SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 2 | 22 CASE REPORT Summary This report describes a 36-year-old male patient admitted with ethanol-induced pancreatitis who developed abdominal compartment syndrome requiring surgical decompression. Abdominal compartment syndrome is an under-recognised and under-treated early complication of acute severe pancreatitis. This case highlights the value of prompt surgical decompression in altering outcome and improving mortality in patients with acute pancreatitis. Case report A 36-year-old male was admitted with severe ethanol- induced pancreatitis. He reported a recent alcohol binge and had a short history of progressively worsening central abdominal pain, distension and vomiting. His triage vital signs were normal. Clinically the patient was in discomfort with significant abdominal distension and tenderness. Index arterial blood gas showed a lactate of 3,5mmol/L and a base excess of -7.1mmol/L. Blood results revealed a serum lipase of 795U/L, a white cell count of 23,65 x 109/L and a normal creatinine of 59umol/L. The patient was initially admitted to the emergency department resuscitation area and treated supportively with intravenous fluid, pain control, intravenous proton pump inhibitor and nasogastric decompression, with regular monitoring of vital signs and urine output. Over the next 16 hours, his urine output deteriorated despite intravenous fluid resuscitation and regular fluid boluses. He developed anuria and repeat arterial blood gas analysis showed mild hypoxaemia, worsening hyperlactataemia and non-resolving metabolic acidosis. Clinically the patient’s abdomen was markedly distended and tense and he became inotrope-requiring. The intra- abdominal pressure was measured and found to be 26mmHg. The diagnosis of abdominal compartment syndrome was made, and the patient taken to theatre for laparotomy and surgical decompression. Intra-operative findings were 1000mls of ascites, significant small bowel distension and an oedematous enlarged pancreas with retroperitoneal saponification. Temporary abdominal closure was performed with a negative pressure wound dressing. The patient was admitted to ICU post-operatively and recovered rapidly. He began to pass urine 3 hours after surgery. Inotropes were weaned completely in 36 hours and the patient was extubated 3 days post ICU admission. Urine output and renal function were normal within 48 hours of ICU admission. The patient was transferred to the general surgical ward. He was discharged from hospital after skin graft closure of the open abdominal wound with a 3 month follow up to evaluate for hernia repair. In total, hospital stay was 24 days. Discussion As per the World Society of Abdominal Compartment Syndrome (WSACS) 1 Guidelines of 2013, abdominal compartment syndrome (ACS) is defined as the sustained increase in intra-abdominal pressure above 20mmHg associated with new onset organ dysfunction or failure. Intra- abdominal hypertension is defined as an intra-abdominal pressure above 12mmHg. As many as 50% of patients with severe pancreatitis develop intra-abdominal hypertension 2 , and 15% develop abdominal compartment syndrome. Patients who present with acute severe pancreatitis and abdominal compartment syndrome face a grim mortality rate: approaching 75% 3 . As much as it is a recognised entity in acute pancreatitis (AP), research on the topic is lacking 4 but intra-abdominal hypertension is slowly gaining recognition as a point of specific intervention to alter disease outcome and improve mortality in acute pancreatitis 5 . The development of intra-abdominal hypertension in acute pancreatitis is multi-factorial 2 : - The pancreas itself becomes inflamed, enlarged and oedematous. - Significant ascites can develop as a result of systemic inflammation and overzealous intravenous fluid resuscitation. - Ileus is prominent. - And in addition, abdominal wall oedema and abdominal pain add to the intra-abdominal pressure. The diagnosis of abdominal compartment syndrome in acute pancreatitis is challenging because the symptoms may resemble those of other complications such as systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) 4 . In addition, clinical examination to detect ACS is notoriously unreliable 2 , therefore, early measurement of intra-abdominal pressure is important in severe pancreatitis. Serial measurements of intra-abdominal pressure should be implemented when any known risk factor for ACS is present in a critically ill patient 6 . Serial intra-abdominal pressure measurements are not part of major international guidelines for acute pancreatitis which decreases clinician awareness 5 . ACS developing in severe AP is typically an early phenomenon 2 , leading one to believe that a few cases of early mortality in acute severe pancreatitis may be due to untreated ACS5. Under pressure… Abdominal compartment syndrome in acute pancreatitis Correspondence T Giles email: tim123giles@gmail.com T Giles, E Georgiou Paarl Provincial Hospital, Paarl, South Africa Department of General surgery, Provincial Hospital, Paarl, South Africa