Abdominal compartment syndrome

Last revised by Craig Hacking on 28 Sep 2023

Abdominal compartment syndrome is a disease defined by the presence of new end-organ dysfunction secondary to elevated intra-abdominal pressure. Radiological diagnosis is difficult and usually suggested when a collection of imaging findings are present in the appropriate clinical setting or if the signs on sequential imaging studies are seen to progress. Diagnosis is usually clinically supported by elevated intravesicular pressure which closely parallels intra-abdominal compartment pressure.

Abdominal compartment syndrome is formally defined as a persistently elevated intra-abdominal pressure >20 mmHg with concomitant organ dysfunction or failure 10. Abdominal perfusion pressure (APP) is a supplementary measurement, with values of <60 mmHg concerning for compromised organ perfusion. 

Pathologically elevated intra-abdominal compartment pressures >12 mmHg define intra-abdominal hypertension (IAH), which is further subdivided into four grades based on the degree of elevation. 

Patients present with one or many organs failing due to the elevated pressure in the abdomen having direct or indirect effects on the major body systems. Most patients will have abdominal distension. Patients often have multifactorial diseases and injuries, and abdominal compartment syndrome is particularly associated with:

Typically, the severely ill patient is in the intensive care unit (ICU) and clinically presents with massive abdominal distension, anuria, or progressive oliguria despite adequate cardiac output and/or increasingly difficult mechanical ventilation. 

The elevated intra-abdominal pressure in abdominal compartment syndrome has numerous causes which can be subdivided accordingly:

The ratio of maximal anteroposterior to transverse abdominal diameter (>0.8) and the peritoneal to abdominal height ratio (PAR ≥0.52) in CT seem to be statistically associated with elevated intra-abdominal pressure in critically ill patients 6.  Several other overlapping CT and sonographic signs may support the diagnosis, but none are considered sensitive or specific for abdominal compartment syndrome 2:

  • reduced diastolic flow in portal, hepatic, and/or renal veins

Mortality is high in abdominal compartment syndrome, in the range of 60-70% 2. Treatment of abdominal compartment syndrome requires restoration of the perfusion gradient across the abdomen, and broadly involves four approaches:

  • removal of intraperitoneal collections and intraluminal bowel contents 8

    • paracentesis of ascites or hemoperitoneum, if present

    • gastric decompression with an orogastric tube

  • addressing factors decreasing abdominal wall compliance

    • optimization of analgesia and sedation

  • optimize fluid status

    • fluids, diuresis or dialysis to achieve euvolemia 9

  • surgical management with decompressive laparotomy

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Cases and figures

  • Figure 1: abdominal ratio
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  • Figure 2: peritoneal to abdominal height ratio
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