Bowel Ischemia / Necrosis

In the OR

Separate threatened bowel from irreversibly dead bowel.

Inspect the entire bowel and identify the vascular/mechanical cause rather than judging one isolated segment
Release strangulation or correct the occlusive process and reassess perfusion when restoration is possible
Assess color, peristalsis, mesenteric pulsation and adjunct perfusion information in context; no single sign is perfect
Resect clearly nonviable bowel while preserving potentially recoverable intestine when safe
Use a planned second-look operation when viability remains uncertain or extensive ischemia risks unnecessary massive resection

After the OR

Continue aggressive resuscitation, hemodynamic optimization and treatment of the underlying thrombotic, embolic or low-flow cause.
Reassess urgently for recurrent ischemia, worsening acidosis, persistent shock or abdominal compartment concerns.
When a second look is planned, define timing clearly and avoid falsely reassuring closure of an uncertain abdomen.
Antithrombotic and vascular management should be individualized to etiology and bleeding risk with the relevant specialty team.