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Abdominal Compartment Syndrome

Etiology

  • Pathologic intra-abdominal hypertension (>20mmHg) which leads to organ dysfunction, can be due to primary or secondary sources

Primary – Intra-abdominal disease or injury

    • Trauma
    • Surgery – abdominal packing, post-operative haemoperitoneum
    • Pancreatitis
    • Ascites
    • Pneumoperitoneum
    • Ruptured abdominal aortic aneurysm (AAA)

Secondary – extra abdominal disease or injury

    • Splanchnic reperfusion after massive resuscitation
    • Burns
    • Sepsis

Pathophysiology

  • Tissue fluid within the peritoneum and retroperitoneal space accumulates in such large volumes until the abdomen can no longer expand – leads to rise in intra-abdominal pressure
  • Initially causes intra-abdominal hypertension (>12mmHg)
  • ACS is defined as sustained intra-abdominal pressure above 20mmHg with new onset organ dysfunction

Pathology

  • Underlying cause is due to increased in capillary permeability due to the systemic inflammatory response syndrome (SIRS) – causes fluid to leak out of capillary beds into the interstitial space
  • Abdominal organs begin to collapse under the increased pressure – eventually causes compromise of the cardiovascular and respiratory systems

Clinical features

  • Abdominal distension – may be tense and tender
  • Difficulty breathing, wheezing, cyanosis
  • Decreased urine output

Complications

  • Renal failure – due to decreased renal perfusion
  • Respiratory distress and failure
  • Bowel ischemia
  • Increased intracranial pressure
  • Decreased cardiac output and decreased venous return

Investigations

  • Bladder pressure – gold standard for measuring intra-abdominal pressure
    • Measured with Foley’s catheter
  • Lab studies – CBC, amylase, PT + aPTT, urinalysis, ABGs
  • Abdominal CT
    • Round belly sign – abdominal distension with an increased ratio of anteroposterior to transverse abdominal diameter (>0.8)
    • Elevated diaphragm
    • Flattened inferior vena cava
    • Displacement of solid abdominal viscera

Treatment

  • Removal of intraperitoneal collections and intraluminal bowel contents
    • Paracentesis – for ascits or hemoperitoneum
    • Gastric decompression
  • Analgesia and sedation
  • Optimise fluid status
  • Surgical management
    • Decompressive laparotomy – mortality is 70% if this is delayed
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