Decompressive laparotomy reduces IAP by relieving the tension exerted by the abdominal wall on the inferior vena cava and the portal vein to allow more blood to return to the heart [5
]. This explains the sudden normalization of the patient's blood pressure after surgery. Conversely, closure of the abdomen following a laparotomy cannot be done without tension, it is recommended that delayed closure (staged abdominal repair) be undertaken to prevent IAH and ACS, postoperatively.
Surgical abdominal decompression has long been the standard treatment for patients who develop ACS. It represents a life-saving intervention when a patient's IAH becomes refractory to medical treatment options and organ dysfunction and/or failure is evident. Most patients tolerate primary fascial closure within 5 to 7 days if decompressed before significant organ failure develops [7
Multiple and profound physiologic abnormalities are caused by ACS/IAH, both within and outside the abdomen. Early recognition of increased IAP is primordial in the management. In order for this to occur, monitoring of IAP, either intermittent or continuous, is necessary for all patients presenting with risk factors. Additionally, understanding of the pathophysiology of ACS/IAH is of prime importance when trying to apply patient-tailored treatments. Moreover, surgical intervention should be indicated by IAH and not delayed until ACS is clinically apparent.
Medical interventions aimed at decreasing IAP target the 3 important contributors to IAH: 1) solid-organ and hollow-viscera volume; 2) space occupying lesions, such as ascites, blood, fluid, or tumors; and 3) conditions that limit expansion of the abdominal wall. When using medical management options to decrease IAP, it is important to always consider individualized pathophysiologic mechanisms leading to IAH because these may differ considerably from one patient to another. Critically, in patients with IAH, small changes in intra-abdominal volume may have a pronounced effect on IAP.
Ileus is a common finding in critically ill patients, especially those with abdominal conditions such as pancreatitis, peritonitis, and abdominal trauma, and postoperative patients. Administration of prokinetic agents is used to overcome abdominal distention and ileus and thus is a treatment option for IAH. When such pharmacologic measures are unsuccessful in decreasing intraluminal volume, endoscopic decompression can be considered.
Ascites and blood are the most common components of space-occupying lesions, but abscesses and free air also can contribute to IAH. When located in the free intraperitoneal space, these collections may be easy targets for percutaneous drainage, which can be performed at the bedside in the ICU under ultrasound guidance. Limited abdominal wall compliance also may be an important contributor to IAH. Increased abdominal muscle tone, most often due to pain or agitation, can be relieved by adequate analgesia and sedation if necessary. Use of restrictive bandages should be avoided. Neuromuscular blockade repeatedly has effectively decreased IAP in patients with IAH [8
]. A trial with neuromuscular blocking agents could be considered when simpler measures are not sufficient or are ineffective, and continuous infusion of these agents could be considered when a clinically relevant effect is shown.
The WSACS recently proposed a medical treatment algorithm based largely on expert opinion that is aimed at both decreasing IAP and optimizing fluid resuscitation and systemic perfusion. The medical treatment options discussed may be applied in a stepwise fashion; critically, the present level of evidence supporting these and other elements of this algorithm is limited, and the separate elements are not supported by clinical outcome data. However, this algorithm was part of an integrated approach that Cheatham et al. [9
] found to improve outcome and decrease hospital costs.
NHL rarely presents primarily with a pelvic or retroperitoneal mass; during post-mortem studies of NHL patients less than 1% incidence was demonstrated [10
]. In our case study, the uncommon primary retroperitoneal NHL made the diagnosis more difficult, and even after the NHL was identified in the retroperitoneal space, IAP presentation did not occur in other cases. Our case study is the first with such clinical presentation submitted for publication.
Our case study is a reminder to include the differential diagnosis of NHL when a patient admits to emergency with increased IAP, at which time decompressive laparatomy might be considered as a first line treatment.