In this episode of Hospital Medicine Unplugged, we race through acute mesenteric ischemia (AMI)—recognize early, image fast, revascularize now, salvage bowel.

We open with the do-firsts: high-flow crystalloids, bowel rest + NG decompression, broad-spectrum antibiotics, and therapeutic anticoagulation (arterial/venous causes) unless contraindicated. Loop in surgery, vascular, interventional radiology, and ICU immediately.

Diagnosis that doesn’t dawdle:
• Classic clue: severe abdominal pain out of proportion to exam; normal lactate/WBC do not exclude AMI.
• Imaging: triphasic CT angiography is the gold standard—call it for sudden pain, high-risk hosts (AFib, atherosclerosis, shock, vasopressors, hypercoagulable states).
• Use CTA to label the subtype: SMA embolus, in-situ arterial thrombosis, mesenteric venous thrombosis (MVT), or NOMI; assess perfusion and bowel viability.

Risk stratify (any = high risk): age >70, AFib or recent MI, diffuse atherosclerosis, shock/vasopressors, dialysis/cirrhosis/malignancy, hypercoagulable state, peritoneal signs, metabolic acidosis, CTA showing occlusion or non-enhancing bowel. High risk → parallel tracks (resuscitate + CTA + consults), not serial steps.

Definitive therapy—reperfuse early:
• Arterial occlusion (embolus/thrombosis): endovascular-first (aspiration/lysis/thrombectomy ± angioplasty/stent) when feasible—lower mortality, less bowel resection, shorter LOS. Open surgery for peritonitis, failed endovascular, or instability; use damage-control with second-look 24–48h when viability’s unclear.
• MVT: full-dose anticoagulation is first-line; operate only for peritonitis or failure of medical therapy.
• NOMI: fix the physiology—optimize cardiac output, wean vasoconstrictors, correct hypovolemia; consider intra-arterial vasodilators (e.g., papaverine). Cut only if transmural necrosis/perforation.

Operative pearls when bowel’s threatened:
• Resect frankly necrotic segments; preserve marginal bowel.
• Second-look laparotomy reduces over-resection; plan it when any doubt remains.
• Watch for reperfusion injury (acidosis, hyperK), compartment syndrome, and ongoing sepsis.

ICU & postoperative plays:
• Serial exams + lactate/ABG/electrolytes, urine output, and hemodynamics.
• Early enteral nutrition once perfusion is restored and bowel viable; TPN if needed after major resection.
• Anticoagulation continuation (tailored to etiology and bleeding risk); evaluate for thrombophilia in idiopathic MVT.
• Rehab and nutrition support to prevent short bowel syndrome.

What not to miss:
• Delays kill—mortality often >50% without prompt diagnosis and revascularization.
• Normal labs are false reassurance; do not wait for lactate to rise.
• NOMI in the ICU is quiet—distension, diarrhea, or unexplained organ failure may be the only flags.
• Overuse of vasopressors worsens splanchnic ischemia; prefer inotropes or vasodilator-friendly strategies when possible.

Medication and systems pitfalls:
• Anticoagulation early improves survival and doesn’t meaningfully raise bleeding when monitored—don’t skip it without a reason.
• Antibiotics up front for translocation risk; de-escalate when cultures guide.
• Build the intestinal stroke pathway: (1) trigger = “pain out of proportion” or high-risk ICU decline → STAT CTA; (2) auto-page surgery + IR + ICU; (3) default endovascular-first for arterial occlusion; (4) algorithmic NOMI bundle (optimize flow, vasodilate, de-press); (5) mandatory second-look criteria; (6) standardized anticoag + nutrition protocols; (7) track time-to-CTA and time-to-reperfusion as quality metrics.

Take-home: Think AMI early, scan fast, anticoagulate, and revascularize—preferably endovascular—while you resuscitate. Treat the cause, spare the bowel, and standardize the system to drive down deaths and recurrences.