Case Presentation:
A 33 year-old female with a history of alcohol abuse presented to our emergency department with a four day history of abdominal pain, nausea, and vomiting. This was preceded by intake of 1/5 of vodka for what she reported as an extended period of time. Vital signs were remarkable for tachycardia and tachypnea. O2 saturation was 95% on RA. CT angiogram was negative for pulmonary embolus. CT of the abdomen and pelvis showed evidence of acute pancreatitis with focus of hypoenhancement in the pancreatic head suspicious for parenchymal necrosis. Serum lipase was 1132 U/L. She was evaluated by both surgery and the medical ICU prior to admission to a general medicine floor where she was treated for alcohol withdrawal with diazepam and continued on IVF for acute necrotizing pancreatitis. Patient continued to endorse diffuse abdominal pain associated with respiratory distress, marked abdominal distension, and decreased urine output on hospital day 2. A foley catheter was placed to monitor urine output. Chest X-ray showed very low lung volumes. Patient was transferred to the surgical ICU given concern for abdominal compartment syndrome with associated respiratory compromise and acute kidney injury. In the surgical ICU, her intraabdominal pressure, estimated by bladder pressure was found to be 24 mmHg. An arterial line, central line, and NGT were placed. Serial monitoring of intraabdominal pressure showed improvement to 10 mmHg and then 8 mmHg following decompression. Urine output improved. She was monitored in the surgical ICU for 4 days prior to transfer back to the medicine floor and discharged to inpatient rehabilitation.
Discussion:
Abdominal compartment syndrome refers to organ dysfunction in the setting of increased intraabdominal pressure, > 20 mmHg, but may occur at > 12 mmHg. It is life-threatening and frequently associated with critical illness. Although traditionally reported in trauma patients, there is increased recognition of abdominal compartment syndrome in association with acute pancreatitis. Inflammation, increased vascular permeability, and aggressive fluid administration increase risk of elevated intraabdominal pressure in acute pancreatitis. Progressive oliguria and increased oxygen requirements with evidence of low lung volumes should prompt concern for abdominal compartment syndrome which is managed with supportive care and either nonsurgical or surgical decompression to improve intraabdominal pressure.
Conclusions:
We present a case of abdominal compartment syndrome precipitated by severe acute pancreatitis to raise awareness of a potentially life-threatening complication of acute pancreatitis. Early recognition, critical care consultation, and treatment are associated with improved patient outcomes.