In this episode, we cover intestinal (mesenteric) ischemia, a high-acuity vascular emergency characterized by reduced blood flow to the intestines leading to ischemia, necrosis, and potential perforation. We break down the four primary mechanisms—arterial embolism, arterial thrombosis, nonocclusive low-flow states, and venous thrombosis—and highlight key risk factors such as atrial fibrillation, atherosclerosis, shock states, and hypercoagulability. Clinically, we emphasize the classic presentation of severe abdominal pain out of proportion to physical exam findings, along with differences between acute and chronic mesenteric ischemia. The episode reviews a targeted diagnostic approach, focusing on CT angiography as the test of choice, and outlines time-sensitive management including hemodynamic stabilization, anticoagulation, and urgent revascularization. Key pearls reinforce early recognition and rapid intervention to prevent bowel infarction, sepsis, and death.

References

1. Bushardt RL, Colomb-Lippa DM, Klinger AM, Reed H. The JAAPA QRS Review for PAs: Study Plan and Guide for PANCE and PANRE. 1st ed. LWW; 2021. ISBN: 9781975143817.
2. Theodore S, Xia T, Saillant N. Intestinal Ischemia — Etiology and Foundational Concepts NEJM Evidence. 2024; 3(3).
3. Theodore S, Xia T, Saillant N. The Evaluation and Management of Intestinal Ischemia NEJM Evidence. 2024; 3(4).
4. Deranged Physiology. Mesenteric ischaemia. Deranged Physiology. Accessed April 28, 2026. https://derangedphysiology.com/main/required-reading/gastrointestinal-intensive-care/Chapter-26/mesenteric-ischaemia