Abdominal compartment syndrome: what radiologist needs to know.

The intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) are life-threatening conditions with a significant rate of mortality; therefore, early detection is paramount in their optimal management. IAH is diagnosed when the intra-abdominal pressure (IAP) is more than 12 mmHg. It can occur when the intra-abdominal volume increases (ileus, ascites, trauma, pancreatitis, etc.) and/or the abdominal wall compliance decreases. IAH can cause decreased venous flow, low cardiac output, renal impairment, and decreased respiratory compliance. Consequently, these complications can lead to multiple organ failure and induce the abdominal compartment syndrome (ACS) when IAP rises above 20 mmHg. The diagnosis is usually made with intravesical pressure measurement. However, this measurement was not always possible to obtain; therefore, alternative diagnostic techniques should be considered. In this setting, computed tomography (CT) may play a crucial role, allowing the detection and characterization of pathological conditions that may lead to IAH. This review is focused on the pathogenesis, clinical features, and radiological findings of ACS, because their presence allows radiologists to raise the suspicion of IAH/ACS in critically ill patients, guiding the most appropriate treatment.

Abdominal perfusion pressure is superior from intra-abdominal pressure to detect deterioration of renal perfusion in critically Ill patients.

BACKGROUND: Intra-abdominal hypertension (IAH) is a frequent cause of acute kidney injury (AKI) among critically ill patients who have risk factors. This study aimed to determine the relation between Abdominal Perfusion Pressure (APP) and AKI showed by the Doppler-based renal resistive index (RRI). METHODS: In this study, 38 patients older than 18 years old who received mechanical ventilation and had risk factors for the development of IAH were prospectively studied. All measurements and parameters were divided into two groups according to renal dysfunction (Group I: RRI <0.72 vs Group II: RRI >0.72). RESULTS: The mean IAPs were not significant between the groups, 11.5±6.9 mm Hg in Group I (n=35) and 13.5±5.8 in Group II (n=33), respectively. APPs were statistically higher in Group I (81.2±13.6) than Group II (66.4±9.5) (p<0.001). The AUC for the association between APP at RRI >0.72 was 0.802 (p<0.001), with the APP ≤72 mmHg having a sensitivity of the 76% (95% CI 58-89%) and a specificity of 71% (95% CI 54-85%). CONCLUSION: Our findings suggest that an APP with a threshold of ≤72 mmHg is associated with a significant increase in renal RRI, which may be predictive of worsening of renal perfusion.

Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries.

After experiencing blunt or penetrating trauma, patients in unstable condition who are more likely to die of uncorrected shock than of incomplete injury repairs undergo emergency limited exploratory laparotomy, which is also known as damage control surgery (DCS). This surgery is part of a series of resuscitation steps, with the goal of stabilizing the patient's condition, with rapid surgical control of hemorrhage followed by supportive measures in the intensive care unit before definitive repair of injuries. These patients often are imaged with multidetector CT within 24-48 hours of the initial surgery. Knowledge of this treatment plan is critical to CT interpretation, because there are anatomic derangements and foreign bodies that would not be present in patients undergoing surgery for other reasons. Patients may have injuries beyond the surgical field that are only identified at imaging, which can alter the care plan. Abnormalities related to the resuscitation period such as the CT hypoperfusion complex and ongoing hemorrhage can be recognized at CT. Familiarity with these imaging and clinical findings is important, because they can be seen not only in trauma patients after DCS but also in other patients in the critical care setting. The interpretation of imaging studies can be helped by an understanding of the diagnostic challenges of grading organ injuries with surgical materials in place and the awareness of potential artifacts on images in these patients. Online supplemental material is available for this article. ©RSNA, 2019 See discussion on this article by LeBedis .

First Report of Fatal Secondary Abdominal Compartment Syndrome Induced by Intestinal Gas Accumulation without Organic Occlusive Intestinal Lesion in a Child with Sepsis.

BACKGROUND Abdominal compartment syndrome (ACS), characterized by an increased intra-abdominal pressure and new-onset organ dysfunction, is a critical and potentially fatal condition, with no case of ACS caused by intestinal gas without intestinal lesion being reported to date. CASE REPORT A 2-year-old girl with a chromosomal abnormality of 1p36 deletion presented with fever and diarrhea following upper-gastrointestinal series for the evaluation of gastroesophageal reflux. After 20 days, she experienced septic shock and multiple-organ failure, accompanied with rapidly growing, severe abdominal distension. A marked increase in the intra-abdominal pressure was indicated by the complete loss of elasticity in the extremely hard and distended abdomen. She died 14 h after the onset of shock. Her autopsy examination revealed extensive pneumonia and excessive intestinal gas, despite no occlusive intestinal lesion present. CONCLUSIONS It is critical to be aware that secondary ACS can occur following sepsis due to the accumulation of extensive intestinal gas, without an occlusive intestinal lesion.

Interventional Management of Subcapsular Hepatic Hematoma with Hepatic Compartment Syndrome After Laparoscopic Adrenalectomy.

Hepatic compartment syndrome is an increase in intrahepatic pressure sufficient to cause compromised hepatic perfusion. Early recognition and prompt management are essential for preventing catastrophic consequences including ischemic liver failure and hypovolemic shock. This is the rare case of laparoscopic adrenalectomy resulting in subcapsular hepatic hematoma with hepatic compartment syndrome. Contrast-enhanced computed tomography demonstrated extensive subcapsular hepatic hematoma with collapse of portal vein and inferior vena cava suggesting impending compartment syndrome. Diagnostical catheter angiography of the liver revealed innumerable foci of petechial extravasation from disrupted isolated arteries. Emergent percutaneous catheter decompression and transarterial embolization were successful.

Abdominal compartment syndrome secondary to megarectum and megasigmoid.

A 31-year-old male patient with chronic constipation of unknown aetiology presented emergently with worsening nausea, vomiting and abdominal distension of one week duration. On examination, his abdomen was distended with minimal tenderness. A plain film of the abdomen demonstrated severe faecal loading. The patient was haemodynamically unstable on admission and appeared sick. An urgent CT abdomen and pelvis was conducted showing extensive rectal dilatation and associated proximal colonic stercoral perforation. The patient proceeded straight to theatre for laparotomy as his general condition was deteriorating rapidly. On transfer to the operating table, the patient suffered cardiopulmonary arrest. Resuscitation was immediately commenced. Abdominal compartment syndrome was suspected. Cardiac output was re-established following a midline laparotomy which acted relieve the abdominal pressure. The rectosigmoid faecal content was decompressed via an enterotomy. The perforated segment of transverse colon was resected and an end colostomy fashioned. A year later, the continuity of the bowel was re-established.

The role of point-of-care ultrasound in intra-abdominal hypertension management.

BACKGROUND: Intra-abdominal hypertension is a common complication in critically ill patients. Recently the Abdominal Compartment Society (WSACS) developed a medical management algorithm with a stepwise approach according to the evolution of the intra-abdominal pressure and aiming to keep IAP ≤ 15 mm Hg. With the increased use of ultrasound as a bedside modality in both emergency and critical care patients, we hypothesized that ultrasound could be used as an adjuvant point-of-care tool during IAH management. This may be particularly relevant to the first and second basic stages of the algorithm. The objective of this paper is to test the use of POCUS as an adjuvant tool in the management of patients with IAH/ACS. METHODS: Seventy-three consecutive adult critically ill patients admitted to the surgical intensive care unit (ICU) of a single urban institution with risk factor for IAH/ACS were enrolled. Those who met the inclusion criteria were allocated to undergo POCUS as an adjuvant tool in their IAH/ACS management. RESULTS: A total of 50 patients met the inclusion criteria and were included in the study. The mean age of study participants was 55 ± 22.6 years, 58% were men, and the most frequent admission diagnosis was post-operative care following abdominal intervention. All admitted patients presented with a degree of IAH during their ICU stay. Following step 1 of the WSACS IAH medical management algorithm, ultrasound was used for NGT placement, confirmation of correct positioning, and evaluation of stomach contents. Ultrasound was comparable to abdominal X-ray, but shown to be superior in determining the gastric content (fluid vs. solid). Furthermore, POCUS allowed faster determination of correct NGT positioning in the stomach (antrum), avoiding bedside radiation exposure. Ultrasound also proved useful in: 1) evaluation of bowel activity; 2) identification of large bowel contents; 3) identification of patients that would benefit from bowel evacuation (enema) as an adjuvant to lower IAP; 4) and in the diagnosis of moderate to large amounts of free intra-abdominal fluid. CONCLUSION: POCUS is a powerful systematic ultrasound technique that can be used as an adjuvant in intra-abdominal hypertension management. It has the potential to be used in both diagnosis and treatment during the course of IAH.

The use of bi-planar tissue expanders to augment abdominal domain in a pediatric intestinal transplant recipient.

Intestinal transplantation is a well-accepted treatment for SBS. However, patients with SBS often have decreased abdominal capacity, which makes size-matching of donor organs more difficult, thus decreasing organ availability. Reported approaches for addressing this problem include surgically reducing the graft size, leaving an open abdomen for a prolonged period, and cotransplanting rectus fascia as a non-vascularized allograft. Each approach has significant disadvantages. There has been one previous report of tissue expanders used intra-abdominally and two reports of subcutaneous use to increase intra-abdominal capacity prior to transplantation. We report the first use of bi-planar expander placement for this purpose. In our case, a two-yr-old male child with SBS due to malrotation was treated with tissue expanders 10 months prior to intestinal transplantation, thus allowing transplantation of a larger graft with the ability to close the abdomen safely. There were no complications, and the patient is now doing well and tolerating diet off PN. The use of tissue expanders prior to intestinal transplantation is a promising approach for such patients and avoids the morbidity associated with other approaches. This approach requires a multidisciplinary effort by gastroenterology, transplant surgery, and plastic surgery teams.