Abdominal compartment syndrome

Last revised by Dr Joshua Yap on 01 Aug 2022

Abdominal compartment syndrome (ACS) is a disease defined by the presence of new end-organ dysfunction secondary to elevated intra-abdominal pressure (IAP). 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 less than 60 mmHg concerning for compromised organ perfusion. 

Pathologically elevated intra-abdominal compartment pressures exceeding 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 disease 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 distention, 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.  There are several other overlapping CT and sonographic signs that may support the diagnosis but none of these are considered specific or sensitive for abdominal compartment syndrome 2:

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

Mortality is high in abdominal compartment syndrome ranging between 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 acheive euvolemia 9
  • surgical management with decompressive laparotomy

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Cases and figures

  • Figure 1: abdominal ratio
    Drag here to reorder.
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