Hrev_master Abstract Acute mesenteric ischemia is a life-threatening condition with high mortality, often caused by arterial or venous hypoperfusion of the intestines. Early diagnosis remains challenging due to nonspe- cific clinical findings and the unreliability of laboratory biomark- ers. Serum L-lactate, a marker of tissue hypoperfusion, has been investigated as a potential prognostic and diagnostic indicator in acute mesenteric ischemia. This retrospective study analyzed 75 patients who underwent emergency surgery for acute mesenteric ischemia between 2010 and 2015. Demographic data, comorbidi- ties, preoperative serum L-lactate levels, operative details, intesti- nal resection length, and survival outcomes were collected and sta- tistically evaluated. ROC analysis was used to assess the diagnos- tic power of L-lactate in predicting the extent of bowel resection and to define a cut-off value. The overall mortality rate was 62.7%. Mortality was significantly associated with age ≥65 (p=0.011) and the presence of diabetes mellitus (p=0.041). Preoperative serum L- lactate levels were significantly higher in non-survivors than in survivors (median: 4.88 mmol/L vs. 3.00 mmol/L; p=0.011). However, no significant correlation was found between L-lactate levels and bowel resection length (p=0.316). ROC analysis failed to identify a statistically significant cut-off value for L-lactate in predicting resection extent (AUC=0.580; p=0.316). Preoperative serum L-lactate levels are significantly associated with mortality in patients with acute mesenteric ischemia and may serve as a prog- nostic biomarker. However, they do not reliably predict the extent of intestinal resection. Larger, prospective studies are required to define clinically meaningful diagnostic thresholds for L-lactate in acute mesenteric ischemia. Introduction Acute mesenteric ischemia is a critical clinical condition char- acterized by a sudden and severe hypoperfusion of the arterial or venous circulation of the small intestine, associated with high mor- tality rates. The pathogenesis may involve occlusive arterial obstruction, non-occlusive hypoperfusion, or venous outflow obstruction. While acute mesenteric ischemia predominantly affects the small intestine, it may also involve the colon in some cases. Delayed diagnosis can lead to irreversible tissue damage, intestinal infarction, and multiorgan failure, resulting in catas- trophic clinical outcomes. Therefore, prompt and accurate diagno- sis is crucial for altering the clinical course. Approximately 60–70% of all mesenteric ischemia cases are attributed to arterial hypoperfusion, while the remainder are asso- ciated with chronic or colonic ischemia.1 With the aging popula- tion and increasing prevalence of cardiovascular diseases, the inci- dence of acute mesenteric ischemia has markedly risen. Although the incidence of mesenteric ischemia among patients presenting with abdominal pain is about 1-2%, this rate can increase to as high as 18% in individuals over the age of 65.2 Despite advancements in imaging techniques and intensive care capabilities, mortality rates associated with acute mesenteric ischemia remain between Emergency Care Journal 2025; volume 21:14023 [Emergency Care Journal 2025; 21:14023] [page 95] L-lactate in acute mesenteric ischemia: a reliable biomarker for diagnosis and prognosis? Rıza Deryol,1 Duray Şeker,2 Gaye Ebru Şeker,2 Şener Balas3 1Department of Surgical Oncology, Ministry of Health, Istanbul Başakşehir Çam and Sakura City Hospital, Istanbul; 2Department of General Surgery, Ministry of Health, Ankara Etlik City Hospital, Ankara; 3Department of General Surgery, Health Sciences University, Ankara Oncology Training and Research Hospital, Ankara, Turkey Correspondence: Rıza Deryol, Department of Surgical Oncology, Ministry of Health, Istanbul Başakşehir Çam and Sakura City Hospital, G-434 Street No. 2L, Başakşehir Neighborhood, Başakşehir, Istanbul, Turkey. E-mail: dr.deryol@gmail.com Tel.: +90.212.909.60.00 - +90.506.563.3802 Key words: acute mesenteric ischemia, l-lactate, mortality, progno- sis, biomarker, resection length, ROC analysis. Conflict of interest: the authors declare that there is no conflict of interest. Funding: none Ethics approval: the Ethics Committee of Ankara Dışkapı Yıldırım Beyazıt Training and Research Hospital (Protocol 36125894, Date:02/03/2016). The study is conformed with the Helsinki Declaration of 1964, as revised in 2013, concerning human and ani- mal rights. Informed consent: all patients participating in this study signed a written informed consent form for participating in this study. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. Availability of data and materials: the datasets generated during and/or analyzed during the current study are available from the cor- responding author on reasonable request. Received: 21 May 2025. Accepted: 24 June 2025. Early view: 27 August 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:14023 doi:10.4081/ecj.2025.14023 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. 60% and 90%.3,4 This persistently high mortality is attributed not only to delays in diagnosis but also to factors such as advanced patient age, underlying comorbidities, and late presentation. One of the main challenges in achieving early diagnosis is the nonspe- cific nature of acute mesenteric ischemia symptoms and the lack of sufficiently reliable laboratory markers. The classic clinical triad of acute mesenteric ischemia — abdominal pain, hematochezia, and fever — is observed in only about one-third of patients.5 The most critical factor in reducing acute mesenteric ischemia- related mortality is the rapid restoration of blood flow through timely diagnosis and intervention. One of the significant diagnostic challenges in acute mesenteric ischemia is the absence of specific laboratory markers. Given that delays in diagnosis and treatment significantly increase mortality, the use of rapid and reliable bio- chemical markers has become increasingly important. Laboratory findings such as leukocytosis, increased anion gap, and elevated lactate levels are commonly observed but are limited in diagnostic specificity. L-lactate, a product of anaerobic glycolysis, is consid- ered a biochemical indicator of tissue hypoperfusion.6 Elevated serum L-lactate levels are frequently detected in acute mesenteric ischemia patients and have been reported to correlate with mortal- ity. However, its diagnostic power and an optimal cut-off value predictive of mortality have not yet been established. This study aims to evaluate the prognostic and diagnostic value of preoperative serum L-lactate levels in patients diagnosed with acute mesenteric ischemia, and to determine a diagnostic “cut-off” level that can predict mortality risk. Materials and Methods This retrospective study included patients who underwent surgery with a preoperative diagnosis of acute mesenteric ischemia at the General Surgery Department of our hospital between 2010 and 2015. A total of 75 patients who underwent emergency surgical intervention for acute mesenteric ischemia during the five years were included in the study. Patients with incomplete or inaccessi- ble medical records—such as missing operative notes, laboratory results, or outcome data—were excluded to ensure data integrity. This exclusion criterion may have introduced selection bias and should be taken into account when interpreting the study results. Data were collected through patient discharge summaries and hos- pital archive records. Ethics approval for the study was obtained from the Ethics Committee of Ankara Dışkapı Yıldırım Beyazıt Training and Research Hospital (Protocol 36125894, Date:02/03/2016). Demographic characteristics (age, sex), comor- bidities, preoperative biochemical findings, type of surgical inter- vention, resected bowel segment and length according to patholo- gy reports, length of hospital stay, and survival status were system- atically recorded for each patient. Preoperative serum L-lactate levels were obtained from the final arterial blood gas analysis performed before surgery. Samples were collected under anaerobic conditions using heparinized syringes, transported on ice, and analyzed within 30 minutes using an enzymatic amperometric method on a calibrated blood gas ana- lyzer. Measurements were taken according to manufacturer guide- lines, and internal quality controls were routinely applied. Due to lactate’s instability, strict pre-analytical precautions were taken to minimize degradation. Patients were categorized based on survival status (survivors vs. non-survivors), age group (<65 years and ≥65 years), length of bowel resection (<3 cm vs. ≥3 cm), and resected bowel segment. In addition to L-lactate levels, other biochemical parameters were statistically analyzed about mortality and resec- tion length. Statistical analysis All statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) version 15.0. The distribution characteristics of continuous variables were assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. For normally dis- tributed variables, comparisons were made using the independent samples t-test, whereas the Mann-Whitney U test was used for non-normally distributed data. Differences between categorical variables were analyzed using the Chi-square test or Fisher’s Exact test when appropriate. Correlations between variables were assessed using Pearson and Spearman correlation coefficients, and statistical significance was reported using p-values. Descriptive statistics were presented as mean ± standard devi- ation for normally distributed continuous variables and as median (minimum–maximum) for non-normally distributed data. Categorical variables were expressed as frequency (n) and percent- age (%). A p-value of <0.05 was considered statistically significant for all analyses. Results A total of 75 patients who underwent surgery with a diagnosis of acute mesenteric ischemia were included in our study. Among these, 46 (61.3%) were male and 29 (38.7%) were female. The mean age was 66.07±13.03 years, ranging from 33 to 87 years. Thirty-four patients (45.3%) were younger than 65 years, while 41 (54.7%) were aged 65 years or older. Regarding comorbidities, 29 patients (38.7%) had Coronary Artery Disease (CAD), 40 (53.3%) had Hypertension (HT), 21 (28%) had Diabetes Mellitus (DM), and 13 (17.3%) had Chronic Obstructive Pulmonary Disease (COPD). In addition, 35 patients (46.7%) had more than one comorbidity. Atrial Fibrillation (AF) was present in 19 patients (25.3%), Deep Vein Thrombosis (DVT) in 9 (12%), Pulmonary Thromboembolism (PTE) in 1 (1.3%), and Cerebrovascular Disease (CVD) in 12 (16%). Of the 75 patients who underwent surgery for acute mesenteric ischemia, 28 (37.3%) were discharged without complications. However, 47 patients died within the first 7 days postoperatively, corresponding to an early postoperative mortality rate of 62.7%. The mortality rate was 60.9% among males and 65.5% among females. A second-look operation was performed in 18 patients (24%), and postoperative complications developed in 4 patients (5.3%). Bowel resections were categorized based on resection length: patients who underwent resections of <3 m were placed in Group 1, and those with resections of ≥3 m were placed in Group 2. This classification considered the risk of short bowel syndrome. Of the 75 patients who underwent laparotomy, 63 (84%) had bowel resection, while 12 (16%) had laparotomy only without resection. Among the 63 resected cases, 42 (56%) underwent resections of <3 m, and 21 (28%) had resections of ≥3 m. There was no statistically significant difference in preoperative lactate levels between patients with resection lengths <3 m and ≥3 m (p=0.316). Additionally, resection length was not significantly associated with age, gender, white blood cell count, INR levels, blood pH, comorbidities (CAD, HT, DM, COPD), history of thrombosis (AF, DVT, PTE, CVD), ICU stay duration, hospital length of stay, second-look operations, postoperative complica- tions, or time to death (Table 1). Article [page 96] [Emergency Care Journal 2025; 21:14023] The median preoperative lactate level was 3.00 mmol/L (range: 0.71–10.67) in survivors, while it was 4.88 mmol/L (range: 1.12–27.77) in non-survivors (Table 2). Elevated lactate levels were significantly associated with increased mortality (p=0.011), and a direct correlation was observed between lactate levels and mortality rates. However, lactate levels did not differ significantly among age groups, the need for a second-look operation, or the occurrence of postoperative complications. Patients were further categorized based on the site of bowel resection into three groups: small intestine only, colon only, and both small intestine and colon. There was no significant difference in lactate levels among these groups (p=0.396). Additionally, no significant association was found between the resection site and the presence of AF or DVT; AF was evenly distributed across dif- ferent resection sites. A statistically significant difference in mortality was observed between age groups (<65 vs. ≥65 years), with advanced age being associated with higher mortality (p=0.011). The presence of dia- betes mellitus was also found to increase mortality (p=0.041) sig- nificantly. Conversely, no statistically significant differences in mortality were observed based on gender, resection length (<3 m vs. ≥3 m), presence of comorbidities (CAD, HT, COPD), history of thrombotic events (AF, DVT, PTE, CVD), or whether bowel resec- tion was performed during surgery. To evaluate potential predictors of mortality, clinical and laboratory variables were compared between survivors and non-survivors. The comparisons included demographic features, comorbid conditions, thrombotic history, operative variables, and preoperative serum L-lactate levels. The statistical significance of differences between groups was assessed using appropriate tests (Chi-square or Fisher’s exact test for cate- gorical variables, and Mann-Whitney U test for continuous vari- ables). The results are summarized in Table 3. The ability of lactate level to distinguish patients who under- went resection ≥3 m from those with <3 m was assessed using the Receiver Operating Characteristic (ROC) curve. The Area Under the Curve (AUC) was calculated as 0.580 with a standard error of 0.080. Based on a 95% confidence interval, the AUC was estimat- ed to lie between 0.423 and 0.737 in similar samples. This result was not statistically significant (p=0.316), suggesting that lactate level does not have sufficient diagnostic power to predict resection length, and therefore, no cut-off value could be calculated (Figure 1). The diagnostic accuracy of lactate for this purpose was deemed inadequate. Similarly, when patients were grouped based on a resection length of <2 meters and ≥2 meters, the AUC was also not statisti- cally significant (p=0.202), indicating that a cut-off value could not be calculated for this grouping either. Discussion Acute mesenteric ischemia is a life-threatening condition marked by sudden gastrointestinal hypoperfusion and high mortal- ity. It predominantly affects the small intestine and arises from either occlusive or non-occlusive vascular compromise. The main etiologic subtypes include arterial embolism (most common), arte- rial thrombosis, mesenteric venous thrombosis, and non-occlusive ischemia. Literature suggests that 60–70% of acute mesenteric ischemia cases are due to acute mesenteric blood flow insufficien- cy, while the remainder result from chronic or colonic ischemia.1 Early diagnosis plays a crucial role in the management of acute mesenteric ischemia. Patients typically present with acute abdom- inal pain, minimal physical signs, and metabolic acidosis. Delayed recognition often leads to bowel necrosis, sepsis, and multiorgan failure. Given the nonspecific nature of symptoms, particularly in high-risk individuals, maintaining a high level of clinical suspicion is essential. The diagnostic challenge significantly contributes to the condition’s high mortality. Mesenteric vascular diseases account for approximately 1–2% of all gastrointestinal diseases. However, with increasing clinical awareness and the aging population, the incidence of acute mesen- teric ischemia has shown a notable rise in recent years. Elderly individuals, particularly those with significant cardiovascular or systemic comorbidities, are more susceptible to this condition. Although some literature has suggested that acute mesenteric ischemia accounts for up to 18% of abdominal pain presentations in patients aged ≥65 years,2 this figure may be an overestimation. Article Table 1. Comparison of clinical and laboratory variables according to resection length (<3 m vs. ≥3 m). Variables <3 m Median (Min–Max) ≥3 m Median (Min–Max) p Age (years) 65 (33-84) 70 (38-85) 0.461 White blood cell count (mm³) 13,675 (3,900-50,300) 18,190 (6,200-33,200) 0.117 INR 1.29 (0.90-5.69) 1.28 (0.96-2.24) 0.884 Lactate (mmol/L) 3.56 (1.12-26.00) 4.69 (0.86-17.10) 0.316 pH 7.39 (6.99-7.57) 7.37 (7.07-7.47) 0.556 ICU stay (days) 3 (0-49) 2 (1-62) 0.935 Total follow-up duration (days) 7 (0-49) 8 (1-62) 0.417 Time to death (days) 2.5 (0-49) 2 (1-62) 0.976 [Emergency Care Journal 2025; 21:14023] [page 97] Table 2. Distribution of lactate levels according to survival status. Survival Status Mean (mmol/L) Standard Error Median Min Max n Survived 3.48 2.38 3.00 0.71 10.67 26 Deceased 6.44 5.73 4.88 1.12 27.77 45 Total 5.35 4.97 4.00 0.71 27.77 71 In an extensive retrospective analysis of 5,340 patients presenting with acute abdominal pain in an urban emergency department, Cervellin et al. reported considerably lower rates of mesenteric ischemia,7 highlighting the rarity and diagnostic challenge of acute mesenteric ischemia in real-world settings. According to this trend, 54.7% (n=41) of the patients in our study were 65 years or older, with a mean age of 66 years for the cohort. Analysis by age group revealed that mortality was significantly higher in the ≥65 age group (p=0.011), reinforcing the role of advanced age as an inde- pendent risk factor for mortality in acute mesenteric ischemia. Age-related vascular changes, including loss of elasticity, the pres- ence of atherosclerotic plaques, and multiple comorbidities, increase susceptibility to ischemia and negatively impact treatment outcomes.8 In our study, 46.7% of patients had multiple comorbidities, with HT (53.3%), CAD (38.7%), DM (28%), and COPD (17.3%) being most common. DM was significantly associated with mortal- ity (p=0.041). Its impact may be explained by microvascular dam- age, endothelial dysfunction, and impaired immune response, which increase susceptibility to ischemia and accelerate progres- sion to necrosis. These results align with prior studies identifying diabetes as an independent predictor of mortality in acute mesen- teric ischemia.9 Despite advancements in diagnosis and treatment, acute mesenteric ischemia continues to carry a high mortality rate, often exceeding 60%.1 Oldenburg et al. reported mortality rates of 44% in mesenteric venous thrombosis, 66% in arterial occlusions, and 89% in non-occlusive cases.8 Similarly, our study found a mortal- ity rate of 62.7%, likely influenced by factors such as delayed diag- nosis, advanced age, comorbidities, and late hospital admission. A distinctive feature of our study is its assessment of the prog- nostic utility of preoperative L-lactate levels in acute mesenteric ischemia. As a recognized indicator of hypoperfusion and anaero- bic metabolism, L-lactate was evaluated about both mortality and bowel resection extent. Despite its relevance, no single non-inva- sive biomarker currently demonstrates sufficient sensitivity and specificity for the early diagnosis of acute mesenteric ischemia, prompting continued investigation into novel candidates in recent literature. Typical laboratory findings in intestinal ischemia, such as leukocytosis, elevated hematocrit, metabolic acidosis, and increased serum lactate, often appear in advanced stages, limiting their value for early diagnosis.10 L-lactate rises due to anaerobic metabolism during hypoperfusion but lacks disease specificity, as it can elevate in other critical conditions like sepsis or organ fail- ure.11 Although serum lactate shows high sensitivity (~86%) for acute mesenteric ischemia, its low specificity (~44%) limits its standalone diagnostic utility. While animal models support L-lac- tate elevation following superior mesenteric artery occlusion,12,13 human data remain inconsistent.14 D-lactate, a stereoisomer pro- duced by gut bacteria, may serve as a more specific marker, though its clinical use is limited by delayed elevation and methodological challenges.6,15 In our study, L-lactate demonstrated limited diagnostic utility for predicting bowel resection length. ROC analysis yielded an AUC of 0.58 (p=0.316), and no significant difference was observed for a ≥2 m resection threshold (p=0.202). These findings align with previous meta-analyses suggesting that serum lactate is a nonspecific marker for early ischemic injury.16 Nevertheless, in our study, preoperative L-lactate levels were found to be significantly associated with mortality (p=0.011). This suggests that elevated preoperative L-lactate levels may reflect poorer prognosis and increased mortality risk in acute mesenteric ischemia patients. Similar associations between elevated serum lactate and in-hospital mortality have been reported in several pre- vious studies.17 In this context, L-lactate may be better interpreted as a prognostic marker rather than a diagnostic one. However, no ROC analysis was performed to determine an optimal cut-off value for predicting mortality, primarily due to the limited sample size, which could compromise statistical robustness. Moreover, L-lac- tate was measured only once in the preoperative period. Serial or dynamic lactate monitoring may provide more accurate prognostic Article Figure 1. ROC curve evaluating the diagnostic performance of preoperative serum L-lactate levels in predicting the need for ≥3 meters of intestinal resection. The area under the curve (AUC) was 0.580 (Standard Error: 0.080; p=0.316; 95% Confidence Interval: 0.423-0.737). Table 3. Summary of clinical variables and their association with mortality. Variable p Interpretation Age (<65 vs. ≥65) 0.011 Significant Gender (male vs. female) ns Not significant Coronary artery disease ns Not significant Hypertension ns Not significant Diabetes mellitus 0.041 Significant Chronic obstructive pulmonary disease ns Not significant Atrial fibrillation ns Not significant Deep vein thrombosis ns Not significant Pulmonary thromboembolism ns Not significant Cerebrovascular disease ns Not significant Bowel Resection (Yes vs. No) ns Not significant Resection Length (<3 m vs. ≥3 m) ns Not significant Second-look Operation ns Not significant Postoperative complications ns Not significant Preoperative L-lactate Level 0.011 Significant Note: “ns” denotes non-significant results (p > 0.05). Statistical tests included Chi-square, Fisher’s exact test, and Mann–Whitney U test, depending on variable type. [page 98] [Emergency Care Journal 2025; 21:14023] insights by capturing ongoing perfusion changes and clinical responses. In recent years, a variety of novel biomarkers have been inves- tigated for their potential utility in diagnosing intestinal ischemia. These include alpha-Glutathione S-Transferase (α-GST), Intestinal Fatty Acid-Binding Protein (I-FABP), Cobalt-Albumin Binding Assay (CABA), Ischemia-Modified Albumin (IMA), Diamine Oxidase (DAO), citrulline, and C-Reactive Protein (CRP).18-20 While many of these biomarkers have shown promising results in experimental or early-phase clinical studies, sufficient validation and standardization for routine clinical use have not yet been established. Thromboembolic events of cardiac origin, particularly atrial fibrillation, are a significant cause of acute mesenteric ischemia.21 In our cohort, 25.3% had AF, 12% DVT, 1.3% PTE, and 16% CVD, underscoring the role of cardiovascular comorbidities in acute mesenteric ischemia pathogenesis. However, AF was not sig- nificantly associated with mortality, potentially due to limitations in preoperative documentation or incomplete clinical data. The mean hospital stay was 10 days, with an average ICU stay of 7.8 days. These durations are shorter than the ~23-day hospital stays reported in the literature,22 possibly due to variations in patient selection, surgical timing, or institutional practices. Second-look laparotomy was performed in 24% of cases. In most initially borderline viable segments, progression to necrosis required further resection. While second-look surgery may increase morbidity, literature supports its role in enabling timely necrosis management and improving long-term outcomes.22 Recent studies have demonstrated the prognostic significance of elevated L-lactate levels in acute mesenteric ischemia.23 The updated guidelines of the World Society of Emergency Surgery (WSES) emphasize the adjunctive role of serum biomarkers, par- ticularly in cases of high clinical suspicion.24 Our findings make a meaningful contribution to this growing body of evidence. One of the main strengths of this study is its focused assess- ment of preoperative L-lactate levels as a prognostic marker in acute mesenteric ischemia, specifically regarding mortality and the length of bowel resection. Few studies have evaluated these parameters concurrently, making this research a valuable contribu- tion to the field. Additionally, a comprehensive analysis of clinical, laboratory, and operative data identified advanced age and diabetes mellitus as significant mortality-related factors, aiding in the early identification of high-risk patients. However, this study also has several limitations. Primarily, its retrospective and single-center design restricts the generalizability of the findings. Additionally, the relatively small sample size may have limited the statistical power, particularly in the ROC analysis used to determine diagnostic accuracy. Another limitation stems from the incomplete availability of some preoperative clinical data, which constrained the comprehensive evaluation of comorbid con- ditions. Moreover, L-lactate levels were measured at a single time point only, which precluded assessment of their dynamic changes over time. Furthermore, acute mesenteric ischemia was analyzed as a sin- gle entity without stratification by etiology (e.g., embolism, throm- bosis, non-occlusive), which may have masked differences in biomarker behavior across subtypes. It should also be noted that elevated L-lactate levels are not specific to acute mesenteric ischemia and may be observed in various systemic conditions such as sepsis, shock, or hepatic dysfunction. As these potential con- founding factors were not fully controlled in our study, the inter- pretation of L-lactate as a prognostic biomarker should be approached with caution. Therefore, to determine a clinically meaningful “cut-off” value for L-lactate and to enhance its utility in clinical decision-making, larger, multicenter, prospective studies are warranted. Conclusions In this study, the mortality rate among patients who underwent surgical treatment for acute mesenteric ischemia was 62.7%, which is consistent with the high mortality rates reported in the lit- erature. Advanced age and the presence of diabetes mellitus were significantly associated with mortality, suggesting that these two variables may serve as independent risk factors influencing the prognosis of acute mesenteric ischemia. Preoperative serum L-lactate levels were also found to be sig- nificantly associated with mortality. This finding supports the potential use of L-lactate as a prognostic biomarker for predicting adverse clinical outcomes in acute mesenteric ischemia. However, L-lactate failed to predict the extent of intestinal resection, as the ROC analysis did not yield a statistically significant cut-off value (p=0.316), limiting its diagnostic utility in this context. These findings highlight the importance of early diagnosis and prompt intervention, particularly in elderly or diabetic patients. While L-lactate may aid in risk stratification, it remains insuffi- cient for guiding surgical decisions. Further large-scale, prospec- tive studies are needed to establish reliable thresholds and identify more specific biomarkers. A high index of suspicion, multidisci- plinary assessment, and improved diagnostic tools remain essential to optimize outcomes in acute mesenteric ischemia. References 1. McKinsey JF, Gewertz BL. Acute mesenteric ischemia. Surg Clin North Am 1997;77:307-18. 2. Yasuhara H. Acute mesenteric ischemia: the challenge of gas- troenterology. Surg Today 2005;35:185-95. 3. Herbert GS, Steele SR. Acute and chronic mesenteric ischemia. Surg Clin North Am 2007;87:1115-34. 4. Paterno F, Longo WE. The etiology and pathogenesis of vas- cular disorders of the intestine. Radiol Clin North Am 2008;46:877-85. 5. Chang RW, Chang JB, Longo WE. Update in management of mesenteric ischemia. World J Gastroenterol 2006;12:3243 7. 6. Collange O, Tamion F, Chanel S, et al. D-lactate is not a reli- able marker of gut ischemia-reperfusion in a rat model of supraceliac aortic clamping. Crit Care Med 2006;34:1415 9. 7. Cervellin G, Mora R, Ticinesi A, et al. Epidemiology and out- comes of acute abdominal pain in a large urban emergency department: a retrospective analysis of 5,340 cases. Ann Transl Med 2016;4:362. 8. Schoots IG, Koffeman GI, Legemate DA, et al. Systematic review of survival after acute mesenteric ischemia according to disease aetiology. Br J Surg 2004;91:17-27. 9. Block TA, Acosta S, Bjorck M. Endovascular and open surgery for acute occlusion of the superior mesenteric artery. J Vasc Surg 2010;52:959-66. 10. Glenister KM, Corke CF. Infarcted intestine: a diagnostic void. ANZ J Surg 2004;74:260. 11. Cudnik MT, Darbha S, Jones J, et al. The diagnosis of acute mesenteric ischemia: a systematic review and meta-analysis. Acad Emerg Med 2013;20:1087. Article [Emergency Care Journal 2025; 21:14023] [page 99] 12. Gunel E, Caglayan O, Caglayan F. Serum D-lactate levels as a predictor of intestinal ischemia-reperfusion injury. Pediatr Surg Int 1998;14:59 61. 13. Kulacoglu H, Kocaerkek Z, Moran M, et al. Diagnostic value of blood D-dimer level in acute mesenteric ischaemia in the rat: an experimental study. Asian J Surg 2005;28:131-5. 14. Acosta S, Nilsson TK, Malina J, Malina M. L-lactate after embolization of the superior mesenteric artery. J Surg Res 2007;143:320-8. 15. Lange H, Jackel R. Usefulness of plasma D-lactate as a diag- nostic marker for intestinal ischemia. Eur J Med Res 2004;9:385-90. 16. Demir IE, Ceyhan GO, Friess H. Beyond lactate: is there a role for serum lactate measurement in diagnosing acute mesenteric ischemia? Dig Surg 2012;29:226-35. 17. Martinez JP, Hogan GJ. Mesenteric ischemia. Emerg Med Clin North Am 2004;22:909-28. 18. Gearhart SL, Delaney CP, Senagore AJ, et al. Prospective assessment of the predictive value of alpha-glutathione S- transferase for intestinal ischemia. Am Surg 2003;69:324. 19. Kanda T, Fujii H, Tani T, et al. Utility of intestinal fatty acid- binding protein in diagnosing small bowel ischemia. World J Gastroenterol 2020;26:1103-13. 20. Gunduz A, Turedi S, Mentese A, et al. Ischemia-modified albu- min in the diagnosis of acute mesenteric ischemia: a prelimi- nary study. Am J Emerg Med 2008;26:202. 21. Hylek EM, Skates SJ, Sheehan MA, Singer DE. An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N Engl J Med 1996;335:540. 22. Ryer EJ, Kalra M, Oderich GS, et al. Revascularization for acute mesenteric ischemia. J Vasc Surg 2012;55:1682. 23. Cecchi A, De Marchi L, Fabbri A, et al. Serum lactate and base deficit as predictors of mortality in acute mesenteric ischemia. Ann Intensive Care 2017;7:92. 24. Bala M, Kashuk J, Moore EE, et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2017;12:38. Article [page 100] [Emergency Care Journal 2025; 21:14023]