Current Evidence on the Management of Non-occlusive Mesenteric Ischemia: A Comprehensive Narrative Review

Non-occlusive mesenteric ischemia (NOMI) is a life-threatening form of acute mesenteric ischemia (AMI), caused by severe intestinal hypoperfusion in the absence of an obstructive lesion of the mesenteric arteries. Early diagnosis and management remain challenging because the condition often develops in critically ill patients and frequently presents with non-specific clinical manifestations. This comprehensive narrative review summarizes the current evidence regarding the management of NOMI. A comprehensive literature search was performed. Evidence relating to hemodynamic resuscitation, imaging, catheter-directed therapies, surgical management, bowel viability assessment, nutritional support, and postoperative care was critically synthesized. Current evidence supports immediate correction of the underlying low-flow state, optimization of systemic perfusion, and urgent multiphase computed tomography angiography as the cornerstones of management. Catheter-directed intra-arterial vasodilator therapy with papaverine may improve mesenteric perfusion in carefully selected patients without established bowel infarction, although supporting evidence remains predominantly observational. Conversely, patients with peritonitis, perforation, or convincing evidence of transmural necrosis require prompt surgical exploration, using damage-control principles when appropriate. Despite recent advances in critical care, imaging, and endovascular techniques, the available evidence remains limited by small retrospective studies and considerable heterogeneity. Early recognition, multidisciplinary management, and standardized institutional treatment pathways are likely to represent the most effective strategies for improving outcomes, while prospective multicenter studies are needed to establish evidence-based management algorithms and optimize patient selection for emerging therapeutic interventions.