Mesenteric Ischemia Still Kills—But Only If We Let It
Pain Out of Proportion—and Time Out of Reach: How We Still Miss Mesenteric Ischemia
There are few diagnoses that still carry the same dread for both patients and surgeons as acute mesenteric ischemia (AMI). It’s the kind of pathology that whispers before it screams, presenting vaguely until it explodes into irreversible catastrophe. And yet, as a general surgeon who’s managed my share of these cases, the real tragedy is this: many patients still die not because the ischemia was too aggressive, but because we were too late.
A new review in The Journal of Trauma and Acute Care Surgery1 by Tolonen and Vikatmaa (2025) doesn’t just rehash what we already know. It tightens the focus around a central, stubborn truth: timing is everything. Their paper is an essential read for any acute care surgeon, vascular colleague, or even emergency physician staring down a patient with nonspecific abdominal pain and a nagging sense that something’s off.
The Clock Starts Before the Pain Peaks
The authors remind us that, historically, mesenteric ischemia has carried a mortality rate hovering near 50%, especially when diagnosis and revascularization are delayed. But that number isn’t set in stone. The moment of clinical suspicion should be the starting gun.
“Successful treatment of AMI is entirely dependent on timely diagnosis and revascularization,” they write, noting that delays as short as a few hours can make the difference between reversible ischemia and necrotic bowel.
This isn’t news—but it’s often forgotten in the fog of vague presentations and competing diagnoses.
The article drives home that mesenteric ischemia is not a singular disease. It’s a spectrum of mechanisms—arterial embolism, arterial thrombosis, non-occlusive ischemia, and mesenteric venous thrombosis—each with its own tempo. Embolic events are fast and furious. Thrombotic occlusions may smolder longer. Venous clots can mimic garden-variety gastroenteritis. Non-occlusive ischemia, often in critically ill patients on vasopressors, may be the hardest to catch—and the deadliest.
CT Angiography or Bust
If there’s a single, unambiguous message from this review, it’s this: Get the CTA early. Gone are the days of waiting for peritoneal signs or lactate to skyrocket.
“Computed tomography angiography (CTA) remains the gold standard for diagnosis and should not be delayed by other imaging modalities,” Tolonen and Vikatmaa emphasize.
Waiting for diagnostic clarity via ultrasound or non-contrast CT is a disservice to the patient. Even plain lactate levels, while associated with worse prognosis when elevated, aren’t sensitive enough to rule out early ischemia. A normal lactate doesn’t mean anything until you’ve seen the vessels.
Surgery Isn’t Always First—But It Better Be Ready
One of the most clinically relevant shifts in AMI management over the last decade is the movement toward endovascular-first strategies for select patients. In cases of embolic or thrombotic arterial disease without peritonitis, percutaneous revascularization is becoming standard in many centers. And for good reason.
“Mortality following endovascular-first approaches has shown a downward trend in contemporary series,” the authors write.
But this is only half the story. Every surgeon knows the game changes when you open the belly. If there’s concern for necrosis or peritonitis, surgical exploration remains the first—and sometimes only—lifesaving move. And it’s a brutal one.
The authors call attention to the use of second-look laparotomies as both a prognostic and therapeutic step. It’s often not enough to resect and re-anastomose in one go. Leaving the abdomen open with plans for reassessment 24 to 48 hours later allows time for borderline bowel to declare itself.
What We’re Still Getting Wrong
Here’s where the review hits hardest. Despite these advances, we’re still missing diagnoses. We’re still waiting too long. And we’re still operating too late.
One major limitation of current practice is the under-recognition of AMI in the ICU setting. Non-occlusive mesenteric ischemia (NOMI), often seen in elderly, vasopressor-dependent patients, doesn’t have the dramatic CT findings of arterial embolism. Instead, it whispers—mild bowel wall thickening, delayed enhancement, pneumatosis if you’re lucky. And by the time it’s obvious, the patient may already be spiraling.
Another issue is the over-reliance on percutaneous interventions in patients who clearly need surgery. Endovascular therapy is attractive—but it’s not a panacea. If there’s any suspicion of infarction, the knife must follow the wire.
Criticism: Still Too Little Focus on Post-Op Management
While the article covers diagnostic and interventional timing thoroughly, it underplays the role of postoperative care in determining outcomes. These patients often face prolonged ICU stays, complex nutrition decisions, and the challenges of short bowel syndrome. Postoperative ischemia recurrence is a major issue, especially in NOMI cases. Surveillance protocols, including follow-up CTA and aggressive hemodynamic optimization, deserve more emphasis.
The Takeaway: Trust Your Gut… And Image Early
Mesenteric ischemia isn’t going away. But the mortality doesn’t have to stay high. The crux is suspicion. If the pain is out of proportion, if the patient looks worse than their labs, if you’ve ruled out everything else—stop hesitating and order the CTA. You’ll rarely regret getting it. You might never forgive yourself if you don’t.
As the paper reminds us,
“There is no diagnostic marker or sign that can rule out AMI reliably enough to obviate imaging in a patient at risk.”
In other words: this diagnosis is a trap for the unwary. But it’s also an opportunity for the vigilant.
Tolonen, M., & Vikatmaa, P. (2025). Diagnosis and management of acute mesenteric ischemia: What you need to know. The Journal of Trauma and Acute Care Surgery. https://doi.org/10.1097/TA.0000000000004585