A 55-year-old previously healthy Caucasian male was transferred from a regional hospital after one week stay for worsening ileus in the setting of gall stone related acute pancreatitis. Vital signs were remarkable for tachycardia and tachypnea. Physical examination revealed a firm, distended and diffusely tender abdomen with hypoactive bowel sounds. Labs showed WBC of 20 x 103/µL, Hemoglobin of 16 g/dL, Hematocrit of 48%, Lipase of 448 (16414 one week back, nl 8-78 U/L). Liver enzymes were normal on admission. US liver showed cholelithiasis but no common bile duct stone or dilation. CT abdomen showed pancreatic head necrosis and no abscess. Patient was treated for conservatively for gall stone ileus with nasogastric decompression, narcotics, IV fluids and TPN. Two weeks into his hospital stay he developed worsening abdominal distention, acute respiratory failure and oliguric acute renal failure. Intra-abdominal pressure estimated by bladder pressure was 30 mm Hg. He was diagnosed as abdominal compartment syndrome secondary to severe acute pancreatitis. He was intubated and had decompressive laparotomy with an open abdomen post operatively. Post-operative course was complicated by worsening renal failure needing renal replacement therapy, septic shock, multi-organ failure leading to death four weeks from presentation.
Discussion:
Abdominal compartment syndrome (ACS) is defined as a sustained Intra-abdominal pressure (IAP) > 20 mm Hg and associated with new organ dysfunction/failure. Acute pancreatitis is a well-established risk factor for ACS and occurs in about 30% with severe acute pancreatitis. Pancreatic inflammation along with aggressive fluid resuscitation, paralytic ileus and acute fluid/necrotic collections results in ACS. Diagnosis requires measuring IAP as physical signs and imaging alone are insufficient to diagnose ACS. Measuring bladder pressures is a simple, non-invasive method that accurately estimates IAP. Routine monitoring of IAP has been suggested in all patients with severe acute pancreatitis with multi-organ failure. Mortality rate for patients with ACS is high at 50-75%. Early decompressive surgery is recommended for ACS with multiorgan failure and may improve survival but morbidity and mortality are significantly higher due to complications from open abdomen.
Conclusions:
Acute pancreatitis is a well-established risk factor for development of abdominal compartment syndrome. Early recognition and prompt decompressive surgery of this potentially life threatening condition is crucial to decrease morbidity and improve patient outcomes. Hospitalists should be able to recognize abdominal compartment syndrome and involve multidisciplinary teams early in the course of severe acute pancreatitis.