Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Bowel ischaemia in shock
NOMI can progress silently to transmural infarction in sedated or ventilated patients even though the major mesenteric arteries remain patent.
Action: Obtain immediate arterial and venous phase CTA, correct the precipitating low-flow state, involve surgery and critical care, and operate without delay for peritonitis, perforation or non-viable bowel.
Synopsis
Detect intestinal hypoperfusion despite patent mesenteric arteries, avoid false reassurance from biomarkers or vessel patency, and coordinate haemodynamic correction, bowel assessment and selective catheter therapy.
Suspect NOMI in a shocked or critically ill patient with abdominal distension, pain, bleeding, feed intolerance or otherwise unexplained deterioration, even if the patient is sedated.
Obtain urgent contrast CTA in arterial and venous phases with thin slices; major mesenteric arteries may be patent while the bowel fails to enhance.
No single lactate or D-dimer measurement confirms or excludes NOMI. Only after cause correction, when bowel remains potentially viable and there is no peritonitis, perforation or clear necrosis, may an expert centre consider SMA catheter vasodilators under protective heparinisation; laparotomy overrides catheter rescue when bowel is non-viable.
Key red flags
Peritonism, perforation, pneumoperitoneum or clinical collapse indicates likely transmural necrosis and demands urgent operative exploration.
Shock with new abdominal distension, gastrointestinal bleeding, feed intolerance or unexplained organ failure should trigger NOMI suspicion even without reported pain.
Absent bowel enhancement, pneumatosis or portal venous gas on CTA with no significant SMA occlusion is a high-risk non-occlusive pattern.
Rising vasopressor requirements, low cardiac output, severe hypovolaemia or abdominal compartment syndrome perpetuates mesenteric vasoconstriction and tissue hypoxia.
A normal early lactate does not exclude intestinal ischaemia; waiting for a biomarker threshold can sacrifice viable bowel.
Masked ICU presentation
A ventilated patient may show only distension, feed intolerance, maroon stool, rising support needs or new organ failure; absence of reported pain is meaningless.
Peritoneal transition
Guarding, rebound, rigidity, perforation or sudden deterioration indicates likely transmural infarction and moves management from rescue assessment to urgent surgery.
Investigation priorities
01
Urgent biphasic CT angiographyFirst step
Assess bowel viability and exclude arterial embolism, thrombosis and mesenteric venous thrombosis.
Management branches
Worked caseDeterioration during septic shock
A sedated patient on increasing vasopressors develops distension, feed intolerance, acidosis and rising lactate.
Recognise the high-risk NOMI pattern and examine for distension, bleeding and peritoneal signs while alerting critical care, radiology and surgery; do not wait for pain or a diagnostic lactate.
Perform immediate arterial and venous phase CTA and simultaneously restore effective volume, optimise cardiac output, treat sepsis, stop enteral feeding, decompress the stomach and review avoidable vasoconstrictors.
Key medicines
Intra-arterial papaverine (specialist catheter rescue; no standard licensed UK NOMI regimen identified)In an angiography suite, ESVS describes a study-derived 80 mg papaverine bolus directly into the superior mesenteric artery followed by 30–60 mg/hour for 24–72 hours. A current eMC search returned no papaverine SmPC, and no standard licensed UK intra-arterial NOMI regimen was identified; do not infer that every papaverine product or use is categorically unlicensed. The interventional, vascular, critical-care and pharmacy team must verify the available product and legal route, then select preparation, duration and protective heparinisation and stop for harm or lack of response.Evidence is low and comparative dose studies are absent. Continuous arterial-pressure and rhythm monitoring is essential because sudden systemic hypotension can be fatal; assess bleeding risk, hepatic handling, line complications and the separate heparin indication. Never delay laparotomy for peritonitis, perforation or necrotic bowel.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 13 Sept 2026; clinical approval remains outstanding.
eMC papaverine searchCurrent UK SmPC index search returned no papaverine result; this supports the limited statement that no eMC product or standard licensed UK intra-arterial NOMI regimen was identified, not a categorical product-status claim.