Intensive Care Med (2006) 32:906–909DOI 10.1007/s00134-006-0106-9 BRIEF REPORT

Alok TiwariFiona MyintGeorge Hamilton

Recognition and management of abdominalcompartment syndrome in the United Kingdom

Received: 2 October 2005Accepted: 9 February 2006Published online: 7 April 2006© Springer-Verlag 2006

Electronic supplementary materialThe electronic reference of this article ishttp://dx.doi.org/10.1007/s00134-006-0106-9. The online full-text version of this articleincludes electronic supplementary material.This material is available to authorisedusers and can be accessed by means of theESM button beneath the abstract or in thestructured full-text article. To cite or link tothis article you can use the above reference.

Presented in part as an oral presentationat the World Congress on AbdominalCompartment Syndrome in December2004 at Noosa, Australia, and as a posterat the Intensive Care Society, December2004, London, UK, and at the Associationof Surgeons of Great Britain and Irelandmeeting in April 2005.

A. Tiwari · F. Myint · G. Hamilton (�)Royal Free and University College MedicalSchool, Department of Vascular Surgery,Royal Free Hospital,Pond Street, NW3 2QG London, UKe-mail: g.hamilton@medsch.ucl.ac.ukTel.: +44-207-7940500Fax: +44-207-4726278

Abstract Objective: Abdominalcompartment syndrome(ACS) isa condition associated with high mor-tality if undiagnosed and untreated.ACS is seen in patients managedin intensive care units. Very littleis known on the causes, diagnosisand treatment of this condition inthe United Kingdom. Design:Questionnaire study. Settings: 222intensive care units in the UK dealingwith acute abdominal condition.Results: 127 (57.2%) questionnaireswere returned (32 from teachinghospitals and 95 from district generalhospitals. Among these, 96.9% ofteaching hospitals and 72.6% ofdistrict general hospitals had seencases of ACS. The conditions mostfrequently associated with ACSwere small and large bowel surgery(67%), vascular surgery (62%) andtrauma (60%). ACS was suspectedmainly when there was a distendedabdomen (98.6%), oliguria (94.5%)and increased ventilatory support(72.2%). The diagnosis wasconfirmed either clinically (68.4%)

or by measuring intra-abdominalpressure (83.7%). The commonestmethod for measuring intra-abdominal pressure was the intra-vesical route. The pressure thresholdfor diagnosing the condition wasvariable, with a range of11–50 mmHg. There was a largevariation in the number of patientswho were decompressed. Conclu-sion: Fewer patients are diagnosedwith ACS in district general hos-pitals compared with teachinghospitals. The threshold for thediagnosis of ACS is variable in theUK, as were the numbers of patientswho were decompressed, suggestingthat many doctors are still reluctantto accept this condition. This studywould suggest that there is a needfor standardisation of diagnosticthreshold and protocols regardingdecompression in ACS.

Keywords Abdominal compart-ment syndrome · Decompression ·Intensive care unit · Intra-abdominalpressure · Questionnaire

Introduction

Abdominal compartment syndrome (ACS) is defined asthe presence of both an intra-abdominal pressure (IAP) ofmore than 20 mmHg, with or without an abdominal per-fusion pressure (APP) of less than 50 mmHg recorded bya minimum of three standardised measurements conducted1–6 h apart; and single or multiple organ system failurewhich was not previously present [1]. This condition has

significant morbidity and mortality if unrecognised or un-treated [2]. It is diagnosed in intensive care units because itis seen in patients who have major intra-abdominal pathol-ogy or who have needed major surgery, are unstable andneed close monitoring. Not all doctors universally acceptACS, and this may be due to a reluctance to accept thecondition or lack of knowledge, resulting in inadequatetreatment [3]. Very little is known about the diagnosis andmanagement of ACS in the United Kingdom. The aim of

907

our questionnaire study was therefore to test the generalknowledge of ACS, causes, current methods for diagnosisand its subsequent treatment.

Materials and method

A postal questionnaire was sent to clinical directors ofall the intensive care units in the UK in 2004 who wouldbe expected to treat patients susceptible to abdominalcompartment syndrome, i.e., general hospitals and notspecialised units (Appendix A). A total of 222 question-naires were sent out and a prepaid addressed envelopeincluded. A reminder was sent to units that had not repliedwithin a few weeks. The total survey period was 12 weeks.All statistical analysis was done using GraphPad Prismversion 3.00 for Windows, GraphPad Software, SanDiego, CA, USA.

Results

One hundred twenty-seven (127, 57.2%) questionnaireswere returned (32 from teaching hospitals and 95 fromdistrict general hospitals) [4, 5]. Thirty-one (96.9%) ofthe teaching hospital intensive care units had seen ACScompared with 69 (72.6%) of intensive care units indistrict general hospitals (p = 0.0037, chi-squared test).

Causes of ACS

These are summarised in Table 1. It is interesting tonote the other types of conditions associated with ACSthat were seen in our survey, including pancreatitis, liverfailure, intra-abdominal sepsis, ascites and patients onextra-corporeal membrane oxygenator (ECMO). Themain difference between district general hospitals andteaching hospitals was that district general hospitals rarelysaw cases of ACS after hepatobiliary surgery, reflectingthe centralisation of this type of operation to specialisedunits in teaching hospitals (p < 0.0001, chi-squared test).

Teaching hospitals District general hospitals p (chi-squared test)n = 31 n = 69

Gynaecological surgery 2 (6.70) 5 (7.2) 0.89Hepatobiliary surgery 9 (30.0) 1 (1.4) < 0.0001Small/large bowel obstruction 8 (26.7) 29 (42.0) 0.06Small/large bowel surgery 17 (54.8) 50 (72.5) 0.08Trauma 16 (53.3) 44 (63.8) 0.25Urological surgery 2 (13.3) 6 (8.7) 0.70Vascular surgery 21 (70.0) 41 (59.4) 0.43Other 6 (19.4)∗ 15 (21.7)∗∗ 0.79

∗ Includes pancreatitis, liver failure and patients on extra-corporeal membrane oxygenator∗∗ Includes pancreatitis, ascites, intra-abdominal sepsis and pseudo-obstruction

Table 1 Differing conditionsassociated with abdominalcompartment syndrome (ACS) inintensive care units that had seencases of ACS (% are given inparentheses)

The commonest cause of ACS in teaching hospitals wasvascular surgery, whilst in the district general hospitalsthis was small/large bowel surgery.

Recognition and diagnosis of ACS

ACS was suspected in teaching hospitals, compared withdistrict general hospitals, when there was a distendedabdomen (100% vs. 97.1%), oliguria (90.3% vs. 98.6%),increased ventilatory support requirement (67.7% vs.76.8%), hypotension (54.8% vs. 63.8%) and other (26.7%vs. 24.6%). The others in this survey refer to persistentacidosis, increased lactate, feeding difficulties, persistentileus, hepatic dysfunction and palpitations.

Diagnosis was confirmed in teaching hospitals, com-pared with district general hospitals, by measuring IAP(93.5% vs. 73.9%), clinically (60% vs. 76.8%), witha computed tomography scan (3% vs. 11.6%) or by pHmanometry (3% vs. 0%). If IAP was measured, this wasdone by measuring the intra-vesical pressure (89.7% inteaching hospitals and 96.1% in district general hospi-tals) or by using an intra-abdominal catheter (10.3% inteaching hospitals and 3.9% in district general hospitals).The pressure thresholds for diagnosing ACS were veryvariable. In the teaching hospitals, the pressure thresholdfor diagnosing was 11–30 mmHg, and in the districtgeneral hospitals this was 11–50 mmHg.

Treatment of ACS

The number of patients in the units who were decom-pressed following a diagnosis of ACS is summarised inTable 2. This shows that, in the majority of the units, lessthan 50% of the patients were decompressed.

Discussion

ACS is increasingly being recognised as a significant causeof morbidity and mortality worldwide. It is frequently seen

908

Percentage of patients decompressed Teaching hospitals (%) District general hospitals (%)

< 10 32.1 25.810–25 14.3 14.525–50 14.3 21.050–75 10.7 17.775–100 28.6 21.0

Table 2 Percentage of patientsdecompressed followingdiagnosis of abdominalcompartment syndrome in theintensive care units. There wasno statistical difference(chi-squared test)

in patients in the intensive care units but not always recog-nised, as shown by a recent multicentre prevalence study.In this study by Malbrain et al., 8.2% of patients in in-tensive care units had ACS, which, based on clinical andbiochemical factors alone, would not have been evident,demonstrating the need for a high index of suspicion [6].Therefore, we conducted this survey to find out how manypatients were being diagnosed, and then treated, for ACSin the UK. A questionnaire study on ACS in the intensivecare unit has also recently been published by Ravishankarand Hunter [7]. In their study they looked at when IAPwas measured, the pressure threshold for diagnosing ACSand when they would recommend decompression. Theyshowed that 75.9% of units had measured IAP, which wassimilar to our study (78.7% of units). However, we havealso shown that the recognition of this condition in teach-ing hospitals was good, whilst this was relatively poor indistrict general hospitals, with 27.4% of the units not see-ing this condition. Our study, which was more comprehen-sive than that of Ravishankar and Hunter, also showed thediffering causes for ACS, the pressure thresholds for diag-nosing ACS and the reasons for measuring IAP.

In terms of causal factors, our survey showed resultssimilar to those previously published, mainly vascular,trauma and following large and small bowel surgery [8,9, 10]. The other common causal factors for ACS werepancreatitis and ascites. Pancreatitis as a causal factor isprobably under-recognised by doctors who manage thiscondition in the UK [11].

The diagnosis was confirmed by most of the units bya combination of clinical parameters and IAP measure-ment. However, district general hospitals were more likelyto diagnose ACS based only on clinical examination,though there is no evidence to support this, and diagnosisshould only be made after measuring IAP. The mostimportant part in the diagnosis of ACS is to have a highindex of suspicion for the condition [6, 8].

Measuring the intra-abdominal pressure is the goldstandard for confirming this condition, though othermethods have been described. These include gastric pHmanometry and computed tomography scans, but in oursurvey these were rarely used and reflect the limiteddata on using these modalities [12, 13]. Computed to-mography may show compression of the inferior venacava and the round belly sign (increased ratio of theanteroposterior to transverse abdominal greater then0.80) [13].

Intra-abdominal pressure can be measured directly byusing an intra-abdominal catheter or indirectly using intra-vesical or intra-gastric pressure. The current method usedin most published series has been the intra-vesical mea-surement, as popularised by Kron et al., and was previ-ously considered the gold standard [14]. This was reflectedin our survey. However, recent work has shown that the in-termittent method of Kron is not reliable and reproducible,and, therefore, it is recommended that continuous intra-vesical monitoring should be used [15, 16, 17].

The pressure threshold for diagnosing ACS has var-ied in published studies, and this was reflected in our sur-vey. However, a consensus on this was recently reached atthe World Society of the Abdominal Compartment Syn-drome (WSACS) meeting (www.wsacs.org), which is thatACS will be diagnosed if IAP is more than 20 mmHg. Thisdefinition should help in the diagnosis and managementof these patients. In the future, intra-abdominal pressurealone may be less important, with the APP thought to bemore sensitive [12].

The treatment of ACS is decompression of the ab-domen, failure of which results in a high mortality.However, even with decompression, mortality remainshigh, because these patients are very unwell, with highAPACHE (acute physiology and chronic health evalua-tion) and ISS (injury severity score) scores [2]. In oursurvey, many units, even after diagnosing this condition,had a limited number of patients who were actually de-compressed. This shows that there is reluctance amongstsurgeons to operate on these ill patients, and, again, thiscould be because of lack of awareness or reluctance toaccept this condition. We also found that many units hadno proper data on the overall mortality and morbidity ofpatients with ACS.

In this study, we have shown that recognition of ACSis relatively poor in district general hospitals. The pres-sure threshold for diagnosing this condition is variable, andrates of decompression of patients with ACS are low. Thefounding of the WSACS and adoption of the definition forACS should result in standardisation and improvement inthe management of this condition.

Conclusion

ACS is a condition with a high morbidity and mortality ifunrecognised and treated. In this survey, we have shown

909

that this condition is not always recognised and, even if di-agnosed, is not treated. Wider education is needed for alldoctors who deal with conditions leading to ACS.

Acknowledgements. The authors would like to thank the directorsof the intensive care units who sent in their replies, and Sarah Louthfor her help in the sending and collating of the questionnaires.

References

1. Sugrue M (2005) Abdominal compart-ment syndrome. Curr Opin Crit Care11:333–338

2. Tiwari A, Haq AI, Myint F, Hamilton G(2002) Acute compartment syndromes.Br J Surg 89:397–412

3. Malbrain ML (2004) Is it wise not tothink about intraabdominal hyperten-sion in the ICU? Curr Opin Crit Care10:132–145

4. Tiwari A, Louth S, Myint F, Hamilton G(2005) Recognition and treatment ofabdominal compartment syndrome(ACS): a questionnaire study of inten-sive care units in the United Kingdom.Br J Surg 92(S1):40

5. Tiwari A, Myint F, Hamilton G (2005)Recognition and treatment of abdom-inal compartment syndrome (ACS):a questionnaire study of intensive careunits in the United Kingdom. ANZJ Surg 75:A14–15

6. Malbrain ML, Chiumello D, Pelosi P,Wilmer A, Brienza N, Malcangi V,Bihari D, Innes R, Cohen J, Singer P,Japiassu A, Kurtop E, De Keule-naer BL, Daelemans R, Del Tuurco M,Cosimini P, Ranieri M, Jacquet L,Laterre PF, Gattinoni L (2004) Preva-lence of intra-abdominal hypertensionin critically ill patients: a multicentreepidemiological study. Intensive CareMed 30:822–829

7. Ravishankar N, Hunter J (2005) Mea-surement of intra-abdominal pressure inintensive care units in the United King-dom: a national postal questionnairestudy. Br J Anaesth 94:763–766

8. Ivatury RR, Diebel L, Porter JM,Simon RJ (1997) Intra-abdominalhypertension and the abdominal com-partment syndrome. Surg Clin NorthAm 77:783–800

9. Offner PJ, De Souza AL, Moore EE,Biffl WL, Franciose RJ, Johnson JL,Burch JM (2001) Avoidance of ab-dominal compartment syndrome indamage-control laparotomy aftertrauma. Arch Surg 136:676–681

10. Fietsam R Jr, Villalba M, Glover JL,Clark K (1989) Intra-abdominal com-partment syndrome as a complicationof ruptured abdominal aortic aneurysmrepair. Am Surg 55:396–402

11. Gecelter G, Fahoum B, Gardezi S,Schein M (2002) Abdominal com-partment syndrome in severe acutepancreatitis: an indication for a de-compressing laparotomy? Dig Surg19:402–404

12. Ivatury RR, Porter JM, Simon RJ,Islam S, Jofn R, Stalh WM (1998)Intra-abdominal hypertension afterlife-threatening penetrating abdominaltrauma: prophylaxis, incidence, andclinical relevance to gastric mucosal pHand abdominal compartment syndrome.J Trauma 44:1016–1021

13. Pickhardt PJ, Shimony JS, Heiken JP,Buchman TG, Fisher AJ (1999) Theabdominal compartment syndrome:CT findings. AJR Am J Roentgenol173:575–579

14. Kron IL, Harman PK, Nolan SP (1984)The measurement of intraabdominalpressure as a criterion for abdominalreexploration. Ann Surg 199:28–30

15. De Potter TJ, Dits H, Malbrain ML(2005) Intra- and interobserver vari-ability during in vitro validation oftwo novel methods for intra-abdominalpressure monitoring. Intensive CareMed 31:747–751

16. Malbrain ML (2004) Different tech-niques to measure intra-abdominalpressure (IAP): time for a criticalre-appraisal. Intensive Care Med30:357–371

17. Balogh Z, Jones F, D’Amours S,Parr M, Sugrue M (2004) Continuousintra-abdominal pressure measurementtechniques. Am J Surg 188:679–684