Acute Mesenteric Ischemia–Reply–I

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.”