Abdominal compartment syndrome

Background

• Organ dysfunction caused by intrabdominal hypertension
• Increased intrabdominal pressure resulting in decreased organ perfusion, impaired hemodynamics

Pathophysiology

• Abdominal perfusion pressure = MAP - intrabdominal pressure
• Build up of fluid or blood within the peritoneum or retroperitoneum
  • And/or decrease in abdominal wall compliance
• Increased pressure within cavity of fixed volume → hypoperfusion of abdominal organs
  • Also causes restriction of diaphragmatic excursion and impaired central venous return

Causes

• Acute Pancreatitis
• Ascites
• Diffuse peritonitis
• Large volume fluid resuscitation
• Reperfusion of ischemic bowel
• Retroperitoneal hemorrhage
• Small bowel obstruction
• Trauma

Clinical Features

• Most patients are critically ill and unable to communicate
• Decreased central venous return
  • Increased JVP
  • Increased ICP
  • Decreased cardiac preload
  • Increased cardiac afterload
• Increased intrathoracic pressure
  • Decreased lung compliance (will cause high peak pressures in vented patients)
  • Decreased functional residual capacity
  • Worsened V/Q mismatch
• Oliguria, renal failure
• Bowel ischemia

Differential Diagnosis

Abdominal Trauma

• Abdominal compartment syndrome
• Diaphragmatic trauma
• Duodenal hematoma
• Genitourinary trauma
• Liver trauma
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Retroperitoneal hemorrhage
• Renal trauma
• Splenic trauma
• Trauma in pregnancy
• Ureter trauma

Evaluation

Abdominal compartment syndrome caused by bulimia post vomiting. CT shows dilated stomach with food and air pressed other visceral organs and major abdominal vessels.

A case of abdominal compartment syndrome derived from simple elongated sigmoid colon in an elderly man.. Abdominal CT scan of the patient pre-decompression (a) and post-decompression (b). The arrow shows the inferior vena cava, which was collapsed pre-decompression.

Physical exam is neither sensitive nor specific

• Obtain bladder pressure
  • Normal < 12 mmHg
  • Intra-abdominal hypertension 12 - 20 mmHg
  • Abdominal compartment syndrome > 20 mmHg PLUS end-organ damage

Management

Nonoperative

Often first line approach when no abdominal injury present

• Limit fluid resuscitation
• Nasogastric and bladder decompression
• Electrolyte repletion
• Antibiotics
• Pressors
• CRRT
• Percutaneous fluid drainage

Operative

Definitive treatment

• Laparotomy provides decompression
  • High complication rate
  • No guidelines for timing of closure

Disposition

• Admit

See Also

• "Traditional" compartment syndrome