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We thank Dr Chinitz for his comments regarding the management of mesenteric ischemia. Our article highlighted a case of acute mesenteric ischemia, in which an early invasive approach was not pursued, and the patient later required resection of infarcted bowel. In retrospect, we of course agree that the patient should have undergone immediate angiography and infusion with papaverine, per the American Gastroenterological Association guidelines.1 The presence of a normal blood lactate concentration and lack of peritoneal signs on physical examination erroneously biased the management toward a conservative approach with heparin. The case sends a strong message that a high index of suspicion for infarcted bowel is a requisite in the evaluation of patients with suspected bowel ischemia. In our report, we appropriately referenced invasive mesenteric angiography as the “criterion standard” and stated, “It is critical to exclude acute mesenteric ischemia first because it carries considerable mortality, which can be affected by an early invasive approach.”

A 52-year-old woman (gravida 3, para 3, abortus 0) presented to the emergency department with a recent history of intractable nausea, vomiting, and abdominal pain. Three weeks before presentation, she had started taking oral contraceptives (OCPs), which were prescribed to control dysfunctional uterine bleeding. The bleeding was thought to be secondary to a newly discovered uterine fibroid. The patient's daily bleeding had stopped completely 4 days before admission. Her symptoms had begun 1 day before admission, when she woke up feeling nauseated and could not stop vomiting. She thought she had the flu and postponed coming to the hospital. The patient described lower quadrant abdominal pain and several bloody, soft stools the day before admission. She denied any fevers or diarrhea. Her medical history was unremarkable, and she reported only osteoarthritis and a prior tubal ligation. She denied taking any daily medications except for the OCPs, which she had also taken at the age of 19 years with no problems. The patient had a clinically relevant smoking history, having smoked 1 to 2 packs per day since the age of 14 years. She drank wine socially.