A 68-year-old man with atrial fibrillation presents with 12 hours of severe abdominal pain out of proportion to physical findings. He has mild abdominal tenderness but no peritonism, and a markedly elevated serum lactate. CT angiography shows occlusion of the superior mesenteric artery just beyond its origin with no contrast filling of distal branches. What is the most appropriate immediate management?
- A Urgent laparotomy with embolectomy and assessment of bowel viability ✓
- B Anticoagulation with heparin and serial abdominal examination
- C Broad spectrum antibiotics and bowel rest for 48 hours
- D Percutaneous catheter-directed thrombolysis
Correct answer: A. Urgent laparotomy with embolectomy and assessment of bowel viability
Explanation
Acute embolic superior mesenteric artery occlusion with rising lactate demands urgent revascularisation by open embolectomy, allowing simultaneous inspection of bowel viability and resection of necrotic segments. The pain out of proportion to signs is the classic early finding before infarction. Anticoagulation alone risks progression to transmural necrosis, thrombolysis is unsuitable once lactate rises because dead bowel must be removed, and antibiotics are adjunctive rather than definitive treatment.
Reference: Bailey and Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.