fogarty balloon catheter embolectomy
›Combined bowel resection for non-viable segments
›Post-embolectomy anticoagulation
›UFH bridge to long-term anticoagulation
›Warfarin target INR 2-3 or DOAC for underlying AF
›Arterial thrombosis treatment
›Endovascular thrombectomy or thrombolysis with stenting
›Single-vessel SMA revascularization sufficient acutely
›Hybrid approach: endovascular revascularization + open bowel resection
›Open surgical bypass
›Antegrade bypass from supraceliac aorta — preferred for durable results
›Retrograde bypass from iliac artery
›Combined revascularization before bowel resection when possible
›Antiplatelet therapy post-stenting
›Aspirin 81-325 mg daily plus clopidogrel 75 mg daily for 6 months
›Long-term aspirin continued indefinitely
›NOMI treatment
›Treat underlying cause — primary intervention
›Optimize cardiac output: inotropes for cardiogenic shock
›Reduce or eliminate vasoconstrictors when hemodynamically safe
›Correct hypovolemia, sepsis source control
›Catheter-directed papaverine infusion via SMA catheter
›Papaverine 30-60 mg/hour continuous infusion
›Continue 12-24 hours; reassess with repeat angiography
›Vasodilator effect reduces mesenteric arterial spasm
›Anticoagulation with heparin
›Even without occlusive thrombus — prevents secondary thrombosis
›Mesenteric venous thrombosis treatment
›Anticoagulation — first-line therapy
›UFH IV infusion with aPTT monitoring
›Transition to therapeutic LMAC or DOAC when stable
›Minimum 3-6 months anticoagulation; lifelong if provoked by permanent risk factor
›Catheter-directed thrombolysis reserved for deteriorating cases
›Via transhepatic or superior mesenteric vein approach
›Bleeding risk limits routine use
›Surgery for MVT
›Peritonitis or bowel infarction — emergent laparotomy
›Resect only obviously necrotic bowel — damage control principle
›Intraoperative strategy
›Revascularization before resection whenever anatomically feasible
›Revascularization-first reduces 30-day mortality significantly
›Bowel may recover viability after revascularization
›Damage control laparotomy — leave abdomen open
›Temporary abdominal closure with negative pressure wound therapy
›Planned second-look laparotomy at 24-48 hours mandatory for extensive involvement
›Bowel resection of clearly non-viable segments
›Preserve maximum viable bowel length
›Anastomosis deferred to second-look in unstable patients
›Second-look laparotomy
›Mandatory 24-48 hours after initial surgery for extensive involvement
›Reassess bowel viability and complete resection if needed
›Anastomosis or stoma creation at second-look
Post-intervention management
›Long-term anticoagulation
›Warfarin — target INR 2-3 for most indications
›DOAC alternative for AF-related embolism and MVT
›Lifelong for most patients
›Antiplatelet therapy after stent placement
›Aspirin 81 mg daily indefinitely
›Clopidogrel 75 mg daily for 6 months post-stent
›Nutritional rehabilitation
›Parenteral nutrition if short bowel syndrome develops post-resection
›Enteral nutrition restart only after confirmed revascularization
›Dietitian and GI consult for long-term nutritional planning
›Surveillance imaging
›CTA or mesenteric duplex at 3-6 month intervals post-revascularization
›Stent restenosis risk — 6-8% of late deaths from AMI after revascularization
›Open bypass more durable than endovascular stenting long-term