ABDOMINAL COMPARTMENT SYNDROME

 

Abdominal compartment syndrome (ACS) is a medical condition that results from increased intra-abdominal pressure (IAP) due to various underlying pathologies. This condition is associated with significant morbidity and mortality, making early diagnosis and prompt management essential for successful outcomes. In this article, we will review the definition, etiology, signs, symptoms, diagnosis, and management of ACS.

Definition:

ACS is defined as an IAP exceeding 20 mmHg, associated with end-organ dysfunction. The normal IAP is between 0 and 5 mmHg. ACS occurs when the IAP exceeds 20 mmHg and is associated with end-organ dysfunction. The main mechanisms leading to ACS include the accumulation of fluid, gas, or solid material within the abdominal cavity, increased abdominal wall tension, or decreased abdominal wall compliance.

Etiology:

The most common causes of ACS are trauma, severe burns, intra-abdominal bleeding, and post-operative complications. Other causes include pancreatitis, bowel obstruction, ascites, and severe liver disease.

1. Trauma: Trauma is the most common cause of ACS. Trauma can cause bleeding, swelling, or inflammation in the abdominal cavity, leading to increased IAP.

2. Severe burns: Severe burns can cause fluid accumulation and swelling in the abdominal cavity, leading to increased IAP.

3. Intra-abdominal bleeding: Intra-abdominal bleeding can lead to the accumulation of blood in the abdominal cavity, causing increased IAP.

4. Post-operative complications: Post-operative complications, such as bleeding, infection, and anastomotic leaks, can lead to increased IAP.

5. Pancreatitis: Pancreatitis can cause inflammation and swelling in the abdominal cavity, leading to increased IAP.

6. Bowel obstruction: Bowel obstruction can cause accumulation of gas and fluid in the abdominal cavity, leading to increased IAP.

7. Ascites: Ascites is the accumulation of fluid in the abdominal cavity, leading to increased IAP.

8. Severe liver disease: Severe liver disease, such as cirrhosis, can cause ascites and portal hypertension, leading to increased IAP.

Signs and Symptoms:

ACS presents with a wide range of symptoms and signs, which can be non-specific, making diagnosis challenging. The following are some of the most common signs and symptoms associated with ACS:

1. Abdominal distension: Abdominal distension is the most common sign of ACS. It occurs due to the accumulation of fluid, gas, or solid material within the abdominal cavity.

2. Abdominal pain: Abdominal pain is another common symptom of ACS. The pain is usually severe and continuous, and it is often accompanied by nausea and vomiting.

3. Tachycardia: Tachycardia is a common finding in ACS, and it occurs due to decreased venous return and reduced cardiac output.

4. Hypotension: Hypotension can occur in ACS due to reduced cardiac output and decreased venous return.

5. Respiratory distress: Respiratory distress can occur in ACS due to the pressure on the diaphragm, leading to decreased lung compliance.

6. Oliguria: Oliguria is a common finding in ACS due to reduced renal perfusion.

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Diagnosis:

Diagnosis of ACS is based on a combination of clinical examination, laboratory tests, and imaging studies. The following are the most commonly used diagnostic modalities for ACS:

1. Clinical examination: A thorough clinical examination is essential in diagnosing ACS. The presence of abdominal distension, abdominal pain, tachycardia, and hypotension are suggestive of ACS.

2. Laboratory tests: Laboratory tests can aid in the diagnosis of ACS by identifying the underlying pathology. The most common laboratory tests used in ACS include complete blood count (CBC), serum electrolytes, serum lactate, renal and liver function tests.

3. Imaging Studies: Imaging studies such as abdominal X-rays, CT scans, or ultrasounds may be used to help diagnose ACS. These tests can help detect signs of abdominal distension, fluid accumulation, and organ displacement. CT scans are the most sensitive imaging modality for detecting ACS and can provide detailed information on the extent of organ damage.

4. Intra-abdominal Pressure Measurement: The gold standard for diagnosing ACS is measuring the intra-abdominal pressure (IAP). This is typically done using a bladder catheter, which is inserted into the patient's bladder and connected to a pressure monitoring system. The bladder catheter is then filled with sterile saline, and the pressure within the bladder is measured. This pressure is a surrogate measure for the pressure within the abdominal cavity. A sustained IAP of greater than 20 mmHg is considered diagnostic of ACS.

Management:

Management of ACS involves reducing the IAP and treating the underlying pathology. The following are the most commonly used management strategies for ACS:

1. Medical management: Medical management involves the use of pharmacological agents, such as diuretics and vasodilators, to reduce the IAP. Medical management is usually used in conjunction with other management strategies.

2. Decompressive laparotomy: Decompressive laparotomy is the most effective management strategy for ACS. It involves making an incision in the abdominal wall to reduce the IAP.

3. Percutaneous catheter drainage: Percutaneous catheter drainage is a less invasive management strategy that involves the insertion of a catheter into the abdominal cavity to drain fluid or gas.

4. Extracorporeal membrane oxygenation (ECMO): ECMO