Acute mesenteric ischaemia is the sudden interruption of blood flow to part of the intestine. It is among the most dangerous abdominal emergencies, because bowel tissue tolerates loss of its blood supply for only a few hours before tissue death begins. Treatment is therefore a race against the clock: every hour of delay in diagnosis adds to the length of bowel that will be lost. There are four main causes: a clot fragment travelling from the heart and blocking the intestinal artery — often in someone with atrial fibrillation; thrombosis forming on a chronic atherosclerotic narrowing; clotting in the vein that drains the intestine; and a severe fall in blood flow in patients with shock or heart failure. The sign that must be recognised is severe abdominal pain that is out of all proportion to an abdomen that at first feels soft on examination, sometimes with diarrhoea, vomiting or an urgent need to open the bowels. Treatment starts the moment you arrive: intravenous fluids, correction of electrolytes, pain relief, antibiotics on the doctor's decision and an anticoagulant, together with urgent CT angiography, which is the cornerstone of diagnosis. Then flow is restored — by removing or dissolving the clot or widening the artery through a catheter, or by surgery to extract the thrombus or create a bypass. If part of the bowel has died it is removed, a temporary stoma may be brought out, and a second look operation may be planned within hours to reassess what remains alive. A limit and a warning together: never suppress severe unexplained abdominal pain at home with antispasmodics and wait — masking the pain squanders the golden hours. A normal abdominal examination early on does not rule the condition out. Assessment belongs in the emergency department, with examination and imaging — not reading. Smoking and untreated atrial fibrillation are among the most important risk factors.
Procedure steps
- 1
Recognising the condition and getting there fast
Any sudden severe abdominal pain that the examination does not explain — especially in someone with atrial fibrillation, atherosclerosis or recent cardiac surgery — requires immediate emergency assessment without home pain relief. Tell the team the exact time the pain began, because that single fact shapes the treatment options.
- 2
Stabilisation and urgent tests
Intravenous lines are placed and fluids given, blood tests for electrolytes, acid-base status and kidney function are taken, and pulse, blood pressure and an ECG are monitored to detect atrial fibrillation. Analgesia, an anticoagulant and antibiotics are given on the doctor's decision, and imaging is not postponed while waiting for numbers to improve.
- 3
CT angiography
Urgent CT angiography identifies which artery or vein is blocked, where and over what length, assesses the bowel wall, and looks for gas within the wall or perforation. This step determines whether the answer is a catheter procedure, an operation, or both.
- 4
Restoring blood flow
Perfusion is restored by the fastest available route: aspirating or dissolving the clot, or dilating the artery and placing a stent through a catheter; or surgery to extract the thrombus or bypass the narrowing. In venous thrombosis, anticoagulation is the mainstay, with close monitoring of the bowel.
- 5
Resecting dead bowel and the second look
The abdomen is opened when needed, the colour of the bowel and the pulses in its vessels are assessed, and dead segments are resected. The ends may be joined, or a temporary stoma brought out through the abdominal wall, depending on tissue condition; a planned second look operation hours later is often used to confirm that what remains is alive before restoring continuity.
Before the procedure
This is an emergency for which there is no planned preparation, and what you do in the first hour matters most: go to the emergency department at once or call an ambulance, take nothing by mouth, and do not take painkillers, antispasmodics, laxatives or an enema at home, because they mask the signs and waste time. Tell the team the exact time the pain started, describe your medical conditions — especially atrial fibrillation, arterial disease and any previous abdominal or cardiac surgery — and list all your medicines, highlighting blood thinners and anticoagulants and any drug or contrast allergy. If you can, bring your medication list and previous reports or photograph them on your phone, and do not drive yourself.
After the procedure
Expect a stay in intensive care or on the ward with close monitoring, and you may take nothing by mouth for some days until the bowel starts working, with intravenous nutrition if this is prolonged. Move and breathe deeply as your team directs, to prevent clots and chest infection. If a temporary stoma has been created, you will be taught how to care for it before discharge. Take your anticoagulant exactly as prescribed and keep its monitoring appointments, continue treatment for atrial fibrillation or arterial disease without interruption, and stop smoking permanently. Reintroduce food gradually as advised and keep track of your weight and fluid intake. Return to the emergency department immediately if: **severe abdominal pain returns, or the abdomen becomes distended or rigid** · **you vomit repeatedly or pass no wind or stool at all** · **there is blood in the stool or black stool** · you develop fever, shivering, a racing pulse or low blood pressure · an abdominal wound becomes red, discharges pus or opens · a stoma stops working or turns dark · **a leg suddenly becomes painful, swollen and warm** (deep vein thrombosis — do not massage the leg and do not wait) · **chest pain or breathlessness** develops (possible pulmonary embolism — emergency now).
Expected duration
Here time is the treatment: assessment and imaging should be completed within the first hours of the pain starting. A catheter procedure usually takes one to two hours and surgery two to four hours, with a planned second look often twenty-four to forty-eight hours later. Hospital stay commonly ranges from one week to several weeks.
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