Acute intestinal distress syndrome: the importance of intra-abdominal pressure

Intensive Care Unit, Ziekenhuis Netwerk Antwerpen, Antwerpen, Belgium.
Minerva anestesiologica (Impact Factor: 2.13). 11/2008; 74(11):657-73.
Source: PubMed


This review article will focus primarily on the recent literature on abdominal compartment syndrome (ACS) as well as the definitions and recommendations published by the World Society for the Abdominal Compartment Syndrome (WSACS, The risk factors for intra-abdominal hypertension (IAH) and the definitions regarding increased intra-abdominal pressure (IAP) will be listed, followed by a brief but comprehensive overview of the different mechanisms of end-organ dysfunction associated with IAH. Measurement techniques for IAP will be discussed, as well as recommendations for organ function support in patients with IAH. Finally, noninvasive medical management options for IAH, surgical treatment for ACS and management of the open abdomen will be briefly discussed.

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Available from: Manu LNG Malbrain, Dec 15, 2014
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    • "These cytokines and neutrophil migration conversely stimulate vascular endothelial cells, leading to ‘capillary leak syndrome’. As this pathophysiologic process has some analogy with acute lung injury (ALI) or acute renal injury (ARI), it has been suggested that the terms acute intestinal distress syndrome (AIDS) or acute intestinal permeability syndrome (AIPS) are used to describe the intestinal dysfunction resulting from shock or ischemia [42-44]. "
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    ABSTRACT: Abdominal distension is common in critical illness. There is a growing recognition that intra-abdominal hypertension (IAH) may complicate non-surgical critical illness as well as after abdominal surgery. However, the pathophysiological basis of the injury to the intestinal mucosal barrier and its influence on the onset of abdominal compartment syndrome (ACS) and multi-organ dysfunction syndrome (MODS) remain unclear. We measured intestinal microcirculatory blood flow (MBF) during periods of raised intra-abdominal pressure (IAP) and examined how this influenced intestinal permeability, systemic endotoxin release, and histopathological changes. To test different grades of IAH to the injury of intestinal mucosa, 96 New Zealand white rabbits aged 5--6 months were exposed to increased IAP under nitrogen pneumoperitoneum of 15 mmHg or 25 mmHg for 2, 4 or 6 hours. MBF was measured using a laser Doppler probe placed against the jejunal mucosa through a small laparotomy. Fluorescein isothiocyanate (FITC) conjugated dextran was administered by gavage. Intestinal injury and permeability were measured using assays for serum FITC-dextran and endotoxin, respectively, after each increase in IAP. Structural injury to the intestinal mucosa at different levels of IAH is confirmed by light and transmission electron microscopy. MBF reduced from baseline by 40% when IAP was 15 mmHg for 2 hours. This doubled to 81% when IAP was 25 mmHg for 6 hours. Each indicator of intestinal injury increased significantly, proportionately with IAP elevation and exposure time. Baseline serum FITC-dextran was 9.30 (+/-SD 6.00) mug/ml, rising to 46.89 (+/-13.43) mug/ml after 15 mmHg IAP for 4 hours (p < .01), and 284.59 (+/-45.18) mug/ml after 25 mmHg IAP for 6 hours (p < .01). Endotoxin levels showed the same pattern. After prolonged exposure to increased IAP, microscopy showed erosion and necrosis of jejunal villi, mitochondria swelling and discontinuous intracellular tight junctions. Intra-abdominal hypertension can significantly reduce MBF in the intestinal mucosa, increase intestinal permeability, result in endotoxemia, and lead to irreversible damage to the mitochondria and necrosis of the gut mucosa. The dysfunction of the intestinal mucosal barrier may be one of important initial factors responsible for the onset of ACS and MODS.
    Critical care (London, England) 12/2013; 17(6):R283. DOI:10.1186/cc13146 · 4.48 Impact Factor
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    • "Early recognition of IAH is critical for an effective ACS treatment, but is hampered by the poor sensitivity of clinical examination [8]. Bladder and gastric pressure measurements remain the cornerstone to diagnose and monitor IAH [9], but borderline values may be misinterpreted and should be evaluated cautiously because patient size and position and the application of positive endexpiratory pressure affect measurements [10] [11] [12]. Furthermore , mild IAP elevations may be clinically significant only in the presence of hypovolemia [13] or arterial hypotension [14]. "
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    ABSTRACT: Introduction: We investigated whether (a) the inferior vena cava (IVC) is compressed in bowel obstruction and (b) some tracts are more compressed than others. Methods: Two groups of abdominal computed tomography (CT) examinations were collected retrospectively. Group O (N = 69) scans were positive for bowel obstruction, group C (N = 50) scans were negative for diseases. IVC anteroposterior and lateral diameters (APD, LAD) were assessed at seven levels. Results: In group C, IVC section had an elliptic shape (APD/LAD: .76 ± .14), the area of which increased gradually from 1.9 (confluence of the iliac veins) to 3.1 cm²/m² of BSA (confluence of the hepatic veins) with a significant narrowing in the hepatic section. In group O, bowel obstruction caused a compression of IVC (APD/LAD: .54 ± .17). Along its course, IVC section area increased from 1.3 to 2.5 cm²/m². At ROC curve analysis, an APD/LAD ratio lower than 0.63 above the confluence of the iliac veins discriminated between O and C groups with sensitivity of 74% and specificity of 96%. Conclusions: Bowel obstruction caused a compression of IVC, which involved its entire course except for the terminal section. APD/LAD ratio may be useful to monitor the degree of compression.
    09/2013; 2013:469297. DOI:10.1155/2013/469297
    • "Better perfusion of the gastrointestinal tract translates as better absorption of nutrients, thus accounting for the difference in tube feeding tolerance among the three groups.[8] In addition, some studies suggest that the digestive tract is most sensitive to IAH and its injury precedes cardiac, pulmonary, and renal symptoms [Table 2].[2930] "
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    ABSTRACT: Increased intra-abdominal pressure (IAP) results in dysfunction of vital organs. The aim of the present study was to evaluate the effect of mechanical ventilation mode on IAP. In a cohort study, a total of 60 patients aged 20-70 years who were admitted to the ICU and underwent mechanical ventilation were recruited. Mechanical ventilation included one of the three modes: Biphasic positive airway pressure (BIPAP) group, synchronize intermittent mandatory ventilation (SIMV) group, or continuous positive airway pressure (CPAP) group. For each patient, mechanical ventilation mode and its parameters, blood pressure, SpO2, and status of tube feeding and IAP were recorded. Our findings indicate that the study groups were not significantly different in terms of anthropometric characteristics including age (64.5 ± 4, P = 0.1), gender (male/female 31/29, P = 0.63), and body mass index (24 ± 1.2, P = 0.11). Increase IAP was related to the type of respiratory mode with the more increased IAP observed in SIMV mode, followed by BIPAP and CPAP modes (P = 0.01). There were significant correlations between increased IAP and respiratory variables including respiratory rate, pressure support ventilation, and inspiratory pressure (P < 0.05). Tube feeding tolerance through NG-tube was lower in SIMV group, followed by BIPAP and CPAP groups (P < 0.05). There is a significant relationship between respiratory modes and IAP; therefore, it is better to utilize those types of mechanical ventilation like CPAP and BIPAP mode in patients who are prone to Intra-abdominal hypertension.
    International journal of preventive medicine 05/2013; 4(5):552-6.
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