IAH and Pancreatitis
Pancreatitis may be the ultimate medical disease to cause intra-abdominal hypertension. It involves both of the major processes that can cause IAH – direct injury to the peritoneal or retroperitoneal space and a massive systemic inflammatory response syndrome. Initially, severe acute pancreatitis causes inflammation and fluid sequestration in the retroperitoneal space leading to local vascular permeability and edema formation. As this progresses, pro-inflammatory cytokines are released and a systemic inflammatory response occurs, leading to system wide vascular leak with massive amounts of fluid sequestration in the mesentery and bowel wall. The current estimate of the prevalence of intra-abdominal hypertension in severe acute pancreatitis is about 40% to 75, with about 10-50% overall developing abdominal compartment syndrome.[1-5, 19] In addition, multiple organ dysfunction, ICU length of stay and mortality are all significantly increased in those pancreatitis patients who develop IAH.[1, 3, 4, 6, 7]
Treatment of IAH in pancreatitis is dependent first on early detection. Numerous authors strongly emphasize the need to monitor IAP in all severe pancreatitis patients to allow early detection and early intervention to reduce intra-abdominal pressure.[7-9] Once IAH is detected an established treatment algorithm should be used to guide therapy based on the pressure and the unique characteristics of the patient (click here to see internationally developed treatment algorithm provided on this web site). Specific therapies found to be helpful in pancreatis include percutaneous drainage of any fluid pocket present in the retroperitoneal space[10, 11], paracentesis to reduce inflammatory ascites accumulation[12, 20], early hemofiltration to remove pro-inflammatory cytokines as well as excess interstitial fluid[13-15], subcutaneous fasciotomy as an alternate to decompressive surgery [20] and decompressive laparotomy with or without pancreatic exploration when ACS develops.[3, 6, 8, 9, 15-18] More recent data also suggests the choice of fluid used for resuscitation can impact total fluid balance, occurrence or IAH and outcome.[21] In fact, the data on pancreatitis treatment using medical therapies such as Colliods, early hemofiltration and percutaneous drainage of ascites are fairly compelling - showing marked reductions in resource utilization (less mechanical ventilation, earlier return to negative fluid balance, faster extubation, quicker DC from the ICU and hospital) and lower mortality. It should become a standard to measure IAP and intervene with medical therapy in this group of high risk patients.
References:
1. Al-Bahrani, A.Z., et al., Clinical relevance of intra-abdominal hypertension in patients with severe acute pancreatitis. Pancreas, 2008. 36(1): p. 39-43.
2. Al-Bahrani, A.Z., et al., Gut barrier dysfunction in critically ill surgical patients with abdominal compartment syndrome. Pancreas, 2010. 39(7): p. 1064-9.
3. Chen, H., et al., Abdominal compartment syndrome in patients with severe acute pancreatitis in early stage. World J Gastroenterol, 2008. 14(22): p. 3541-8.
4. De Waele, J.J., et al., Intra-abdominal hypertension in patients with severe acute pancreatitis. Crit Care, 2005. 9(4): p. R452-7.
5. Leppaniemi, A., K. Johansson, and J.J. De Waele, Abdominal compartment syndrome and acute pancreatitis. Acta Clin Belg Suppl, 2007(1): p. 131-5.
6. Leppaniemi, A. and E. Kemppainen, Recent advances in the surgical management of necrotizing pancreatitis. Curr Opin Crit Care, 2005. 11(4): p. 349-52.
7. Pupelis, G., et al., Clinical significance of increased intraabdominal pressure in severe acute pancreatitis. Acta Chir Belg, 2002. 102(2): p. 71-4.
8. Tao, J., et al., Diagnosis and management of severe acute pancreatitis complicated with abdominal compartment syndrome. J Huazhong Univ Sci Technolog Med Sci, 2003. 23(4): p. 399-402.
9. Gecelter, G., et al., Abdominal compartment syndrome in severe acute pancreatitis: an indication for a decompressing laparotomy? Dig Surg, 2002. 19(5): p. 402-4; discussion 404-5.
10. Reckard, J.M., et al., Management of intraabdominal hypertension by percutaneous catheter drainage. J Vasc Interv Radiol, 2005. 16(7): p. 1019-21.
11. Papavramidis, T.S., et al., Intra-abdominal pressure alterations after large pancreatic pseudocyst transcutaneous drainage. BMC Gastroenterol, 2009. 9: p. 42.
12. Sun, Z.X., H.R. Huang, and H. Zhou, Indwelling catheter and conservative measures in the treatment of abdominal compartment syndrome in fulminant acute pancreatitis. World J Gastroenterol, 2006. 12(31): p. 5068-70.
13. Oda, S., et al., Management of intra-abdominal hypertension in patients with severe acute pancreatitis with continuous hemodiafiltration using a polymethyl methacrylate membrane hemofilter. Ther Apher Dial, 2005. 9(4): p. 355-61.
14. Maslovsky, O.P. and V.V. Zagorujko, Acute pancreatitis with multiple organ dysfunction syndrome - is high volume hemofiltration helpful? Intensive Care Medicine, 2005. 31, Supplement 1(134): p. S185, Abstract 710.
15. Caronna, R., et al., Clinical effects of laparotomy with perioperative continuous peritoneal lavage and postoperative hemofiltration in patients with severe acute pancreatitis. World J Emerg Surg, 2009. 4(1): p. 45.
16. DeWaele, J.J. and U.J. Hesse, Life saving abdominal decompression in a patient with severe acute pancreatitis. Acta Chir Belg, 2005. 105(1): p. 96-8.
17. Siebig, S., et al., Recovery from respiratory failure after decompression laparotomy for severe acute pancreatitis. World J Gastroenterol, 2008. 14(35): p. 5467-70.
18. Yang, D.J., et al., Early operation for fulminant acute pancreatitis: a possible way to decrease mortality. Chin Med J (Engl), 2009. 122(13): p. 1492-4.
19. Dambrauskas, Z., et al., Early recognition of abdominal compartment syndrome in patients with acute pancreatitis. World J Gastroenterol, 2009. 15(6): p. 717-21.
20. Dambrauskas, Z., et al., Interventional and surgical management of abdominal compartment syndrome in severe acute pancreatitis. Medicina (Kaunas), 2010. 46(4): p. 249-55.
21. Du, X.J., et al., Hydroxyethyl Starch Resuscitation Reduces the Risk of Intra-Abdominal Hypertension in Severe Acute Pancreatitis. Pancreas, 2011.