Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study)

Abstract

Background The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI). Methods All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected. Results AMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1–12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied. Conclusions The overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management. Trial registration: NCT05218863 (registered 19.01.2022).

Managing acute mesenteric ischaemia

“…In addition, patients with AMI are seen by different specialties, many of whom have insufficient experience with this infrequently encountered condition. AMI is diagnosed in 0.04–0.07% of adult hospital admissions, with a highly variable proportion (0–50%) of non-occlusive mesenteric ischaemia (NOMI) observed in different hospitals [ 1 – 4 ]. The variable incidence most likely indicates differences in awareness.…”

“…1 ) [ 5 ]. Although the median age is around 70 years, AMI may occur in patients of any age [ 1 ].

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“…Elevated lactate can support suspicion of AMI, whereas normal lactate should never be used to exclude AMI [ 1 ].…”

“…Appropriately raised suspicion should trigger an immediate referral for computed tomography (CT)-angiography, with possibility of AMI specifically mentioned for the radiologist, increasing chances for timely diagnosis [ 1 , 6 ]. Importantly, increased creatinine level and risk of contrast-induced renal failure should never lead to omission of intravenous contrast in patients suspected of having AMI as timely diagnosis may allow early revascularization in acute superior mesenteric artery (SMA) occlusion with avoidance of bowel resection [ 7 , 8 ].…”

“…Acute mesenteric ischaemia (AMI) is a condition where different etiopathogenetic pathways may lead to necrosis of the bowel and thereby to lethal outcome. Despite the common threat of intestinal necrosis, different subtypes of AMI (occlusive arterial, occlusive venous and non-occlusive) have variable incidence, are managed differently and lead to different outcomes [ 1 ]. In this article, we summarize recent evidence related to diagnosis, management and outcomes of AMI.…”