Abdominal compartment syndrome

Overview

Abdominal compartment syndrome (ACS) is a serious and potentially life-threatening condition that occurs when pressure within the abdomen rises to a level that impairs the function of organs such as the heart, lungs, kidneys, and intestines. This elevated intra-abdominal pressure (IAP) compromises blood flow and oxygenation to vital organs, leading to multi-organ dysfunction. ACS can develop rapidly, particularly in critically ill or post-surgical patients, and requires urgent recognition and intervention to prevent irreversible damage or death.

Causes

Abdominal compartment syndrome typically arises as a secondary complication of other conditions that increase intra-abdominal volume or reduce abdominal wall compliance. Common causes include:

• Abdominal trauma: Blunt or penetrating injuries leading to bleeding or swelling

• Major abdominal surgery: Especially when large volumes of fluid or blood accumulate postoperatively

• Severe infections or sepsis: Leading to fluid shifts and bowel edema

• Acute pancreatitis: With associated inflammation and third-space fluid loss

• Massive fluid resuscitation: In trauma, burns, or shock patients

• Bowel obstruction or perforation: Causing gaseous or fluid buildup

• Liver failure with ascites: Contributing to increased intra-abdominal volume

Symptoms

The symptoms of ACS may be nonspecific and often resemble other critical conditions, making prompt diagnosis challenging. Common signs and symptoms include:

• Severe abdominal distension or tightness

• Abdominal pain or tenderness

• Oliguria (reduced urine output) or acute kidney injury

• Hypotension and tachycardia: Due to impaired venous return and cardiac output

• Respiratory difficulty: Increased intra-abdominal pressure impairs diaphragmatic movement

• Increased intracranial pressure: In some cases, due to impaired venous drainage

Symptoms can escalate rapidly, leading to multi-organ failure if not promptly treated.

Diagnosis

The diagnosis of abdominal compartment syndrome is based on clinical signs and measurement of intra-abdominal pressure (IAP). Diagnostic steps include:

• Bladder pressure measurement: The gold standard for estimating intra-abdominal pressure using a catheter; a sustained IAP ≥ 20 mmHg with organ dysfunction is diagnostic of ACS

• Physical examination: May show tense, distended abdomen with pain and reduced bowel sounds

• Imaging (CT or ultrasound): May reveal intra-abdominal fluid, edema, or organ compression

• Lab tests: Elevated lactate, creatinine, or liver enzymes may indicate organ dysfunction

Treatment

Abdominal compartment syndrome is a medical emergency. Treatment aims to reduce intra-abdominal pressure and support organ function. Management options include:

Initial Medical Management:

• Evacuating intra-luminal contents (e.g., nasogastric or rectal decompression)

• Draining intra-abdominal fluid (e.g., paracentesis or percutaneous catheter drainage)

• Optimizing fluid balance (avoid over-resuscitation)

• Neuromuscular blockade to reduce abdominal wall tension

• Mechanical ventilation adjustments to improve oxygenation

Surgical Intervention:

• Decompressive laparotomy: The definitive treatment for severe ACS, involving surgical opening of the abdomen to relieve pressure

• Temporary abdominal closure: Techniques such as vacuum-assisted closure may be used post-surgery until definitive repair is possible

Prognosis

The prognosis of abdominal compartment syndrome depends on how quickly it is diagnosed and treated. If left untreated, ACS can lead to irreversible organ damage and death. Early surgical intervention significantly improves survival. However, even with treatment, mortality rates remain high, particularly in patients with sepsis, multiple injuries, or delayed recognition. Long-term outcomes also depend on the underlying cause and the degree of organ dysfunction at presentation.