ABDOMEN IN ACUTE/CRITICAL CARE MEDICINE

Organ specific problems

Module Authors Manu LNG Malbrain Jan J De Waele

Director Intensive Care Units Surgical Intensive Care Unit
ZiekenhuisNetwerk Ghent University Hospital
Antwerpen Campus Ghent, Belgium
Stuivenberg – St-Erasmus
Antwerp, Belgium

With input/comments Michael Quintel, Göttingen, Germany; Michael Sugrue, Sydney, Australia;
from Alexander Wilmer, Leuven, Belgium; Pam Lipsett, Baltimore, USA
Daniel De Backer, Brussels, Belgium and Johannes Hoffmann, München,
Germany (Section on Systemic Inflammation and Sepsis)
and the following members of the PACT Steering Committee: Dermot Phelan,
Graham Ramsay, Arend Woittiez, Janice Zimmerman

Editor-in-Chief Graham RAMSAY

Chairman of the PACT Steering Committee
Medical Director, West Hertfordshire Hospitals NHS Trust, UK
Past President, European Society of Intensive Care Medicine

Module Editor Stan J A Aerdts, Dept of Intensive Care Medicine, Isala Klinieken, Zwolle, the
Netherlands

Educational Editor Lia Fluit, Medical Education Training and Consultancy (METC), Nijmegen, the
Netherlands

Editorial Manager Kathleen A Brown, Triwords Limited, Tayport, UK

Editorial Secretary Laurence Van den Bossche, ESICM, Brussels, Belgium

Abdomen in acute/critical care medicine

Organ specific problems

LEARNING OBJECTIVES
After studying this module on Abdominal problems, you should be able to:

1. Recognise and assess the patient with acute abdominal problems using clinical, laboratory and
imaging information
2. Manage the patient with abdominal infection and abdominal hypertension
3. Provide ongoing organ supportive care, pain relief and nutritional support in the patient with
abdominal problems
4. Deal with specific complications and abdominal problems

FACULTY DISCLOSURES
The authors of this module have not reported any disclosures.
DURATION
8 hours
Copyright©2007. European Society of Intensive Care Medicine. All rights reserved.
ISBN 92-95051-85-8 - Legal deposit D/2005/10.772/32

INTRODUCTION
In the critically ill, abdominal complications are common. They can be the initial problem requiring
admission to the ICU, but most are a reflection of the underlying disease. The interactions of the
underlying critical illness with the abdominal contents are complex and can present with a number of
clinical pictures.

In order to perform correct treatment for abdominal problems, a complete initial diagnostic work up, with
early assessment of disease severity (lookinsg at aetiological factors and predisposing conditions) is
necessary, followed by continuous monitoring to anticipate complications and remote organ failure. This
global approach should form the basis of patient management. Each step is graphically represented in
the algorithm and covered in the module tasks.

Prior to starting this module, you should be familiar with definitions of abdominal problems, including
abdominal infections (e.g. peritonitis), abdominal hypertension (e.g. intra-abdominal pressure, intra-
abdominal hypertension and abdominal compartment syndrome) and epidemiology. Further details
follow.

Definitions related to abdominal infections

Primary peritonitis

Primary peritonitis is a microbial infection of the peritoneal fluids in an absence of a gastrointestinal

perforation, abscess, or other localised infection in the gastrointestinal tract. It is also often referred to
as spontaneous bacterial peritonitis (SBP).
Primary peritonitis most often occurs in patients with cirrhosis and ascites, or in children. The
diagnosis is confirmed by a positive abdominal fluid bacterial culture and an elevated leukocyte count
(≥500 cells/mm3).
Other conditions such as peritonitis related to chronic ambulatory peritoneal dialysis (CAPD) and rare
cases of spontaneous streptococcal peritonitis are also considered as primary peritonitis.

Possible differential diagnoses of culture negative SBP include malignant ascites

or tuberculous peritonitis.

Secondary peritonitis

Secondary bacterial peritonitis is defined as a microbial infection of the peritoneal space following
perforation, abscess formation, ischaemic necrosis, or penetrating injury to the intra-abdominal
contents.

Tertiary peritonitis

Tertiary peritonitis is defined as persistent intra-abdominal inflammation and clinical signs of peritoneal
irritation following secondary peritonitis caused by nosocomial pathogens.

NOTE Retroperitoneal infections, for instance infected pancreatic necrosis, present a

 separate entity.
Please see the PACT module on Pancreatitis for more information

In the next ten patients you see with abdominal sepsis, classify peritonitis
according to the definitions given.

Definitions related to abdominal hypertension

Intra-abdominal pressure (IAP)

Intra-abdominal pressure (IAP) is the steady state pressure Clinical examination alone is
concealed within the abdominal cavity. The IAP shifts with an unreliable tool for estimating
respiration as evidenced by an inspiratory increase (diaphragmatic IAP. In order to establish a
contraction) and an expiratory decrease (relaxation). Abdominal diagnosis of IAH or ACS, IAP
pressure values follow the hydrostatic laws. needs to be measured

Full text and additional material including schematic drawings of the different indirect techniques for
measuring IAP available at http://dx.doi.org/10.1007/s00134-003-2107-2 [registration required]

Consensus definitions of the World Society of the Abdominal Compartment Syndrome

http://www.wsacs.org

Intra-abdominal hypertension (IAH)

Normal IAP is thought to be around 5 mmHg. IAH cannot be diagnosed on

the basis of one single maximal
Intra-abdominal hypertension (IAH) is defined as a sustained IAP value above 12 mmHg, but
increase of IAP above a critical threshold of 12 mmHg should be based on a trend of
Above this level changes in microcirculation take place even sustained (mean) IAP above 12
without obvious clinical signs of abdominal compartment mmHg
syndrome
Defined by IAP >12 mmHg. IAH can be graded as:
Grade I. IAH: IAP between 12-15 mmHg
Grade II. IAH: IAP between 16-20 mmHg
Grade III. IAH: IAP between 21-25 mmHg
Grade IV. IAH: IAP >25 mmHg

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is defined by a sustained IAH and ACS are not the same
increase in IAP above 20 mmHg in association with new onset but different stages of the same
single or multiple organ system failure. In contrast to IAH, ACS is pathological process
not graded, but rather considered as an 'all or nothing'
phenomenon.

NOTE ACS can be associated with injury or disease in the abdomino-pelvic region
(primary ACS) or with a condition outside the abdomen, e.g. sepsis, capillary leak,
major burns (secondary ACS). ACS can redevelop after initial treatment (tertiary
 or recurrent ACS).

Consensus definitions of the World Society of the Abdominal Compartment Syndrome

(http://www.wsacs.org).

Epidemiology of abdominal problems

Relevant epidemiological data for you to consider are shown on the subsequent screens.

Abdominal infections

Source control is the

In cirrhotic patients, the incidence of SBP ranges from 10 to cornerstone in the treatment of
30%. However, the incidence of secondary peritonitis is rare with intra-abdominal infections, and
one episode encountered for every 20 episodes of SBP. antibiotics should only be
The incidence of secondary peritonitis varies according to the considered as an adjunct
underlying aetiology, and ranges from less than 2% in cases of
non-infectious aetiology (e.g. anastomotic disruption, inadvertent
bowel injury) to 10% after surgery for infectious disease (e.g.
appendicitis, diverticulitis) to 50% in gangrenous ischaemic
bowel disease and perforation.
The incidence of tertiary peritonitis in patients following ICU
admission for severe abdominal infection can be as high as 50-
75%.
Overall mortality from SBP ranges from 15 to 50% whereas
mortality from secondary peritonitis ranges from 20 to 90%.
However, in secondary peritonitis, mortality is very high if
treatment consists of only antibiotics without surgical
intervention. Conversely the mortality from SBP increases to
80% in cases of unnecessary exploratory laparotomy. Tertiary
peritonitis is associated with longer lengths of stay, organ
dysfunction and mortality (50-70%).

Early diagnosis and the initiation of correct antibiotic treatment have been shown
to reduce morbidity and mortality. Those in the >65-year-old age group are at the
highest risk of death due to co-morbidity. Recent data also show that the
therapeutic delay was related to outcome.

Abdominal hypertension

The incidence of IAH varies according to the use of mean or The incidences of IAH and
maximal IAP values, the different cut-offs and the patient ACS are often underestimated
population studied. The number of IAP measurements per day also due to the lack of clinical
influences the incidence. Classically the incidence is around 10- awareness
20% in medical patients, 30% in elective abdominal surgery
patients and can be as high as 50-75% in emergency surgery and
abdominal trauma patients.

The incidence of ACS also varies according to the patient

population studied and ranges from 2-5% in medical and 5-35% in
surgical and trauma patients.
 The presence of grade III IAH and especially ACS carries a 3 to 5-fold increased
risk of mortality.

Abdominal hypertension following overwhelming infection or any other noxious stimulus that activates
the inflammatory system can cause gut dysfunction. The initial stimulus and subsequent second hits
(such as hypoxia, hypotension, hypovolaemia, haemorrhage) may result in inappropriate reactivation of
inflammation with release of gut toxins. This may result in increased gut permeability, and subsequent
bacterial translocation may play an important role in the development of multiple organ system failure
and death.

Acute abdominal problems requiring ICU admission

The complications are listed in order of frequency per organ together with an approximate incidence as
reported in the literature. See table

Acute abdominal problems occurring during ICU stay

Acute abdominal problems other than peritonitis or abdominal hypertension that can occur during ICU
stay are listed in the table.

Also keep in mind other non-abdominal causes mimicking acute abdominal

problems such as inferior myocardial infarction, lower lobe pneumonia, diabetic
ketoacidosis, uraemia, porphyria, adrenal insufficiency, electrolyte disturbances,
lead poisoning, sickle cell crisis, or haemolysis. These conditions are sometimes
referred to as 'pseudo acute abdomen'.

1/ HOW TO RECOGNISE AND ASSESS THE PATIENT WITH ABDOMINAL PROBLEMS

How to recognise patients with abdominal problems

Patients presenting with acute abdominal problems requiring immediate surgical intervention and
subsequent ICU admission e.g. ruptured abdominal aortic aneurysm or perforation can be easily
identified. Abdominal problems occurring during the ICU stay, however, are often more insidious and
difficult to identify.

ANECDOTE A 60-year-old woman with a long history of oxygen and steroid-dependent chronic
obstructive lung disease was hospitalised for an infectious exacerbation. After initial
improvement the patient's condition worsened with a persistent, slight C-reactive protein
increase, oliguria and ileus. There was neither fever nor increased leukocyte count and
abdominal examination was normal except for the absence of bowel sounds and slight
distension. A routine chest X-ray revealed free air under the diaphragm. Explorative
laparotomy revealed extensive diverticulitis with perforation, peridiverticulitis and
localised peritonitis. Partial sigmoid resection, debridement and decompressive
colostomy were performed. The further course was uneventful.

PRACTICE The major presenting symptom is acute abdominal pain and a general rule is that the
intensity and severity of the pain is related to the severity of the underlying acute
abdominal problem, except in some cases of gut ischaemia. However pain and other
major symptoms (such as fever and nausea) can be masked in the elderly patient and
 by the concomitant use of sedation or corticosteroids.

History

In order to identify the patient who should be suspected of having acute

abdominal problems you should be familiar with key issues that can be
obtained from the patient's history and the clinical examination.

Pain

The type, location, severity, chronology and duration of pain give important clues as to the source of
the abdominal problem.

You should ask about pain

Visceral pain is often poorly localised because of the dull and aggravating and alleviating
aching character. It arises from distension or spasm of a hollow factors, as well as associated
organ (e.g. obstruction or cholecystitis). symptoms
Parietal pain is very localised and sharp. It arises from peritoneal
irritation (e.g. acute appendicitis or diverticulitis).
Referred pain is perceived to be near the surface of the body and
aching (e.g. upper abdominal quadrant pain with basal
pneumonia, shoulder pain with cholecystitis or gastric
perforation).

NOTE Appendicitis begins as peri-umbilical (mesogastric pain) and later moves to the
right iliac fossa as a result of transmural inflammation and parietal pain.

Differential diagnosis of
acute abdominal pain

The location of the abdominal pain with regard to the abdominal

quadrants also helps to narrow the differential diagnosis: as
examples, pain due to acute cholecystitis or hepatitis tends to
occur in the right upper quadrant. See the figure above.
 Diffuse pain is either due to
Right upper quadrant: cholecystitis, cholangitis, pancreatitis, perforation and peritonitis or to
pneumonia, hepatitis, liver abscess other medical conditions
Right lower quadrant: appendicitis, pelvic inflammatory disease, causing a pseudo acute
hernia, inflammatory bowel disease, extra-uterine pregnancy abdomen
Epigastric: stress-related mucosal damage, peptic ulcer, reflux,
myocardial infarction, pancreatitis, gastroenteritis, ruptured
abdominal aortic aneurysm (AAA)
Mesogastric: early appendicitis or diverticulitis, gastroenteritis,
obstruction, ruptured AAA
Left upper quadrant: spleen rupture, abscess or infarction,
pancreatitis, peptic ulcer
Left lower quadrant: diverticulitis, pelvic inflammatory disease,
hernia, inflammatory or irritable bowel disease, extra-uterine
pregnancy

The chronology of the pain is also important. Classically, appendicitis presents with pain in the
periumbilical area afterwards displacing to the right lower quadrant, whereas diverticulitis usually gives
rise to lower abdominal pain in the midline displacing afterwards to the left lower quadrant.
Pain radiation is also important: the pain of pancreatitis classically radiates to the back. The onset,
frequency, type and duration of the pain are helpful features - gradual increasing cramping colicky pain
is seen with obstruction of a hollow viscus while the pain of a ruptured viscus is sudden, stabbing sharp
and maximal from the beginning. On the other hand you should be able to identify the burning pain of
reflux disease.

In your next five patients with abdominal problems, try to classify their pain
intensity, type and location.

Associated symptoms

Besides a complete pain history don't forget to ask for other associated symptoms such as:

Stool pattern and character

Presence of nausea and vomiting and the aspect of it
Fever or chills
Genito-urinary tract symptoms
Skin alterations
Concomittant medication (use of NSAIDs can mask abdominal symptoms)

See the PACT modules on Pancreatitis and Basic clinical examination

What are other key issues you should think about whilst taking your patient's history?

Clinical examination

The classic systemic manifestations of abdominal sepsis are those related to SIRS and include fever,
tachycardia, diaphoresis, hypotension and oliguria. The magnitude of the initial insult and the nature
and duration of the inflammation together with underlying conditions (e.g. hypothermia, acidosis,
coagulopathy) will determine the evolution. Finally, second hits as well as the (in)adequacy of the
compensatory anti-inflammatory response syndrome (CARS) (e.g. diminished host immune response)
may eventually lead to the full blown picture of abdominal septic shock.
Patients with intra-abdominal infection or inflammation present with You should have a high index
abdominal distension, IAH, tenderness and rigidity that can be of suspicion for abdominal
localised, on percussion or on rebound. However the yield of problems where there is a
routine clinical examination for the detection of an abdominal sudden increase in IAP
abscess is low ranging from 5 to 35%.
See the PACT modules on Sepsis and MODS and Severe
infection

Clinical examination is not a good predictor for IAP except in some obvious situations like in this patient
with gastric rupture following CPR.

Abdominal distension

The type and amount of nasogastric residuals and output should be

looked for (e.g. faecal in the case of lower GI obstruction). Rectal
examination can give clues as to the nature and origin of the
abdominal problem (e.g. Douglas pain in the case of appendicitis,
pelvic inflammatory disease (PID) or diverticulitis with localised
peritonitis, blood in the case of ischaemia). The presence or
absence of ileus, bowel sounds and movements add to the
integrated picture.
See the PACT module on Basic clinical examination

ANECDOTE A 90-year-old resident from a nursing home was admitted to the emergency department
with a recent history of altered mental status and collapse. Clinical examination was
non-specific except for slight abdominal tenderness in the right upper quadrant.
Biochemical analysis showed slightly increased inflammatory parameters, but there was
no fever. Radiological investigation revealed a normal chest X-ray while abdominal
ultrasound showed a suspect gall bladder. The patient went for urgent explorative
laparoscopy, however findings were negative except for an oedematous gall bladder
without signs of cholecystitis. On the next day the full picture of an extensive basal
pneumonia became apparent. Blood cultures grew Streptococcus pneumoniae. Despite
adequate antibiotic and supportive treatment the patient died of refractory septic shock.
The second hit caused by the laparoscopy might have triggered the vicious circle
leading to multiple organ failure.

Underlying conditions

The following underlying conditions can aggravate the initial The combination of
abdominal problem: coagulopathy, acidosis and
hypothermia have been
Ongoing sepsis and capillary leak forwarded as the deadly triad
Massive fluid resuscitation associated with abdominal
Polytransfusion compartment syndrome
Coagulopathy
Acidosis
Hypothermia
Abdominal Velcro belt (see image, below)
Liver dysfunction
Ileus
Co-morbidity or immunocompromised state

Explain why all of the above cited conditions can aggravate abdominal problems?

T HINK What is the prevalence of acute abdominal problems in your ICU?

Abdominal Velcro belt

The application of a Velcro belt can dramatically increase IAP

causing haemodynamic and respiratory instability in septic patients.

How to assess the patient with abdominal problems

This section will take you through the aetiological, clinical, biochemical, bacteriological and radiological
assessments.

Aetiological assessment

Patient assessment needs to be performed in order to establish a correct diagnosis and initiate
appropriate treatment as soon as possible. In order to further assess the patient with abdominal
problems it is extremely important that you understand the aetiological factors that can aggravate the
clinical picture.
The following aetiological factors should alert the physician to the possible presence of intra-abdominal
problems:

Remote or recent history of previous abdominal surgery or trauma

Abdominal closure under excessive tension
Persistent or increasing pneumoperitoneum more than one week after surgery
Persistent or increasing haemoperitoneum or haemoretroperitoneum
Previous abdominal infection

Abdominal closure
Example of tight abdominal closure by a so-called 'ventre au fils' or
'tension sutures'.

Assessment of severity

Scoring systems for abdominal sepsis

No single scoring system has been developed to identify patients with abdominal sepsis. Different
prognostic scoring systems have been suggested, amongst these the sequential organ failure
assessment (SOFA) score and the Acute Physiology and Chronic Health Evaluation (APACHE II)
score. See the PACT module on Clinical outcome for details on scoring systems .

Assessment of intra-abdominal pressure

The abdomen can be considered as a closed box with partially rigid (spine and pelvis) walls with an
anchorage above (costal arch) and partially flexible walls (abdominal wall and diaphragm). The degree
of flexibility of the walls (e.g. obesity) and the specific gravity (e.g. ascites) of its contents will determine
baseline pressure at a given point at a given position (prone, supine,...). In real life things are
complicated by the movable diaphragm, the shifting costal arch, the contractions of the abdominal wall,
and the varying content of the intestines.

Intra-abdominal hypertension

Normal IAP is thought to be around 5 mmHg. Intra-abdominal pressure (IAP)

is the steady state pressure
Intra-abdominal hypertension (IAH) is defined as a sustained concealed within the abdominal
increase of IAP above a critical threshold of 12 mmHg cavity. The IAP shifts with
Above this level, changes in microcirculation take place even respiration as evidenced by an
without obvious clinical signs of abdominal compartment inspiratory increase
syndrome (diaphragmatic contraction)
Defined by IAP >12 mmHg. IAH can be graded as: and an expiratory decrease
Grade I IAH: IAP between 12-15 mmHg (relaxation). Abdominal
Grade II IAH: IAP between 16-20 mmHg pressure values follow the
Grade III IAH: IAP between 21-25 mmHg hydrostatic laws
Grade IV IAH: IAP >25 mmHg

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is defined by a sustained IAH and ACS are not the same
increase in IAP above 20 mmHg in association with new onset but different stages of the same
single or multiple organ system failure. In contrast to IAH, ACS pathological process
is not graded, but rather considered as an 'all or nothing'
phenomenon.
 The presence of grade III IAH and especially ACS carries a three to five-fold
increased risk of mortality.

Abdominal hypertension following overwhelming infection or any other noxious stimulus that activates
the inflammatory system can cause gut dysfunction. The initial stimulus and subsequent second hits
(e.g. hypoxia, hypotension, hypovolaemia, haemorrhage) may result in inappropriate reactivation of
inflammation with release of gut toxins. This may result in increased gut permeability, and subsequent
bacterial translocation may play an important role in the development of multiple organ system failure
and death.
Recent studies have shown that a clinical estimation of IAP by abdominal girth or by examiner's feel of
the tenseness of the abdomen is far from accurate with a sensitivity of around 40%.

The IAP therefore has to be measured with an accurate, reproducible and reliable tool. Since the
abdomen and its contents can be considered as relatively non-compressive and primarily fluid in
character, behaving in accordance to Pascal's law, the IAP can be measured in nearly every part of it.
Different direct and indirect measurement methods have been suggested but the most widely used
'gold standard' is the intravesical pressure (IVP) as an estimate for IAP.

Full text and additional material including schematic drawings of the different indirect techniques for
measuring IAP available at http://dx.doi.org/10.1007/s00134-003-2107-2 [registration required]

PRACTICE
'Gold standard' intravesical pressure measurement

A closed needle-free revised method for measurement of intra-abdominal pressure can

be used (see illustration below). A ramp with three stopcocks is inserted between the
Foley catheter and the urine collection bag with conical (C) and male-to-male (M)
connectors. A standard intravenous infusion set is connected to a bag of 1000 ml of
normal saline and attached to the first stopcock. A 60 ml syringe is connected to the
second stopcock and the third stopcock is connected to a pressure transducer via rigid
pressure tubing. The system is flushed with normal saline and the pressure transducer is
zeroed at the symphysis pubis. To measure IAP, the patient needs to be completely
supine ensuring that voluntary muscle contractions are absent. Then the urinary
drainage tubing is clamped distal to the ramp device, 20 ml of normal saline is aspirated
from the i.v. bag into the syringe and then instilled in the bladder. After opening the
stopcocks to the pressure transducer, mean IAP can be read from the bedside monitor
at end-expiration. A normal IAP tracing should show respiratory variations.

In your next five patients admitted to the ICU with abdominal problems, consider
measuring intra-abdominal pressure via the 'gold standard' method.

List some conditions where intravesical pressure is not a good estimate for the intra-abdominal
pressure?

IAP measurement
 The presence of IAH not only
has effects on the function of
abdominal organs but also on
remote organ function (heart,
lungs, brain)

It is important to recognise the pathophysiological alterations in end-organ

function that are induced by intra-abdominal hypertension.

Clinical assessment of abdominal problems

Altered mental status

In a patient with sepsis an often overlooked clinical sign is altered mental status. This alteration initially
may be so subtle that only close relatives can detect it. In ongoing sepsis, alterations in mental status
can range from agitation, anxiety, somnolence, delirium, stupor, epileptic insult to coma. This is called
septic or metabolic encephalopathy. See the PACT modules on Sepsis and MODS and Altered
consciousness

Abdominal pain

Diffuse abdominal pain and tenderness is seen in most patients although it can be subtle and masked
in the elderly, and by the use of corticosteroids.

Nausea and vomiting

Anorexia and nausea are frequent and may precede the emergence of abdominal pain by some time.
Vomiting can be caused by hollow viscus obstruction or peritoneal inflammation. What is the volume of
gastric residuals? What is the aspect of gastric contents; faeculent, bloody, bilious ... Is there
haematemesis?

Diarrhoea

Stool consistency can be changed by alterations in gut mucosal flora or gut hypoperfusion. Is there
blood present in the stool?

Fever

Fever is clearly the most common manifestation of abdominal sepsis although it can be masked in
immunocompromised patients with neutropenia or under corticosteroid therapy. The patient with severe
sepsis can also present with hypothermia.

Haemodynamic alterations

Patients with peritonitis exhibit various signs of third space losses Filiform pulse = pulse that is
and fluid sequestration, resulting in tachycardia, filiform pulse, almost not palpable
dehydration, hypotension, or even overt septic shock. Initial
tachycardia with gallop or third heart sound can evolve to
bradycardia prior to cardiac arrest. Rhythm disturbances have also
been noted as well as the presence of a pulsus paradoxus.

T HINK about functional haemodynamic testing by putting the patient in the Trendelenburg
position or by passive leg raising since this can help in estimating initial fluid
responsiveness.

NOTE Patients at risk with limited oxygen reserve are those with anaemia, underlying
respiratory insufficiency, myocardial insufficiency, underlying coronary or
valvular disease, the elderly, patients under β-blockade, calcium antagonists or
digoxin.

Respiratory alterations

An often overlooked clinical sign in a patient with abdominal sepsis A drop in respiratory rate is not
is the increased respiratory rate to compensate for the underlying always a positive sign but may
metabolic acidosis. Respiratory rate can go from tachypolypnoea prelude fatigue and exhaustion
(fast and profound/deep respiration or hyperventilation) to prior to arrest
bradyhypopnoea (slow and superficial type of respiration) and
finally respiratory arrest. Abdominal distension also influences
respiratory mechanics decreasing tidal volume and functional
residual capacity.

NOTE Respiratory insufficiency can cause further lactic acidosis by the production of
lactic acid by the respiratory muscles in conditions of relative hypoxia triggering a
vicious circle leading to respiratory arrest.

Skin alterations

Some believe that the skin is the mirror of the inner human. If the skin is mottled the intestinal mucosa
probably is too. You should look at the turgor and the presence or absence of sudor or sweating, and
local or generalised signs of inflammation. Is there central or peripheral cyanosis?

Mottled skin on abdominal wall

due to cutaneous necrosis (top
image)

Livedo reticularis on feet and

lower limb with blister formation
(lower image)
Do you see livedo reticularis? Are the extremities cold or warm? Is the capillary refill normal and less
than two seconds?

Renal alterations

Is the urine output normal (above 0.5 ml/kg/hr)? What is the aspect and colour of the urine? Is there
haematuria? Is urinary pH normal? What was the daily fluid balance and the net cumulative fluid
balance of the last four to seven days? Is abdominal perfusion preserved?

Why is kidney function especially sensitive to increased IAP?

Laboratory assessment

In the initial recognition and assessment phase a routine laboratory analysis should be performed.

Blood biochemical assessment

Laboratory biochemical blood analyses can provide clues to the cause of the abdominal problem.
Where there is infection or inflammation the white blood cell (WBC) count will be elevated. The
differential shows mainly polymorphonuclear leukocytes (PMNs) in bacterial infection, lymphocyte
predominance in tuberculosis and a monocytic pattern in the case of chronic inflammation or tertiary
peritonitis. Where C-reactive protein (CRP) values are high, the procalcitonin (PCT) level can help to
differentiate between infection and inflammation. Serial measurements of WBC, CRP and PCT should
be performed during antibiotic therapy and the further course of the patient.
Abnormal levels of aminotransferases, alkaline phosphatase, γGT and bilirubin are seen in patients
with liver disease. Pre-existing liver disease can be evaluated by the classic hepatic synthesis function
tests such as a prothrombin time prolongation, hypoalbuminaemia, and by hyperbilirubinaemia, low
platelet count, or specific tests such as increased venous NH3.

Where the patient has bowel ischaemia, usually the levels of lactate
dehydrogenase (LDH), lactate, lipase, and amylase are increased. In some cases
increased levels of troponin I have been noted. It needs to be emphasised,
however, that these are late findings when injury has occurred and correction may
not be possible. Too many people wait for these signs before undertaking
appropriate action!.

Bacteriological assessment

Where an abdominal problem is suspected, bacteriological assessment should always be performed.

The surgeon should be asked to send perioperative samples to the microbiology laboratory. Samples
should be taken from the blood, the respiratory and urinary tracts and any other accessible open
wound or fluid-like collection. At least one blood draw should be percutaneous while the other can be
obtained via a peripheral or deep central venous catheter.

Ascitic fluid analysis and diagnostic peritoneal lavage

The aspiration and analysis of peritoneal fluid can give important diagnostic information, in the case of
ascites.

Sampling

Practice Different samples should be taken:

Culture (in blood culture bottles)

Cell count and differential
 Tuberculosis polymerase chain reaction (TBC-PCR) (when suspected)
Biochemistry (total protein, albumin, glucose, LDH, amylase, bilirubin, triglycerides (TG)
and cholesterol)
Gram stain
Cytologic exam (where malignancy is suspected)

Character

The ascitic fluid can be clear (transudate), cloudy (infection or Tumours often give bloody
exudate), milky (in chylous ascites triglyceride levels are raised), ascites and then cholesterol
bloody (in tumours cholesterol levels are often raised >60 g/dl), levels are often raised - so
brownish (bilirubin due to perforation or fistula). cholesterol levels can be used
In a traumatic tap a blood clot will be formed. The number of red to differentiate between
blood cells can differentiate between a traumatic tap (>10 000 (non)malignant bloody ascites
cells/mm 3) and frank bleeding (>100 000 cells/mm 3). The red to
white blood cell count can differentiate between infection and
bleeding (normal ratio = 400; a ratio of 100 indicates infection while
a ratio >400 indicates frank bleeding).

Drainage of purulent ascites

in a patient with
spontaneous bacterial
peritonitis

Differential diagnosis

The table below lists how the WBC count and differential, the serum to ascites albumin gradient
(SAAG), the total ascitic protein concentration, the ascitic glucose concentration, the ascitic lactate and
pH, the ascitic lactate dehydrogenase, amylase, bilirubin, cholesterol, and lipid levels can help in
distinguishing the different forms of peritonitis. The SAAG is calculated by subtracting the ascitic fluid
albumin concentration from the serum albumin concentration in simultaneously obtained specimens.

WBC: white blood cell; S-A: serum to ascites ratio; A-S: ascites to serum ratio; SBP: spontaneous
bacterial peritonitis; CAPD: chronic ambulatory peritoneal dialysis; PMN: polymorphonuclear; TBC:
tuberculosis; PCR: polymerase chain reaction
Radiological assessment and imaging techniques

When you order an examination, always provide the necessary clinical

information to the radiologist who reviews the images. Close interaction with the
radiologist is essential for all examinations

Conventional X-ray

A chest X-ray in a standing patient is superior to an abdominal X-ray (AXR) to diagnose free air in the
peritoneum. However, it is often impossible to obtain in critically ill patients. An abdominal X-ray in left
lateral decubitus position may be an alternative as well as a chest X-ray in the sitting position.
Elevations of both diaphragms can point towards abdominal hypertension.
A plain abdominal X-ray can provide a lot of information, but as the critically ill patient is supine or semi-
recumbent when the X-ray is taken bedside, air-fluid levels will not be visible and only distension of the
small or large bowel can be evaluated. Again an abdominal X-ray in lateral decubitus position may be
an alternative.

Free air (arrows) under both diaphragms, dilated stomach and colon, multiple air-fluid levels, fluid level
at the right side of the liver (due to subphrenic abscess with MRSA)
See the PACT module on Clinical imaging

How can you differentiate small from large bowel obstruction?

If the distension is present in the small bowel, there is either a Occasionally, gallstones will be
mechanical obstruction (complete or incomplete, depending on the visible on AXR, and also large
amount of air in the colon), or a paralytic obstruction, related to a volumes of faeces in the colon
primary disease process of the small bowel such as ileus or an and rectum
infectious process.

Distension of the colon points to a colonic problem such as

obstruction or acute colonic pseudo-obstruction (Ogilvie
syndrome). Ogilvie syndrome can be suspected on AXR, but
obstruction should be ruled out by either CT with rectal contrast or
sometimes with colonoscopy.

Ultrasound

Ultrasound (US) is a very convenient imaging technique for The clinician should have a low
critically ill patients. It is commonly used to diagnose acute threshold for ordering an
cholecystitis, the presence of abdominal fluid collections or to ultrasound. However, one
exclude, for example, postrenal causes of acute renal failure. In should keep in mind the poor
patients after abdominal trauma, it also may be used to follow up negative predictive value
on possible intraperitoneal haemorrhage.

Except for the clear indications above, US has little additional value in critically ill
patients, and therefore should be used with caution when investigating patients
with possible other intra-abdominal problems. A negative US in these
circumstances may not exclude a significant intra-abdominal problem.

NOTE The Focused Assessment with Sonography for Trauma (FAST) is a rapid, bedside,
ultrasound examination performed to identify intra-peritoneal haemorrhage or
pericardial tamponade. FAST examines four areas for free fluid: perihepatic and
hepato-renal space, perisplenic, pelvis and the pericardium. FAST was developed
for use in assessing trauma patients.

CT scan

The CT scan has emerged as the imaging technique most useful when clinical examination is equivocal
or unreliable, which is often the case in the ICU. The new generation 16 and 64 slice CT scan
machines limit the time spent in the CT scan to a few minutes, thus minimising the time spent in
unfavourable surroundings for a critically ill patient. It has the additional advantage that other parts of
the body can be examined as well, which often is useful e.g. when looking for a source of infection in a
patient with MODS. The use of intravenous contrast is imperative when looking for infections; the
potential disadvantages of i.v. contrast should be considered in each individual case.

C O M M U N I C AT I O N A diagnostic or therapeutic procedure can be done during the same

examination, e.g. drainage of an abscess or fluid collection. Discuss this with
the radiologist who performs this before the patient is referred for the
examination.

Timing of oral or enteral contrast administration is important in patients

undergoing abdominal CT scans. Discuss this with the radiologist when ordering
the CT scan.

Abdominal CT scan in a
patient with toxic megacolon
related to
pseudomembranous colitis

Arrows show thickened

oedematous colon wall (up to 5
cm)

Free air in caecal wall (arrow)

= sign of impending necrosis
Angiography

The role of angiography (including percutaneous embolisation) often lies in the added value of
immediate endovascular treatment of the problem; haemorrhage being the most obvious indication.
Especially in patients with absolute or relative contraindications for surgical intervention, such as
patients with 'hostile' abdomens after multiple previous surgical interventions, or in patients with a
bleeding source less amenable to surgical treatment, such as haemobilia, or arteriovenous fistula,
angiography can be followed by definite treatment by coil or gelfoam embolisation.

In patients with suspected GI tract ischaemia but without peritonitis, contrast-

enhanced CT may sometimes be equivocal and waste precious time. If
obstruction is not the cause and endoscopy is not helpful, angiography should be
used as a first-line examination. It can be immediately followed by local
thrombolysis - if there is no overt indication for surgery.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) is of limited value in diagnosing abdominal problems in critically ill
patients. Although it is increasingly used in the management of several diseases, it has not been
proven to be superior to contrast-enhanced CT scanning, especially with faster equipment available.
Time spent in the MRI suite is much longer for most procedures (although a cholangio-MRI can be
performed in ten minutes), special ventilator and monitoring equipment is needed, and the patient is not
immediately accessible if a problem occurs during the examination.
However, possible advantages of MRI include better visualisation of common and intrahepatic bile
ducts, main pancreatic duct, and vascular structures. In addition, it is a valid alternative for patients with
contraindications for i.v. contrast media.

Laparoscopy

Just like a laparotomy, we consider laparoscopy to be a surgical approach to the abdomen and not an
imaging technique. Except for selected cases, it should not be used as a diagnostic tool.

2/ HOW TO MANAGE THE PATIENT WITH ABDOMINAL PROBLEMS

This Task will first of all consider how to manage the patient with abdominal infection followed by how
to manage patients with abdominal hypertension and abdominal compartment syndrome.

How to manage the patient with abdominal infection?

Indication for surgery

After the initial clinical, biochemical and radiological assessments have been performed you should be
able to distinguish between abdominal problems necessitating immediate surgery and those not
necessitating surgery. Since most of the problems discussed in this module relate to abdominal
infections, this Task will focus on the management of intra-abdominal infections. See the PACT
modules on Bleeding and thrombosis , Multiple trauma , Pancreatitis and Acute hepatic
failure for discussions of other problems.

Early consultation with an abdominal surgeon is essential in the management of

patients with intra-abdominal infections, not only to discuss an indication for
intervention, but also to optimise the use of additional examinations.

Preoperative management

PRACTICE When a surgical intervention is planned, it should not be deferred, unless the patient is in
shock. In these patients optimisation of the haemodynamic status is preferred. The
ultimate goal is to improve oxygen delivery. This entails oxygen administration, aggressive
fluid resuscitation, and sometimes the use of inotropic agents, guided by invasive
monitoring of haemodynamics in selected patients. It is often difficult to determine when a
patient is ready for surgery, as a normalisation of haemodynamic parameters can rarely be
achieved. See the PACT module on Haemodynamic monitoring

T HINK about why a balanced approach between trying to improve the clinical condition of the
patient and avoiding unnecessary delay is the most important step in the management
of the patient.

In this setting, urinary output is a good tool for monitoring the effect of your resuscitation. In clinical
practice, optimisation beyond four to six hours is usually not helpful.

What are common causes of unnecessary delay in the treatment of intra-abdominal infections?

Source control

The concept of 'source control' consists of 'all physical measures undertaken to eliminate a source
of infection, to control ongoing contamination, and (later) to restore premorbid anatomy and
function'. All different aspects of this definition are important, but the elimination of the source and the
control over ongoing contamination determine early and long-term success of the treatment.

NOTE Source control is based on four principles: drainage, decompression,

debridement and restoration of anatomy and function. All four principles can be
applied independently, and at different moments in a single patient.

T HINK about why it is important to choose the source control measure that will cause the least
physiological upset for the patient whilst still accomplishing the clinical goals.
 In your daily clinical ICU practice, list the source control procedures performed in
the next 20 patients with intra-abdominal infections.

Drainage

Drainage consists of evacuating the contents of an abscess, and in doing so, creating a controlled
fistula or a sinus.
Drainage of an abscess can be performed surgically or percutaneously, using ultrasound or CT scan.
The latter is preferred for most situations, provided that adequate drainage is possible, and no
debridement or repair of anatomical structures is necessary.

NOTE Percutaneous drainage can be used as a temporising strategy in critically ill

patients, where a surgical intervention can be difficult because of inflammation at
the site of the infection and coagulopathy.

Surgical drainage is indicated when percutaneous drainage fails, or when it cannot be performed, for
example when multiple abscesses are present, or when the presence of bowel loops between the
abdominal wall and the abscess prevents passing a needle and guide wire to introduce the drain. It is
often difficult to recognise failure of percutaneous drainage, but the clinical picture of ongoing sepsis a
few days after percutaneous drainage should trigger a new search for a residual infection. In most
cases, ongoing contamination of the abscess because of a connection with an intestine, or the
presence of tissues that need debridement, are the causes. At this point, the character or volume of the
drain effluent is notoriously unreliable and should not be used as a basis to guide therapy.

Institute source control as soon as a new infection is identified. Do not forget to

remove any intravascular or body cavity catheters that are a potential source for
recurrent infection.

Decompression

Decompression may involve decompressing distended bowel in cases of (impending) obstruction or of

IAH (see ).

Debridement

Debridement is the removal of dead tissue and foreign material from the abdominal cavity. This can
only be accomplished surgically, and the extent to which this should be done remains a controversial
topic. Some surgeons favour a minimalist approach, which consists of removing dead tissue and use of
gauze to remove any pus present, whereas others promote an aggressive approach of high volume
peritoneal lavage, and meticulously removing all fibrin adherent to the intestines or abdominal wall. The
latter carries a higher risk for iatrogenic bowel injuries, and has also been associated with a higher rate
of postoperative abscesses.

Restoration of anatomy and function

Restoration of anatomy and function is the final step in the management of intra-abdominal infections,
and as such often the goal of the surgical intervention in patients with intra-abdominal infections.

T HINK of examples of restoration of anatomy such as closure of a perforated gastric ulcer, or

resection of a phlegmonous appendix.

Restoration of anatomy and complete function may need to be delayed if

prolonging the surgical intervention might be harmful to the patient at the first
operation.

Restoration of anatomy and complete function should be assessed on an individual patient basis. In
most patients it can be established at the first operation, but in some patients, it needs to be delayed
until the patient's condition sufficiently improves to allow a sometimes lengthy procedure, and until
tissue healing is adequate. It is advisable not to unnecessarily prolong surgical intervention in patients
who are in shock, or who have severe organ dysfunction.

ANECDOTE A patient who underwent a Hartmann's procedure for perforated diverticulitis was
discharged home before an attempt was made to restore continuity. In some patients,
the delay can extend to months before a definitive procedure.

Antibiotic treatment

Microbiological considerations

The micro-organisms in the human gut differ from site to site, but are similar from one individual to
another. Overall, more than 400 different micro-organisms have been isolated from the human gut.
The mouth and oropharynx harbour about 200 different species, most of them anaerobes and
streptococci. The stomach normally contains no commensals.

Which common micro-organisms are present in the different parts of the gastrointestinal tract?

NOTE The micro-organisms causing infection in community-acquired intra-abdominal

infections are predictable, and any empiric antimicrobial regimen should target
these micro-organisms. Intra-operative cultures in these patients are
unnecessary.

When a patient is treated with antibiotics the flora of the GI tract will be altered, especially the
anaerobic flora. In these patients intra-operative cultures can guide treatment if nosocomial or
antibiotic-resistant organisms are implicated.

What are the factors that might change the flora you expect in the gut?

Expected pathogens

Primary peritonitis
SBP

E. coli (40%)
Streptococcus species (15%)
Klebsiella pneumoniae (7%)
Pseudomonas species (5%)
Proteus species (5%)
Anaerobes (<5%)
Staphylococcus species (3%)

CAPD-related

CNS (43%)
Staphylococcus aureus (14%)
Enterobacteriaceae (14%)
Streptococcus species (12%)
Pseudomonas species (2%)
Candida species (2%)

Secondary peritonitis
Gram-negative and Gram-positive facultative and obligate anaerobic bacteria: Predominant are E. coli
and Bacteroides fragilis

Bacteroides species (30%)

Streptococcus species (18%)
E. coli (14%)
Anaerobes (9%)
 Peptostreptococcus (8%)
Clostridium species (3%)
Klebsiella species (3%)
Enterobacter species (3%)
Pseudomonas species (3%)
Staphylococcus species (3%)
Enterococcus species (3%)
Proteus species (1%)
Candida species (1%)

Tertiary peritonitis

Fungi
Candida species
Pseudomonas species
Enterococcus species
Coagulase-negative staphylococcus
Other non pathogens

Therapy

For more information, see the PACT module on Infection control strategies and the following
reference.

What is the goal of antibiotic therapy in intra-abdominal infections?

Adequate antibiotic therapy should be started from the moment of diagnosis, and should be given
intravenously, at least initially. It is essential that the antimicrobial agent used is directed at the micro-
organisms expected in the infection.

Begin intravenous antibiotics as early as possible.

NOTE The choice of antibiotic agent should be based on the flora expected, and not on
the severity of illness of the patient, although in severe sepsis broad-spectrum
empirical cover is indicated initially, until culture results are known.

Antibiotic therapy should be tailored to the origin of the infection. In gastric or small bowel disease the
pathogens differ from those in colonic disease. Gastric contents are usually sterile except if the patient
is on antacids; the flora resembles the oral mucosal flora, while colonic flora is polymicrobial.
In tertiary peritonitis unusual pathogens can be found; whereas specific pathogens can be found in
cholangitis, biliary or pancreatic disease. For more information see the PACT modules on Pancreatitis
and Severe infection and the following reference.
Several antibiotics or combinations of antibiotics have been Regimens used in prophylaxis
proposed for the treatment of intra-abdominal infection, and none should not be used in the
has proven superior. For examples of regimens see the list below. treatment of intra-abdominal
A treatment based on a single agent is generally preferred. infections. Check your local
guidelines
Suggested antibiotic regimens for intra-abdominal
infections

Community-acquired intra-abdominal infections The choice of antibiotics will

vary from country to country
Cefuroxime + 5-nitro-metronidazole
Beta-lactam + beta-lactamase combination
Amoxicillin + clavulanid acid
Ticarcillin + clavulanid acid
Fluoroquinolone + 5-nitro-metronidazole
Ertapenem (Carbapenem in the USA)

Nosocomial intra-abdominal infections or prior broad-

spectrum antibiotic therapy

Piperacillin + tazobactam
Third or fourth generation cefalosporin (cefotaxime, ceftriaxone,
ceftizoxime, ceftazidime, and cefepime) + 5-nitro-metronidazole
Carbepenem
Imipenem - cilastin
Meropenem
Ciprofloxacin + 5-nitro-metronidazole

The choice of an antibiotic should be guided by local practice guidelines and

knowledge of the local epidemiology of hospital-acquired infections and local
resistance patterns.

What three key questions should you ask before choosing an empiric antibiotic therapy?

If you are concerned with the adequacy of the antibiotic therapy in severely ill patients, you should
optimise administration of antibiotics to improve pharmacokinetics and pharmacodynamics of the
drugs. Increasing the frequency of administration or using continuous infusion of antimicrobial agents
that have a time-dependent killing profile may be appropriate, especially in septic patients with capillary
leak and high volumes of distribution.

T HINK about appropriate antibiotic dosages and how to optimise pharmacokinetics and
dynamics in your patients with abdominal sepsis.

Duration of antibiotic treatment

Antibiotic therapy should continue until the signs and symptoms of the infection have resolved. In most
patients five to seven days should suffice. The decision can be guided by the absence of fever,
normalisation of WBC count and C-reactive protein and/or procalcitonin (although the latter is quite
expensive and still needs to prove its cost-effectiveness).
If these parameters do not improve after three to four days of therapy, the presence of persistent
infection, or ineffective source control should be strongly considered. Merely broadening the
antimicrobial spectrum of the antibiotics is not enough.

What are some key features regarding antibiotic therapy (with respect to flora, susceptibility,
duration, combination,...)?

Candida species and intra-abdominal infections

The role of Candida in intra-abdominal infections is limited, although it is frequently (up to 20%) isolated
from intra-operative cultures. Even if Candida is isolated, therapy with an antifungal agent is not
necessary, except for patients who develop postoperative peritonitis, or patients who are
immunosuppressed.

Beware that the incidence of fluconazole-resistant organisms in this setting is

increasing, and thus identification of the causative organism and possibly
determination of resistance patterns is needed.

Tertiary peritonitis

This clinical picture of persistent intra-abdominal inflammation with clinical signs of peritoneal irritation
has been associated with protracted MODS and consequently, a high mortality rate.

Often nosocomial organisms such as methicillin-resistant staphylococcus aureus

(MRSA), multi-resistant coagulase-negative staphylococcus (MR-CNS),
Pseudomonas or Candida species are isolated from the peritoneal cavity, but it is
difficult to discriminate between infection and colonisation.

It is not clear if tertiary peritonitis is a cause rather than a consequence of disease severity, and
probably reflects the immunosuppressed status of the patient.

How to manage the patient with abdominal hypertension and abdominal

compartment syndrome?

Medical treatment

Before surgical decompression is considered, less invasive medical Secondary IAH is IAH in
treatment options should be tried. Medical treatment will also be patients without an underlying
the treatment of choice in secondary IAH or ACS. abdominal problem and is
mostly related to capillary leak
Specific procedures to reduce IAP and the consequences of and fluid resuscitation
ACS.
General support (intensive care) of the critically ill patient.
Optimisation after surgical decompression to perhaps counteract
some of the specific adverse effects associated with
decompression.

The medical options can be divided into five categories:

1. Improvement of abdominal wall compliance

Sedation
Neuromuscular blockade

2. Evacuation of intra-luminal contents

Gastric tube and suctioning

Gastroprokinetics (erythromycin, metoclopramide)
Rectal tube and enemas
Colonoprokinetics (neostigmine, prostygmine bolus or infusion)
Endoscopic decompression of large bowel
3. Evacuation of peri-intestinal and abdominal fluids

Ascites evacuation
Percutaneous drainage of collections

4. Correction of capillary leak and positive fluid balance

Albumin in combination with diuretics (furosemide/frusemide)

You must first obtain source control then you can try to get rid of the excess fluids by albumin
(see SAFE study results, reference below, showing a more positive fluid balance in the saline
group and showing a trend towards better outcomes in septic patients 30% vs 35%, p=0.09)
Dialysis or ultrafiltration

5. Specific therapeutic interventions

Continuous negative abdominal pressure (CNAP)

Negative external abdominal pressure (NEXAP)
Targeted abdominal perfusion pressure (APP)

Improvement of abdominal wall compliance

The relationship between abdominal contents and IAP is not linear but exponential. Depending on the
compliance of the abdominal wall the curve will be shifted to the left. In septic patients abdominal wall
compliance changes over time and is dependent upon the baseline IAP. Recent studies have shown
that the application of sedation and the use of neuromuscular blockers can help to control IAH by
increasing abdominal wall compliance.

Pressure volume curves of

the abdomen in a patient
with poor abdominal wall
compliance compared to a
patient with normal
abdominal wall compliance
Improvement of abdominal wall compliance can be done by evacuation of the rectus sheath
haematoma (arrow) that developed in this patient on low molecular weight heparin (LMWH).

Evacuation of intra-luminal contents

Ileus is common in critically ill patients and in particular in those who have had abdominal surgery,
peritonitis, major trauma, massive fluid resuscitation, electrolyte abnormality and the administration of
narcotic and sedative drugs.
In view of the abdominal pressure volume relationship any Manual digital evacuation of
decrease in one of its contents will decrease IAP especially where faecal impaction should be
there is ACS with low abdominal wall compliance. Therefore non- considered
invasive evacuation of abdominal contents should be tried by
means of gastric tube placement and suctioning, rectal tube and
enemas and possibly endoscopic decompression.
This treatment can be done in conjunction with gastro- and or
colonoprokinetics such as erythromycin (200 mg i.v. every six
hours), metoclopramide (10 mg i.v. every eight hours), neostigmine
or prostygmine (not available in the USA) (2 mg diluted in up to 50
ml i.v. given slowly by infusion)

Evacuation of abdominal fluid collections

Drainage of tense ascites by insertion of a small tube or single lumen catheter may result in a decrease
in IAP. Paracentesis is also the treatment of choice in burn patients with secondary ACS. CT-guided
fine needle aspiration has recently been described in the setting of IAH and ACS in cases of
haematomas, blood collections or a local abscess.

T HINK Why is it important to maintain adequate intravascular volume during paracentesis?

Correction of capillary leak and positive fluid balance

Patients with ACS retain large volumes of sodium and water after initial resuscitation because of the
nature of the illness and injury associated with it. The capillary leak exacerbates tissue oedema and
third spacing causing a vicious cycle of ongoing IAH. In the early stages diuretic therapy in combination
with albumin can be considered to mobilise the oedema, but only if the patient is haemodynamically
stable.

Give some possible explanations as to why initial and ongoing fluid resuscitation might lead to
further increase in abdominal pressure and impairment of the microcirculation?

Many patients will develop oliguria and anuria, however, as renal blood flow is reduced. In these cases
the institution of renal replacement therapy should not be delayed – with fluid removal by intermittent
dialysis or continuous venovenous haemofiltration (CVVH) with aggressive ultrafiltration. For more
information see the PACT modules on Oliguria and anuria and Acute renal failure and the
following reference.

Specific treatments

Recently the application of continuous negative abdominal pressure by means of a cuirass has been
studied in animals and humans showing a decrease in IAP and increase in end-expiratory lung
volumes.

NOTE In a similar manner to targeting cerebral perfusion pressure(CPP = MAP − ICP) or

coronary perfusion pressure (CoPP = DBP − PAOP) it may be appropriate to target
abdominal perfusion pressure (APP), where APP = MAP − IAP, to a level that
reduces the risk of worsened splanchnic perfusion and subsequent organ
dysfunction, although this needs to be clinically validated.

MAP = mean arterial pressure

ICP = intracranial pressure
DBP = diastolic blood pressure
PAOP = pulmonary artery occlusion pressure

Clear guidance on this subject is currently lacking as are target levels for APP.

Treatment algorithm

A suggestion for management of patients with suspected IAH or ACS based on published data is given
in the algorithm.

Indication for surgery

If IAP continues to increase and organ function further deteriorates after initiation of medical treatment,
consider surgical decompression in all patients with ACS.
Decompressive laparotomy is the only definite treatment available today for ACS. It results in a prompt
decrease in IAP in the majority of patients, although in most of them IAP remains above 12 mmHg, and
in some patients some degree of organ dysfunction may persist. Timing of the procedure, the degree of
pre-existing organ dysfunction and its evolution are possible factors affecting outcome in patients with
ACS.
In patients with circumferential abdominal burns, escharotomy should be performed early to prevent
ACS.
Extraperitoneal release of the abdominal muscles without opening the peritoneum –  component
separation –  may be an alternative, but to date results have only been reported from experimental
models of ACS.
Abdominal decompression obviously results in an open abdomen, which often is a challenge to the ICU
physicians and nurses. Several methods for temporary abdominal closure (TAC) are available (see
Task 3 ).
Early definitive closure has to be pursued in all patients, meaning an abdominal exploration every day
or every two days, either in the operating theatre, or bedside in the ICU. This also gives the opportunity
to assess the viability of the intra-abdominal organs, and explore for missed injuries. At these
explorations, the TAC should be removed, and attempts should be made to close the abdomen.

What are the most common abdominal complications in patients with open abdomen
treatment?

When definitive closure is not possible after 10-14 days, we use a You and your team may use
synthetic polyglactin mesh to close the abdomen, and will postpone another type of TAC
definitive reconstruction until the patient's condition has improved.

Here is a proposed treatment algorithm for patients who require

decompressive laparotomy or in whom the abdomen is left open
after a surgical procedure (adapted from Cipolla et al.).

3/ ONGOING MANAGEMENT OF THE PATIENT WITH ABDOMINAL PROBLEMS

Initial and further pain relief

Where there is intense pain, provide initial relief after the abdominal examination by the intensivist and
surgeon. Use short-acting agents in order to re-evaluate the abdomen at a later stage and not to mask
the clinical picture. See the PACT module on Sedation for more information
After a definitive diagnosis has been established and a treatment The use of remifentanyl has
plan suggested (either surgical or non-surgical) it is extremely gained popularity in the ICU
important to provide sufficient and ongoing pain relief for your setting to provide continuous,
patient. Usually a combination of paracetamol intermittently and predictive and titratable
opioids continuously are necessary. analgesia

Epidural analgesia is an alternative option but should be avoided where there is

an open abdomen or abdominal infection.

Organ supportive therapy

Neurological

Patients with abdominal infections can develop septic Neurological functions may
encephalopathy and can be dangerously agitated. Use a well- also be altered in patients with
established scoring system such as SAS or GCS to follow abdominal trauma (without
neurological function. Provide sufficient pain relief and anxiolytics overt craniocerebral trauma,
when the patient is agitated. Sedate and intubate if the neurological due to IAH)
status deteriorates (SAS >5 or GCS <8). Always use a sedation
protocol and measure the sedation goal afterwards.

An altered mental state can be the first subtle sign of abdominal sepsis.

Cardiovascular
Patients with abdominal problems either related to infection or The average abdomino-
haemorrhage will require adequate fluid resuscitation where there thoracic pressure transmission
is hypotension especially if accompanied by elevated serum lactate is around 50% (range 25-80%)
levels, or other signs of inadequate tissue perfusion.

In IAH and ACS the traditional filling pressures (CVP and PAOP)
are erroneously increased and other (volumetric) preload indicators
should be used.

NOTE A quick idea of transmural filling pressures can be obtained with the following
formula: CVPtm = CVPee − IAP/2, where ee = end expiration.

The initial resuscitation with either colloids, crystalloids or blood should be titrated to a transmural
central venous pressure of >8 mmHg, and a mean abdominal perfusion pressure of 65 mmHg that
results in a urine output >0.5 ml/kg/hr and a normalisation of the central venous oxygen saturation
above 70%.

List some possible options for assessing preload in patients with abdominal problems.

List some possible options for assessing fluid responsiveness in patients with abdominal
problems.

Guiding fluid resuscitation towards static uncorrected filling pressure targets may
lead to unnecessary over- and under-resuscitation in cases of raised intrathoracic
pressures related to increased IAP!

Try to assess preload and calculate the transmural filling pressures in your next
ten patients with IAH.

Respiratory

T HINK why patients with intra-abdominal problems have a greater risk of developing respiratory
problems?

General measurements:

Give oxygen to correct hypoxia.

Provide sufficient analgesia to allow normal breathing, coughs and sighs.
Provide physiotherapy or perform bronchoscopy in case of mucus plugging.
Drain pleural effusions with fine needle aspiration if indicated.
Prevent aspiration pneumonia by nasogastric suctioning and put the bed in semi-recumbent position
(head of the bed raised 45°).

List some of the major respiratory complications that can develop in patients with intra-
abdominal problems.

Specific treatment:

In cases of respiratory distress be cautious with non-invasive ventilation via mask or helmet because
of an increased risk of vomiting and aspiration.
Electively sedate and intubate the patient if there are signs of impending clinical exhaustion, such as
a high respiratory rate (related to metabolic acidosis), superficial respiration (in severe abdominal
distension) or clinical deterioration with evolution to sepsis (fever, shock, ALI/ARDS, other organ
failure).
In cases of IAH apply sufficient PEEP in order to counteract IAP and to prevent atelectasis of the lung
 bases (best PEEP = IAP).
Leave the patient intubated and mechanically ventilated postoperatively in cases of severe bleeding,
shock, bowel ischaemia or peritonitis.

The impact of intra-abdominal problems on respiratory function and lung

mechanics poses a specific challenge to the intensivist. In conditions of high IAP
related to capillary leak and third space fluid sequestration after massive fluid
resuscitation, recruitment manoeuvres and high PEEP levels will be needed to
keep the lungs open to avoid flooding.

Target sedation to predetermined end points. Avoid the use of drugs that have
active metabolites that can accumulate, since patients with abdominal problems
will often have concomitant renal and hepatic dysfunction. Try to avoid
neuromuscular blockers in continuous infusion.

What strategies should you use to mechanically ventilate a patient with abdominal problems?

Renal

The kidneys are especially prone to abdominal problems and increased IAP. Oliguria will develop at
IAP above 10-15 mmHg and anuria at IAP above 20 mmHg. For further details on how IAP affects the
filtration gradient see the answer to Question .
Start renal replacement therapy when indicated. In the case of refractory septic shock, severe
haemodynamic instability, large fluid overload or metabolic deterioration, CVVH offers easier
management, although studies show that intermittent and continuous therapies are equivalent. Do not
perform peritoneal dialysis in cases of peritonitis, haemodynamic instability or respiratory failure. For
more information see the PACT modules on Oliguria and anuria and Acute renal failure

Hepatic and visceral

Studies have shown that alterations in the microcirculation can occur very fast (after 30 to 60 minutes)
and at relatively low IAP pressures (above 10 mmHg). Maintaining adequate splanchnic perfusion is
therefore crucial.
The splanchnic circulation can be assessed non-invasively with Indocyanine green is not used
gastric tonometry or indocyanine green clearance or plasma in critically ill patients in the
disappearance rate (ICG-PDR). USA

Some preliminary reports have shown beneficial effects on splanchnic perfusion with the administration
of dopexamine, dobutamine, ilomedine (prostacyclin) or high dose N-acetylcysteine.

Antibiotics
Re-assess the antimicrobial regimen every 24 hours and stop therapy immediately if the condition
appears to be non-infectious.

Nutrition and metabolic support

Provide adequate caloric intake, administer blood products appropriately, and use stress ulcer and DVT
prophylaxis according to standard international guidelines. Also try to maintain blood glucose levels
within the normal range. See the PACT module on Nutrition

Management and support of the patient with an open abdomen

Open abdomen treatment (or laparostomy) was initially intended for patients with diffuse intra-
abdominal infections, and often used in combination with a planned relaparotomy approach. Due to the
increased awareness of the deleterious effects of intra-abdominal hypertension, open abdomen
treatment – either prophylactic or therapeutic – is more common in the ICU.
Several techniques to cover the open abdomen are used.

Moist gauze

Moist gauze used to be the preferred method of covering the abdomen, but this is no longer used as it
carries a substantial risk of creating intestinal fistulas. Improved solutions are now available.

Towel clip closure

Courtesy of Dr Andy
Kirkpatrick, Calgary, Canada

Towel clip closure is often used as an initial method of TAC after damage control surgery, because of
the speed of closure. Beware that the skin is not closed, which will reduce IAP. After re-exploration, it
can be replaced by one of the other techniques below.

'Bogota bag'

A 'Bogota bag' is a plastic sheet cut from a sterile 3L irrigation bag, and sewn to the skin or fascia.
This system is cheap and offers the advantage that the bowel and abdominal contents can be easily
inspected and accessed, but fluid losses are difficult to control which makes it a real challenge for the
nursing staff.
Removable prosthetic materials. These were used initially in open abdomen treatment of intra-
abdominal sepsis, and are now used for TAC in other circumstances as well. Examples are the zippers
and the Wittman patch (which uses a Velcro closure system).
 Velcro closure system

Vacuum-assisted fascial
closure

Vacuum-assisted fascial closure systems. Different packing techniques that use suction or a vacuum
to control the fluid draining from the open abdomen have been described (the vacuum pack technique
and modified sandwich-vacuum pack technique, or vacuum-assisted closure system).
These are simple solutions for the management of an open abdomen and provide easy control and
quantification of fluid losses.

Check the practice in your hospital regarding the management of open abdomens.
In the next five patients with an open abdomen in your ICU, discuss, with your
senior colleagues, the techniques used to cover the abdomen.

Surgical procedures: planned relaparotomy vs on-demand laparotomy

In some patients, one surgical procedure will not suffice to treat the intra-abdominal problem. The most
common examples are intra-abdominal infection and intestinal ischaemia.
Planned relaparotomy and on-demand laparotomy have often been compared with each other in the
management of complicated abdominal procedures, but both should be applied to different kinds of
patients.

Planned relaparotomy: a surgical intervention is planned after an initial procedure, often because of
massive contamination or ischaemic bowel, irrespective of the patient's condition.
On-demand laparotomy: a surgical procedure is only performed when a postoperative problem is
suspected on clinical grounds, such as an enteral leak or abdominal abscess.

The choice of either procedure should be left to the surgeon treating the patient.

4/ HOW TO DEAL WITH COMPLICATIONS AND SPECIFIC ABDOMINAL PROBLEMS

Long-term management of complicated abdominal fistulas

Definitive reconstructive surgery in patients with multiple enterocutaneous fistulas will be delayed for
weeks or months, until the patient's general condition has improved and peritoneal inflammation has
subsided. Definitive surgical management is impossible when peritonitis is still present.

Nutrition

Feeding of the patient with intestinal fistulas is difficult, and often While awaiting definitive
the patient is or has been catabolic. Enteral nutrition is often surgical correction, nutrition
considered impossible because of the leakage and inefficient and skin/stoma care need
absorption of nutrients, but in many patients, enteral nutrition close attention and often
through a feeding tube inserted distal to the fistula is feasible. specialised care

Fistulas are often associated with electrolyte disorders and fluid losses may be severe. Therefore, in
some patients the fistula output can be simply reinfused together with the enteral nutrition into the
feeding tube.

NOTE In selected patients, strategies to reduce fistula output can be considered :

reinfusion in distal loop or bowel segment, somatostatin, octreotide, ...

Stoma and skin care

The skin should be protected from the intestinal secretions, but this may be very difficult in complex
fistulas and open abdomen treatment. A specialised nurse practitioner can help to care for the patient,
both in and out of hospital.

Acute colonic pseudo-obstruction

Acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, mimics an acute large bowel
obstruction but there is no distal mechanical obstruction. In some patients, the large bowel can be
massively dilated; if not treated, the large bowel may eventually perforate and peritonitis may occur. An
imbalance in the autonomic innervation appears to be the cause of this.
Patients complain of abdominal pain, and the clinical picture cannot be easily distinguished from an
anatomic large bowel obstruction. It includes abdominal distension, nausea and vomiting. It may lead to
intra-abdominal hypertension and abdominal compartment syndrome in some patients. It has been
associated with a variety of factors, such as electrolyte disorders, surgical procedures, sepsis, and the
use of steroids or narcotics among many others. In most cases several of these symptoms are present
in patients presenting with Ogilvie syndrome in the ICU.
The syndrome is suspected on plain abdominal X-ray. The diameter of the large bowel is important;
when it exceeds 10 cm, decompression should be considered.

Dilated bowel in Ogilvie

syndrome (arrow)
 NOTE Exclusion of an anatomic obstruction is necessary for the diagnosis of Ogilvie
syndrome. This can be done either with a contrast study or abdominal CT scan.
Colonoscopy should only be performed if medical treatment fails.

Underlying medical problems should be dealt with, and treatment should also be directed at the dilated
colon. According to recent studies neostigmine is considered as the treatment of choice (2 mg diluted
in up to 50 ml i.v. given slowly by infusion). It should be used with caution in patients with renal failure,
epilepsy, asthma, and bradycardia.

Colonoscopy can help in establishing the diagnosis, though aspiration of air

and introduction of a decompressive tube will be therapeutic in 50-60% of
patients. Dilatation can recur after decompression, and for selected patients,
especially with impending perforation or peritoneal signs, surgery may be
indicated. In these patients, caecostomy is the procedure of choice. In the
case of severe ischaemia or perforation, subtotal colectomy may be
necessary.

Ileus
Ileus is a 'normal' phenomenon in the postoperative patient, at least to some extent. It refers to
paralytic ileus, and generally affects the whole gastrointestinal tract, from the stomach to the rectum. Its
duration depends on the extent of the surgical procedure.

T HINK Why is ileus often encountered in ICU patients with severe sepsis, burns, trauma or
shock?

List some factors that may contribute to the development of ileus in the ICU?

NOTE In the postoperative setting, an ileus that persists for more than five to seven days
should be considered unusual, and a plain abdominal X-ray should be ordered to
exclude the presence of a mechanical obstruction.

PRACTICE A nasogastric tube should be inserted to relieve the stomach, but there is little evidence
to support the use of prokinetics in patients with postoperative ileus. Also for non-
postoperative patients, there is no accepted pharmacological treatment.

Acalculous cholecystitis
Acalculous cholecystitis is a condition typically encountered in critically ill patients, and is believed to be
caused by an impaired microcirculation in the gall bladder wall, which leads to inflammation and
ischaemia. The diagnosis should be considered in all critically ill patients with persistent or unresolving
severe sepsis without an obvious cause. Signs and symptoms are not specific, and include SIRS,
jaundice and abnormal liver function tests.

NOTE Clinical abdominal examination is often not reliable in ICU patients, and in these
patients, acalculous cholecystitis should be excluded using CT scan or abdominal
ultrasound.

On ultrasound, the gall bladder wall is thickened (3 mm or more), there is subserosal oedema and fluid
may be present around the gall bladder. Often, sludge can be observed in the gall bladder, and
occasionally, gas may be seen in the gall bladder wall.
 Acalculous cholecystitis is a potentially life-threatening disease, and should be
dealt with accordingly, in a timely fashion. If not treated properly, gall bladder wall
necrosis and perforation will occur resulting in secondary peritonitis.

Preferred treatment of acalculous cholecystitis is cholecystectomy, which

can be done laparoscopically in stable ICU patients, or open in others.

In severely ill patients percutaneous cholecystostomy is a valuable alternative, if the risk of

undergoing surgery is too high. This can be performed with a high success rate bedside in the ICU
under local anaesthesia. The gall bladder is then left to drain externally for two to three weeks. The
drain can then be removed if the cystic duct is open, the symptoms have resolved and the underlying
disease has improved.
If the clinical condition of the patient does not improve after percutaneous drainage, progression to wall
necrosis and perforation should be suspected. Prompt diagnosis and therapy is warranted.

Vascular events
Be aware that in patients with abdominal problems important and even life-threatening vascular events
can occur during the course of their illness, either related to bleeding or thrombo-embolic events.

CONCLUSION
Although patients with abdominal problems are commonplace in the ICU, the problems are diverse and
frequently complex. You will encounter patients who present with acute abdominal problems requiring
immediate surgery followed by ICU admission and also patients already in the ICU who develop
abdominal problems. Timely management of abdominal problems – especially of infection, ischaemia
and increased intra-abdominal pressure – will result in a better outcome. The stepwise approach
presented in this module – recognition, early assessment, initial and on-going management, and
dealing with complications – should be a helpful guide.

PATIENT CHALLENGES

The first patient you see is a 63-year-old man who was admitted to your ICU after an emergency procedure for a
ruptured abdominal aortic aneurysm (AAA). He was on an angiotensin II receptor antagonist because of
hypertension, and suffered a transient ischaemic attack one week before admission.

The surgical procedure was uncomplicated, and two units of red blood cells were administered intra-operatively.
On admission to the ICU, the patient was haemodynamically stable but still intubated because of hypothermia.

The patient was extubated a few hours later. At that time a right-sided hemiparesis became apparent. A CT scan
of the brain showed no abnormalities, and the clinical situation gradually improved.

Learning issues

Epidemiology of abdominal problems

One day after surgery, the patient became progressively dyspnoeic, and he expectorated purulent sputa. His
temperature rose to 38.9 °C. The chest X-ray is below.
 Learning issues

Radiological assessment and imaging techniques

PACT module on Clinical imaging

What is your diagnosis?

Learning issues

Organ supportive therapy – respiratory

PACT module on Respiratory failure

Given the purulent secretions, the patient was diagnosed as having pneumonia, and cefuroxime i.v. was started.

Three days post surgery, C-reactive protein (CRP) levels increased to 40 mg/dl, and the patient started complaining of
severe abdominal pain.

What abdominal complications may occur after aortic surgery?

Learning issues

Complications

What diagnostic tool(s) would you use in this setting?

Learning issues

Colonoscopy (1)
Colonoscopy (2)

Colonoscopy revealed ischaemic changes in the distal colon (see figure).

The patient was taken to the operating room (OR). At laparotomy, the
 sigmoid colon was ischaemic and perforation had occurred, with resulting
diffuse peritonitis. A sigmoidectomy was performed with a terminal
colostomy on the descending colon.

Learning issues

Laparotomy (1)
Laparotomy (2)
Peritonitis (1)
Peritonitis (2)

NOTE Gastrointestinal ischaemia is an emergency. Prompt surgical exploration is mandatory.

Postoperatively, the patient remained ventilated because of the associated pneumonia, but the other organ
systems functioned normally. Inflammatory parameters gradually improved. Antibiotics were switched to
piperacillin-tazobactam.

Two days later, 600 ml of fresh blood was evacuated from the colostomy, which looked ischaemic. Clinical
examination revealed diffuse abdominal tenderness, with guarding and rebound tenderness. Laboratory results
showed a WBC count of 23 400, and a C-reactive protein of 35.6 mg/dl.

Learning issues

Antibiotic treatment
Clinical examination
Laboratory assessment

What approach would you suggest at this stage: operation, endoscopy or other imaging techniques?

Learning issues

Laparotomy (1)
Laparotomy (2)

The patient was reoperated, and intra-operatively, a new large bowel perforation was found. The colon was
further resected up to the midtransverse colon, and a new colostomy constructed. The abdomen was closed, and
an on-demand laparotomy approach preferred.

Postoperatively the patient needed vasopressor support, and progressively he became oliguric, and platelets
decreased to 80 000/mm3. Because of the recurrent haemorrhage, administration of rhAPC was not considered.
Enteral nutrition was started via the nasogastric route at 20 ml per hour.
After three days, vasopressor support could be stopped, the bilateral infiltrates had subsided, and renal function
had recovered. The patient was extubated one day later.

The abdomen, however, remained grossly distended, and bowel sounds were absent. The patient did not
tolerate enteral feeding, and complained of nausea. IAP remained stable around 9 mmHg.

NOTE Close interaction with the surgeon is essential in the management of abdominal
complications.

Learning issues

Organ supportive therapy – renal

Nutrition (1)
Nutrition (2)

PACT module on Nutrition

How would you assess the bowel function in this patient?

A few days later, fluid stool began to evacuate from the colostomy, and the patient complained of cramping pain.

What technical examination would you request?

Learning issues

Managing complications – ileus

Microbiological testing for Clostridium difficile toxin –   ordered by the attending physician –  was negative. The
patient received antibiotics for seven days after the last surgical intervention.

Oral feeding was started in the next few days, and was well tolerated. Three days after antibiotics were stopped,
spiking fever developed, and inflammatory parameters rose sharply.

Learning issues

Microbiological considerations

What complication would you expect in this patient?

Learning issues

Complications
Clinical examination
PACT module on Basic clinical examination
Clinical examination showed a normal wound, and the abdomen was not painful. Chest auscultation revealed
diminished breath sounds on the left side. CT scan showed a left subdiaphragmatic abscess, and reactive
pleural effusion. The abscess was drained percutaneously under CT guidance. Intravenous levofloxacin and
metronidazole were started, the drain was rinsed three times daily with 20 ml saline. The patient's condition
continued to improve and the drain was removed five days later. He was discharged from the ICU the same day.

Learning issues

Radiological assessment
PACT module on Clinical imaging

The second patient on your rounds is a 67-year-old woman with a history of colon carcinoma. She was
admitted to the accident and emergency department with a one-week history of intermittent abdominal pain,
nausea and vomiting. She complained of worsening pain after meals. One year before admission she was
treated with a right hemicolectomy followed by chemotherapy (last session five months earlier). She has a Body
Mass Index (BMI) of over 30 and has a known history of severe COPD, insulin-dependent diabetes, Child–  Pugh
class A alcoholic cirrhosis and ischaemic heart disease.

Clinical examination shows an obese woman with stable haemodynamic parameters, a blood pressure of 120/80
mmHg and a regular pulse at 90 bpm. There is a fever of 39 °C with chills. Breath sounds and respiration are
normal. The abdomen is distended and painful without signs of peritonitis. Rectal examination is normal.
Examination shows shifting dullness with positive fluid wave test, suggesting the presence of ascites. Full blood
analysis shows a slightly elevated leukocytosis with left shift and raised CRP. Serum creatinine is 106 µmol/l (1.2
mg/dl).

Learning issues

Clinical assessment – abdominal pain, nausea and vomiting

Epidemiology of abdominal problems

PACT module on COPD and asthma

Clinical examination

PACT module on Basic clinical examination

Laboratory assessment

What is the most likely diagnosis and what further diagnostic tests would you order?

Learning issues

Spontaneous bacterial peritonitis (1)

Spontaneous bacterial peritonitis (2)

Blood and ascites cultures taken on admission grew E. coli, hence confirming the diagnosis of SBP.

The patient is put on broad-spectrum antibiotics. Despite this and adequate intravascular fluid resuscitation, the
patient remains febrile with nausea, vomiting and worsening abdominal pain.
 Learning issues

Ascitic fluid sampling

Antibiotic treatment

Given the patient's history with previous abdominal surgery and chemotherapy what should you exclude?

What would be your next step to confirm this diagnosis?

Learning issues

Indication for surgery (1)

Indication for surgery (2)

Radiological assessment

PACT module on Clinical imaging

Abdominal X-ray shows no free air but signs of small intestine occlusion with multiple centrally located air-fluid
levels. The CT scan confirms the diagnosis of intestinal occlusion and she goes straight to the OR. Explorative
laparotomy confirmed the small bowel obstruction due to adhesions from previous interventions. She is
postoperatively re-admitted to the ICU for overnight observation.

In view of her history, obesity and current problems, what complication in the abdomen might you expect to
develop?

Learning issues

Intra-abdominal hypertension

The intra-abdominal pressure (IAP) is measured via a urinary bladder catheter and the first IAP value is around 6
mmHg. Although initially stable, she develops hypotension which is treated with fluid resuscitation and
noradrenaline infusion. She complains of worsening abdominal pain and shortness of breath. She gets agitated
and pulls out her nasogastric tube. Respiratory rate is 30/min. Clinical examination reveals inspiratory and
expiratory wheezing with use of accessory muscles.

Non-invasive ventilation is applied because of progressive deterioration, and 12 hours later, she develops
asystole. Resuscitation is promptly initiated, the patient is intubated, and is stabilised shortly after.

Learning issues

Intravesical pressure measurement

Organ supportive therapy – respiratory
PACT module on Airway management
PACT module on Respiratory failure
 What do you think has happened?

Colonoscopy revealed ischaemic changes in the distal colon (see figure).

Urgent chest X-ray and abdominal X-ray (figure) showed correct endotracheal
tube positioning, no pneumothorax, but also massive gastric distension. The IAP
at that time was 23 mmHg.

Learning issues

Radiological assessment
Intra-abdominal hypertension

What will you do about it?

Think of simple measures first in the treatment of IAH!

Abdominal compartment syndrome (1)

Abdominal compartment syndrome (2)
Medical treatment

The high IAP value, together with the underlying organ dysfunction was compatible with the diagnosis of ACS. A
nasogastric tube was immediately inserted. This resulted in an almost instantaneous resolution of the intra-
abdominal hypertension with a normalisation of IAP from 23 to 7 mmHg, and resolution of the respiratory
problems. One hour later, the patient was stable on FiO2 of 0.4.

The patient's condition gradually improved, and she could be extubated one day later. In the next few days,
inflammatory parameters improved, however she does not tolerate enteral feeds (gastric residuals above 400
ml). Despite the use of prokinetics, the patient could not be enterally fed. A nasojejeunal tube is placed
endoscopically and jejeunal feeds are started. However progressive abdominal distension is observed.

Nutrition (1)
Nutrition (2)

PACT module on Nutrition

What could be the cause of the abdominal distension and intolerance for enteral feeds?

Learning issues

Managing complications – ileus

 This abdominal X-ray shows normal volume of small intestines but dilated colon
consistent with colonic pseudo-obstruction or Ogilvie syndrome.
Treatment with neostigmine intravenously is started after ensuring no obstruction
was present, which resulted in an almost instant regression of the colon diameter.

Learning issues

Managing complications – colonic pseudo-obstruction

What are other options for treating the Ogilvie syndrome in this patient?

Learning issues

Decompression by colonoscopy

When the situation seemed to be improving, the patient's condition deteriorated again with all the signs and
symptoms of septic shock. An abdominal CT scan to look for peritonitis or abscesses shows unexpectedly diffuse
mesenteric ischaemia as evidenced by pneumatosis coli, and ischaemia of the liver (figures below).

Pneumatosis coli

Learning issues

Peritonitis

Tertiary peritonitis

PACT module on Severe infection

PACT module on Sepsis and MODS

 Liver ischaemia

At laparotomy, the ischaemic large bowel was resected, and liver ischaemia was noted. Postoperatively, liver
function further deteriorated, with ASAT and ALAT at 3000 and 6000 IU/ml respectively, and prolonged
prothrombin time. The patient had become anuric in the meantime and rapidly died of multiple organ failure.

Learning issues

Laparotomy (1)
Laparotomy (2)

PACT module on Acute hepatic failure

PACT module on Oliguria and anuria

The third patient is a 65-year-old man who developed acute abdominal pain, distension and weakness in the
lower limbs. He was transported haemodynamically unstable from the emergency department (ED) to your ICU
by a young colleague on duty. On clinical examination the patient was in shock with a distended abdomen.

Learning issues

Clinical assessment – abdominal pain

Haemodynamic alterations

Clinical examination

PACT module on Basic clinical examination

How can you further assess the abdominal distension?

Is clinical examination enough to evaluate abdominal distension?

Given the history of this patient with the acute onset of his symptoms together with the weakness in his legs,
what is the most likely diagnosis and what diagnostic tests would you perform?

Learning issues

Assessment of intra-abdominal pressure

 Epidemiology of abdominal problems

Normally, ruptured abdominal aneurysms are accompanied by retroperitoneal haemorrhage but in this case there
is also blood observed in the peritoneal cavity.

Bedside abdominal ultrasound showed free fluid around the liver and spleen and an abdominal aneurysm of 7
cm. The patient was immediately taken to the operating room (OR). The aneurysm was repaired, but
coagulopathy, acidosis and hypothermia complicated the procedure.

Learning issues

Radiological assessment and imaging techniques

PACT module on Clinical imaging

What is the most feared complication in this patient?

Learning issues

Intra-abdominal hypertension

To avoid development of abdominal compartment syndrome (ACS), the patient's abdomen is left open and a
plastic intravenous bag (a so-called 'Bogota bag') is sewn to the patient's skin as a temporary abdominal closure.

Temporary abdominal closure with a Bogota bag

Learning issues

Abdominal compartment syndrome (1)

Abdominal compartment syndrome (2)
Management of a patient with an open abdomen
The patient is then transferred to the ICU for rewarming and ongoing resuscitation.

How should you monitor this patient in the ICU?

Learning issues

Monitoring of intra-abdominal pressure

Measuring abdominal perfusion pressure

How would you measure the IAP?

Learning issues

Intra-abdominal pressure measurement

Intravesical pressure

What is a normal IAP?

Learning issues

Definitions related to intra-abdominal hypertension

http://www.wsacs.org/
Consensus definitions of the World Society for Abdominal Compartment Syndrome

In the ICU, the patient remains hypotensive with elevated arterial lactate levels and low urinary output. His heart
rate (HR) is regular at 150 beats per minute (bpm) and the postoperative IAP was 14 mmHg.

Learning issues

PACT module on Hypotension

How would you monitor preload in this patient?

Learning issues

Organ supportive therapy

PACT module on Haemodynamic monitoring

A volumetric pulmonary artery catheter is placed to guide the patient's management. The initial haemodynamic
profile was consistent with profound intravascular volume depletion as a result of his haemorrhagic shock. Urine
output (UOP) was 10 ml/hr.

Aggressive resuscitation using crystalloids and blood products was started to both increase the patient's
intravascular volume as well as correct the patient's coagulopathy. He initially responded appropriately to volume
administration with increased CI, decreased HR, increased right ventricular end-diastolic volume index
(RVEDVI), and a trend towards improved UOP. However respiratory function deteriorated with hypercapnia,
hypoxia and difficult ventilation with increased alveolar pressures (peak and plateau), while IAP was 26 mmHg.

What do the patient's increasing IAP and peak inspiratory pressures suggest?

NOTE IAH can recur in patients with open abdomen treatment. Continued IAP monitoring is
essential in these patients.

Learning issues

Abdominal compartment syndrome (1)

Abdominal compartment syndrome (2)

What is the appropriate treatment now?

NOTE Mortality from ACS is directly correlated with the rapidity with which decompressive
laparotomy is performed. Delays of even 30-60 minutes can make the difference between life
and death for these patients. Diuretics are contraindicated as this will only worsen systemic
perfusion.

Given the severity of the patient's physiological derangements, a decision was made to re-explore the abdomen
in the ICU. The surgeon drained about 1500 ml of blood, and ligated several bleeding vessels. A vacuum-
assisted closure technique was installed, and bleeding stopped.

Learning issues

Laparotomy (1)
Laparotomy (2)

Vacuum-assisted fascial closure

Organ dysfunction gradually improved, and the abdomen could be closed five days later. The patient was
discharged from the ICU shortly thereafter.

Learning issues

Management and support of the patient with an open abdomen

Recognising the patient at risk

Your fourth patient, a 72-year-old lady has undergone a Hartmann's procedure (sigmoidectomy and
terminal colostomy) for an obstructing sigmoid carcinoma. She is admitted to your intensive care unit as
shown in the figure below.

What information do you want with her admission?

Learning issues

How to assess the patient

The anaesthesiologist confirms that the operation was difficult, with extensive inflammation in the abdomen. The
patient was on oral medication for diabetes, and admitted to the hospital only hours before the operation.

Now that the patient is in the ICU, you note the vital signs (figure below): the heart rate is 70, mean arterial
pressure 84, CVP 19, intra-abdominal pressure 23 and oxygen saturation is 98%.
Learning issues

Calculation of filling pressure when IAP present

Transmural CVP

Are you satisfied with her present status?

If we look closely at the patient, we can see there is a potential problem (see figures below)

First of all, what do you notice that would make you concerned?

How are you going to assess this patient for potential intraabdominal problems?

Learning issues

Organ supportive therapy

Abdominal compartment syndrome (1)

Abdominal compartment syndrome (2)

How to assess the patient

NOTE Always perform a thorough clinical examination of the abdomen as a first step in patients
after abdominal surgery.

What additional examinations do you want in this patient?

 Learning issues

Complications

The status of this patient now at 14 hours following surgery, is that her airway pressures have increased to 35
cmH2O, her arterial pCO2 is 52 mmHg, PO2 is 74 mmHg on FiO2 of 80% with a PEEP of 10 cmH2O. Her
mean arterial pressure has fallen to 68, and her urinary output has decreased. The intra-abdominal pressure is
now 22 mmHg.

How are you going to manage this patient?

Learning issues

Managing complications

Abdominal compartment syndrome (1)

Abdominal compartment syndrome (2)

NOTE Organ dysfunction in these patients is often further compromised by administering fluids,
leading to tissue oedema, and secondary ACS.

In discussion with the surgical team, it transpires that during the operation, there was an extreme thickening of
the bowel, with ischaemic points, which were felt to be of a minor nature, in her colon. It was decided that the
colon was viable and a Hartmann's colostomy had been performed.
Digital exploration and passage of a flatus tube by the surgeon does not produce any gas release. The
patient's IAP has now increased to 32 mmHg despite non-surgical therapies.

Do you think this patient needs another operation? On what arguments would you base your decision for
surgical reintervention?

Learning issues

Management of intra-abdominal hypertension

NOTE Unnecessary additional laboratory and imaging examinations often delay adequate therapy
in patients with intra-abdominal problems. Close communication with the surgeon is
essential.

What specific instructions would you advise the anaesthesiologist of during handover?

Learning issues

PACT module on Communication skills

At surgery her entire large bowel was resected where there was frank necrosis of the transverse colon, an
ileostomy was formed. After resection the pressure within the abdomen was relieved allowing the abdominal
wall to be closed.
The IAP was measured after closure, and was 14 mmHg.

Learning issues

PACT module on Communication skills

Was it advisable to close the abdomen in this patient? Give your reason.

Further surgery was not anticipated in this lady as there was no intra-abdominal sepsis and hence the
probability of a third laparotomy would be unlikely.
The patient returned to intensive care and during a stormy 24-hour period required significant fluid
resuscitation with a positive balance of 3.8 litres of crystalloid. Her renal function was maintained clinically,
although biochemically her urea increased to 12.8, and creatinine to 216. Her liver function became slightly
abnormal, and she was commenced on enteral feeding, 20 ml per hour via nasogastric tube.
She eventually was discharged from the ICU on day eight and home on day 19.

NOTE Despite significant intra-abdominal problems, the enteral route can be used if anatomically
intact.

On reflection, you were presented with challenging cases demonstrating the diversity of abdominal problems in the ICU,
and the need for an individualised approach.

Close cooperation with the surgeon, and other specialties is important for successful management of these often-
complicated cases

Thinking about the management of these patients, what are the key issues in the management of intra-
abdominal problems?