Abdominal compartment syndrome: radiological signs Poster No.: C-0903 Congress: ECR 2011 Type: Scientific Exhibit Authors: R. Ignarra, C. Acampora, R. MAZZEO, C. muzj, L. Romano ; 1 1 2 2 3 3 1 4 4 napoli/it, Napoli (NA)/IT, NAPOLI/IT, Naples/IT Keywords: Safety, Education, Ultrasound, CT, Conventional radiography, Emergency, Abdomen DOI: 10.1594/ecr2011/C-0903 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 22
Purpose Abdominal compartment syndrome is a severe condition in which an acute increased intra-abdominal pressure is associated with organ dysfunction, which interferes on the functionality of tissues, resulting in cardiac, respiratory and renal failure. The aim of our study is to illustrate the radiological findings that allow to suspect this condition, that requires emergent surgical decompression in order to reduce the mortality. Methods and Materials We reviewed abdominal CT, abdominal conventional plain film, ultrasound and colordoppler intra-abdominal hypertension findings in 20 patients with blunt abdominal trauma, major abdominal surgery, severe pancreatitis and other more rare clinical conditions (as toxic megacolon) complicated with abdominal organ functional damage. Results The x-ray film, ultrasound and contrast-enhancement CT findings most frequently observed in abdominal compartment syndrome are the elevation of the diaphragm (8 patients), the "round belly sign" (5 patients), the presence of free fluid and air in the intraperitoneal and retroperitoneal spaces (7 patients), the collapsed inferior vena cava (6 patients), the hyperenhancement and thickening of the intestine bowel wall ( 4 patients) and an elevated hepatic artery resistance index Color-Doppler with diastolic flow reversed (20 patients). Images for this section: Page 2 of 22
Fig. 1: Case 1: 29-year old man with abdominal pain. Axial CT image shows toxic megacolon that collapses renal veins and inferior vena cava. This patient underwent colectomy sparing the rectum. Page 3 of 22
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Fig. 2: Case 1: 29-year old man with abdominal pain. Coronal CT image shows toxic megacolon, the dilated colonic loops filled with fecal material. This patient underwent colectomy sparing the rectum. Page 5 of 22
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Fig. 3: Case 1: Scout CT image obtained after colectomy for sudden hypotension shows elevated left diaphragm, free endo-peritoneal air caused by ileal perforation. Intra-vesical pressure was 18 mmhg. Fig. 4: Case 1: After surgery, Axial CT image shows elevated left diaphragm, free air and liquid in the peritoneal cavity with heart compression. Page 7 of 22
Fig. 5: Case 1: After surgery, Axial CT image shows small bowell loops mucosal hyperenhancement was caused by mesenterial vascular compression. The intra-vesical pressure was 18mmHg. Page 8 of 22
Fig. 6: Case 2: 58-year old woman after pancreatic surgery, the patient presents with sudden hypotension, dyspnea and tachycardia. X-ray film image obtained shows elevated right diaphragm. The intra-vesical pressure was 15 mmhg. Page 9 of 22
Fig. 7: Case 2: A coronal CT image shows elevated right diaphragm caused by fluid collection in the right subfphrenic space. The intra-vesical pressure was 15 mmhg. An abdominal drainage tube resolved the respiratory symptoms. Page 10 of 22
Fig. 8: Case 2: An axial CT image shows elevated right diaphragm caused by fluid collection in the right subfphrenic space and free intraperitoneal liquid. The intra-vesical pressure was 15 mmhg. An abdominal drainage tube resolved the respiratory symptoms. Page 11 of 22
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Fig. 9: Case 3: 14-year-old girl with traumatic liver contusion with signs of active bleeding treated with packing. After surgery, this young patient shows signs of respiratory distress. A scout CT image shows elevated right diaphragm. Intra-vesical pressure was 20 mmhg. Fig. 10: Case 3: 14-year-old girl with traumatic liver contusion with signs of active bleeding treated with packing. After surgery, this young patient shows signs of respiratory distress. An axial contrast-enhanced CT image shows free intraperitoneal liquid and collapsed inferior vena cava. Intra-vesical pressure was 20 mmhg. Surgeons involved with the packing to limit bleeding in liver trauma, but sometimes the excessive compression of gauze, determines iatrogenic abdominal compartment syndrome. Only the intervention of depacking resolved the clinical symptoms. Page 13 of 22
Fig. 11: Case 3: 14-year-old girl with traumatic liver contusion with signs of active bleeding treated with packing. After surgery, this young patient shows signs of respiratory distress. An axial contrast-enhanced CT image shows collapsed supra-hepatic veins. Only the intervention of depacking resolved the clinical symptoms. Page 14 of 22
Fig. 12: Case 4: 69-year-old man with erroneous diagnosis of liver trauma contusion at other hospital, came in second treatment at our hospital. Scout CT image shows elevated right diaphragm. Intra-vesical pressure was 22 mmhg. Page 15 of 22
Fig. 13: Case 4: 69-year-old man with erroneous diagnosis of liver trauma contusion at other hospital, came in second treatment at our hospital. Scout CT image shows globose abdomen. Intra-vesical pressure was 22 mmhg. Page 16 of 22
Fig. 14: Case 4: 69-year-old man with erroneous diagnosis of liver trauma contusion at other hospital, came in second treatment at our hospital. Coronal CT image shows elevated right diaphragm, globose abdomen, free intraperitoneal liquid. No hepatic lesion was found, but a tumor disease with peritoneal involvement was found. Intra-vesical pressure was 22 mmhg. Page 17 of 22
Fig. 15: Case 4: 69-year-old man with erroneous diagnosis of liver trauma contusion at other hospital, came in second treatment at our hospital. An axial CT image shows the "round belly sign", an increased ratio of anteroposterior-to-trasverse abdominal diameter (white arrow), a sign of abdominal compartment syndrome; the abdominal shape usually is oval, with predominantly transverse diameter on the anteroposterior, the latter measured in the CT scan in which the left renal vein crosses the abdominal aorta to throw himself into the inferior vena cava, without including the subcutaneous fat. Intravesical pressure was 22 mmhg. Emergency decompressive laparotomy was performed, but the patient died of respiratory failure, as the diaphragm did not resume regular feature. Page 18 of 22
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Fig. 16: Case 5: 51-year-old present dyspnea after a liver transplant. X-ray film image shows elevated left diaphragm (black arrow). Intra-vesical pressure was 21 mmhg. Fig. 17: Case 5: 51-year-old present dyspnea after a liver transplant. A color-doppler sonogram evaluation shows an elevated hepatic artery resistance index with diastolic flow reversed. Intra-vesical pressure was 21 mmhg. Page 20 of 22
Conclusion The abdominal compartment syndrome is a life-threatening condition which interferes on the functionality of tissues and organs, resulting in cardiac, respiratory and renal failure. It requires urgent surgical decompression. The normal intra-abdominal pressure is about 0-5 mmhg. When the pressure exceeds 12 mmhg, it can already determine organ ischemia and inpairment. The main causes of abdominal compartment syndrome are blunt abdominal trauma, major abdominal surgery, severe pancreatitis and other conditions that increase the intrabdominal pressure. Typically, these patients undergo routine imaging examinations with x-ray film, ultrasound examination and contrast enhanced CT to assess the severity of complications that can depend on the basic pathology. The identification of patients at risk of abdominal compartment syndrome is extremely important in order to reduce the mortality. The diagnosis is easily made by measuring intra-vesical pressure with a special catheter.the early identification of x-ray film, ultrasound exmination and CT findings may allow the Radiologist to suspect this condition, that requires emergent surgical decompression. References 1) Kron IL, Harman PK, Nolan SP (1984) The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 199: 28-30. 2) De Waele JJ (2005) Life saving abdominal decompression in a patient with severe acute pancreatitis. Acta Chir Belg 105: 96-98. 3) Biancofiore G, Bindi ML, Romanelli AM, Boldrini A (2003) Intra-abdominal pressure monitoring in liver transplant recipients: a prospective study. Intensive Care Med 29: 30-36. 4) Zissin R, Pickhardt PJ (2000) The significance of a positive round belly sign on CT. AJR 175: 267-268. 5) Pickhardt PJ, Shimony JS (1999) The abdominal compartment syndrome: CT findings. AJR 173: 575-579. 6) Burch JM, Moore EE (1996) The abdominal compartment syndrome. Surg Clin North Am 76: 833-842. Page 21 of 22
7) Laffargue G, Taourel P (2002) CT diagnosis of abdominal compartment syndrome. AJR 178: 771-772. 8) Patel A, Lall CG (2007) abdominal compartment syndrome. AJR 189: 1037-1043 Personal Information Ignarra Rosa MD, Acampora Ciro MD, Mazzeo Raffaele MD, Muzj Carlo MD, Romano Luigia MD Department of Radiology Imaging, UOSC General and Emergency Department Director: Luigia Romano MD, "A. Cardarelli" Hospital, Naples, Italy Tel FAX: 081-7472974 Page 22 of 22