Intestinal ischemia

Last updated: August 1, 2023

Summarytoggle arrow icon

Intestinal ischemia occurs if bowel perfusion cannot meet the metabolic demands of the intestine. This relative hypoperfusion may be the result of atherosclerosis, thromboembolic disease, or severe systemic hypotension. Intestinal ischemia is often classified based on its onset and location: acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), or colon ischemia (ischemic colitis). Each type has a different manifestation and treatment. AMI is a vascular emergency and manifests with sudden, severe abdominal pain; CMI manifests with chronic recurrent postprandial abdominal pain. Colon ischemia manifests with cramping abdominal pain and bloody diarrhea and is often self-limited, though, rarely, it may progress to fulminant bowel necrosis. Diagnosis is primarily made with cross-sectional imaging and CT angiography (CTA). Laboratory studies are used to determine disease severity and monitor the effects of resuscitation. Early diagnosis, surgical consultation, and definitive treatment with urgent surgical or endovascular revascularization are essential in AMI, which has a mortality rate of > 50%. Patients with CMI have a more favorable prognosis but still benefit from timely revascularization. Colon ischemia is primarily managed with supportive care and monitoring for symptom progression. Bowel perforation, intestinal infarct, and/or sepsis are associated with a poor prognosis, regardless of the type of intestinal ischemia.

Overviewtoggle arrow icon

Overview of intestinal ischemia


Colon ischemia

Acute mesenteric ischemia Chronic mesenteric ischemia
Sites of ischemia
Clinical features
Diagnostic tests

Colon ischemiatoggle arrow icon

Definition [1][2][3]

Epidemiology [2][4]

  • Most common type of intestinal ischemia
  • Most commonly affects individuals > 60 years of age
  • ∼ 80% of cases are nongangrenous, resolving without surgery
  • Isolated right-sided colon ischemia (IRCI): 10–25% of cases [5]

Etiology [3][6]

Older patients with risk factors for atherosclerosis are at especially high risk for developing colon ischemia. [8]

Severe abdominal pain and bloody diarrhea after an abdominal aortic aneurysm repair is a classic manifestation of colon ischemia.

Pathophysiology [4][6]

Injury to the intestinal mucosa can occur after just 20 minutes of ischemia; transmural infarction and gangrene occur after 8–16 hours of ischemia. [6]

Clinical features [2][3]

Consider colon ischemia in any patient with abdominal pain and/or bloody diarrhea without a clear infectious etiology, as many do not have the classic presentation of colon ischemia. [3]

In colon ischemia, pain is typically milder and more laterally located than in small intestinal ischemia. [3]

Red flags in colon ischemia

The following are poor prognostic markers:


The severity of colon ischemia determines the appropriate approach to diagnostics and treatment. . [2]

Diagnostics [2][3][11]


CT abdomen is the preferred initial test for all patients with suspected colon ischemia.

Laboratory studies [3]

Hallmark findings of severe colon ischemia include leukocytosis, metabolic acidosis, lactate, LDH, and CPK.

Imaging [8]


Colonoscopy confirms the diagnosis, defines the distribution of the ischemia, and excludes other pathology.

Colonoscopy should be performed within 48 hours in patients with suspected colon ischemia. [2]

Differential diagnoses [3]

Treatment [2][3][12]

  • Colon ischemia usually resolves spontaneously and requires no specific therapy.
  • Surgical intervention is required in severe cases (e.g., patients with gangrenous bowel).

Initial management

Conservative management



Prognosis [2]

  • Overall mortality: 4–12%
  • Recurrence rate: up to 10% within 5 years

Acute mesenteric ischemiatoggle arrow icon



  • Most commonly occurs in individuals > 60 years of age [14]
  • Prevalence in patients with acute abdomen: ∼ 1% [15]
  • Mortality: 50–70% [13][16][17]

Etiology [13][15][16]

AMI has various etiologies, which manifest with similar clinical features despite having different underlying risk factors and pathology.

Pathophysiology [15][16]

Clinical features [13][15][16]

Patients with acute mesenteric artery embolism typically present with the classic triad of severe abdominal pain, bloody diarrhea, and atrial fibrillation.

Patients with acute mesenteric artery thrombosis typically have known cardiovascular or peripheral vascular disease and/or symptoms of CMI in addition to acute symptoms.

Evaluate patients with atrial fibrillation and acute abdominal pain for acute mesenteric ischemia. [15]

Approach to management

Patients presenting with peritonitis and/or hemodynamic instability may need to proceed to surgery before imaging can be obtained.

Diagnostics [13][15][21][22]

CTA abdomen and pelvis [22]

CTA is the test of choice for AMI. [16][17]

Do not delay CTA while waiting for other diagnostic test results. [16][17]

Other imaging

Laboratory studies [13][15][16]

These can help establish AMI severity and guide resuscitation efforts but are not diagnostic for AMI. [13]

Patients with AMI may have normal lactate levels and pH on initial presentation.

Treatment [13][16]

Initial treatment [17][23][24]

Definitive treatment [15]

Definitive treatment is determined by the etiology of the AMI, the integrity of the bowel wall, and institutional resources .

Emergency laparotomy is indicated if there are signs of peritonitis, intestinal infarct, or hemodynamic instability. [13][15]

Immediate anticoagulation and endovascular revascularization may be considered in hemodynamically stable patients with AMI and no signs of advanced bowel ischemia.

Patients who do not improve after endovascular intervention should undergo surgical intervention. [24]

Long-term management [13][23][24]


Acute management checklisttoggle arrow icon

Chronic mesenteric ischemiatoggle arrow icon

Definition [27]

Epidemiology [27][28][29]

  • MAOD is common, while CMI is rare.
  • CMI most commonly occurs in adults > 60 years of age; >

Etiology [27][28]


CMI manifests as postprandial pain because oxygen demand increases significantly during digestion but the supply is limited by the fixed obstruction. [27][28]

Clinical features [28]

The recurrent dull postprandial pain associated with CMI is sometimes referred to as intestinal or abdominal angina.

Diagnostics [15][18][27][28]

Evidence of mesenteric artery stenosis is diagnostic for CMI in patients with suggestive clinical features and no other etiologies of postprandial abdominal pain. [27]

Differential diagnoses [28]

Treatment [15][18][27][28]



Revascularization is recommended in all patients with CMI.

Nutritional therapy

  • Frequent, small meals and a low-fat diet may provide some symptom relief.
  • Total parenteral nutrition should only be considered as a temporary supportive measure.

Long-term management


  • 5-year mortality for untreated CMI is close to 100%. [27][30]
  • Symptoms are relieved in 95% of patients following revascularization. [23]

Referencestoggle arrow icon

  1. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. Gastroenterology. 2000; 118 (5): p.954-968.doi: 10.1016/s0016-5085(00)70183-1 . | Open in Read by QxMD
  2. Brandt LJ, Feuerstadt P, Longstreth GF, Boley SJ. ACG Clinical Guideline: Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia (CI). Am J Gastroenterol. 2015; 110 (1): p.18-44.doi: 10.1038/ajg.2014.395 . | Open in Read by QxMD
  3. Cotter TG, Bledsoe AC, Sweetser S. Colon Ischemia. Mayo Clinic Proceedings. 2016; 91 (5): p.671-677.doi: 10.1016/j.mayocp.2016.02.006 . | Open in Read by QxMD
  4. Baixauli J, Kiran RP, Delaney CP. Investigation and management of ischemic colitis.. Cleve Clin J Med. 2003; 70 (11): p.920-921.doi: 10.3949/ccjm.70.11.920 . | Open in Read by QxMD
  5. Sotiriadis J, Brandt LJ, Behin DS, Southern WN. Ischemic Colitis Has a Worse Prognosis When Isolated to the Right Side of the Colon. Am J Gastroenterol. 2007; 102 (10): p.2247-2252.doi: 10.1111/j.1572-0241.2007.01341.x . | Open in Read by QxMD
  6. Washington C, Carmichael J. Management of Ischemic Colitis. Clinics in Colon and Rectal Surgery. 2012; 25 (04): p.228-235.doi: 10.1055/s-0032-1329534 . | Open in Read by QxMD
  7. Arif R, Farag M, Zaradzki M, et al. Ischemic Colitis after Cardiac Surgery: Can We Foresee the Threat?. PLoS ONE. 2016; 11 (12): p.e0167601.doi: 10.1371/journal.pone.0167601 . | Open in Read by QxMD
  8. Iacobellis F, Narese D, Berritto D, et al. Large Bowel Ischemia/Infarction: How to Recognize It and Make Differential Diagnosis? A Review. Diagnostics. 2021; 11 (6): p.998.doi: 10.3390/diagnostics11060998 . | Open in Read by QxMD
  9. Lanzer P. PanVascular Medicine. Springer ; 2015
  10. Hung A, Calderbank T, Samaan MA, Plumb AA, Webster G. Ischaemic colitis: practical challenges and evidence-based recommendations for management. Frontline Gastroenterol. 2019; 12 (1): p.44-52.doi: 10.1136/flgastro-2019-101204 . | Open in Read by QxMD
  11. Brandt LJ, Feuerstadt P. Beyond Low Flow: How I Manage Ischemic Colitis. Am J Gastroenterol. 2016; 111 (12): p.1672-1674.doi: 10.1038/ajg.2016.456 . | Open in Read by QxMD
  12. Díaz Nieto R, Varcada M, Ogunbiyi OA, Winslet MC. Systematic review on the treatment of ischaemic colitis. Colorectal Disease. 2010; 13 (7): p.744-747.doi: 10.1111/j.1463-1318.2010.02272.x . | Open in Read by QxMD
  13. Tilsed JVT, Casamassima A, Kurihara H, et al. ESTES guidelines: acute mesenteric ischaemia. European Journal of Trauma and Emergency Surgery. 2016; 42 (2): p.253-270.doi: 10.1007/s00068-016-0634-0 . | Open in Read by QxMD
  14. Aliosmanoglu I, Gul M, Kapan M, et al. Risk factors effecting mortality in acute mesenteric ischemia and mortality rates: a single center experience.. Int Surg. ; 98 (1): p.76-81.doi: 10.9738/CC112.1 . | Open in Read by QxMD
  15. Björck M, Koelemay M, Acosta S, Bastos F, et al-. Editor's Choice – Management of the Diseases of Mesenteric Arteries and Veins. European Journal of Vascular and Endovascular Surgery. 2017; 53 (4): p.460-510.doi: 10.1016/j.ejvs.2017.01.010 . | Open in Read by QxMD
  16. Bala M, Kashuk J, Moore EE, et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery. 2017; 12 (1).doi: 10.1186/s13017-017-0150-5 . | Open in Read by QxMD
  17. Luther B, Mamopoulos A, Lehmann C, Klar E. The Ongoing Challenge of Acute Mesenteric Ischemia. Visceral Medicine. 2018; 34 (3): p.217-223.doi: 10.1159/000490318 . | Open in Read by QxMD
  18. Anderson JL, Halperin JL, Albert NM, et al. Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations). Circulation. 2013; 127 (13): p.1425-1443.doi: 10.1161/cir.0b013e31828b82aa . | Open in Read by QxMD
  19. Hmoud B, Singal AK, Kamath PS. Mesenteric venous thrombosis.. Journal of clinical and experimental hepatology. 2014; 4 (3): p.257-63.doi: 10.1016/j.jceh.2014.03.052 . | Open in Read by QxMD
  20. Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD. Acute Mesenteric Ischemia. Arch Intern Med. 2004; 164 (10): p.1054.doi: 10.1001/archinte.164.10.1054 . | Open in Read by QxMD
  21. Fidelman N, AbuRahma AF, Cash BD, et al. ACR Appropriateness Criteria ® Radiologic Management of Mesenteric Ischemia. Journal of the American College of Radiology. 2017; 14 (5): p.S266-S271.doi: 10.1016/j.jacr.2017.02.014 . | Open in Read by QxMD
  22. Ginsburg M, et al. ACR Appropriateness Criteria® Imaging of Mesenteric Ischemia. Journal of the American College of Radiology. 2018; 15 (11): p.S332-S340.doi: 10.1016/j.jacr.2018.09.018 . | Open in Read by QxMD
  23. Tabriziani H, et al. A Nonsurgical Approach to Mesenteric Vascular Disease. Cardiol Rev. 2018; 26 (2): p.99-106.doi: 10.1097/crd.0000000000000180 . | Open in Read by QxMD
  24. Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016; 374 (10): p.959-968.doi: 10.1056/nejmra1503884 . | Open in Read by QxMD
  25. Aboyans V, Ricco J-B, Bartelink M-LEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur Heart J. 2017; 39 (9): p.763-816.doi: 10.1093/eurheartj/ehx095 . | Open in Read by QxMD
  26. Pillai AK, Kalva SP, Hsu SL, et al. Quality Improvement Guidelines for Mesenteric Angioplasty and Stent Placement for the Treatment of Chronic Mesenteric Ischemia. J Vasc Interv Radiol. 2018; 29 (5): p.642-647.doi: 10.1016/j.jvir.2017.11.024 . | Open in Read by QxMD
  27. Huber TS, Björck M, Chandra A, et al. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. Journal of Vascular Surgery. 2021; 73 (1): p.87S-115S.doi: 10.1016/j.jvs.2020.10.029 . | Open in Read by QxMD
  28. Terlouw LG, Moelker A, Abrahamsen J, et al. European guidelines on chronic mesenteric ischaemia – joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterology Journal. 2020; 8 (4): p.371-395.doi: 10.1177/2050640620916681 . | Open in Read by QxMD
  29. Kougias P, El Sayed HF, Zhou W, Lin PH. Management of chronic mesenteric ischemia. The role of endovascular therapy.. J Endovasc Ther. 2007; 14 (3): p.395-405.doi: 10.1583/07-2102.1 . | Open in Read by QxMD
  30. Zeller T, Rastan A, Sixt S. Chronic atherosclerotic mesenteric ischemia (CMI). Vasc Med. 2010; 15 (4): p.333-338.doi: 10.1177/1358863x10372437 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer