A 70-year-old man with atrial fibrillation presents with sudden severe abdominal pain and bloody diarrhoea. CT angiography reveals occlusion of the superior mesenteric artery (SMA) at its origin. His lactate is 8 mmol/L. The primary diagnosis and immediate management is:

• A Non-occlusive mesenteric ischaemia; intra-arterial papaverine infusion
• B Mesenteric venous thrombosis; systemic anticoagulation with heparin
• C Acute mesenteric ischaemia from embolism; emergency laparotomy with bowel viability assessment and SMA embolectomy ✓
• D Ischaemic colitis; conservative management with IV fluids

Explanation

SMA occlusion at the origin with AF and peritonism/high lactate is acute embolic mesenteric ischaemia. Emergency laparotomy is mandatory for peritonism or signs of intestinal infarction (elevated lactate). The operation involves SMA embolectomy or bypass, bowel viability assessment (with planned second-look laparotomy at 24–48 hours), and resection of non-viable bowel. Endovascular intervention may be considered in early cases without peritonitis.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.