| Abstract: Introduction
Several reports described abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis. Traditionally, the treatment for ACS necessitated immediate decompression of the abdominal cavity with celiotomy and temporary abdominal wall closure with either mesh, bagota bag and/or the use of the vacuum assisted dressing (VAC) to avoid the significant morbidity and mortality associated with ACS. Recently, percutaneous decompression was found to be a safe and effective alternative method of decreasing intra abdominal hypertension and preventing ACS in patients with thermal injury in an attempt to prevent the long-term sequale associated with decompressive celiotomy. We present the first case report of a patient with severe phlegmonous pancreatitis and ACS who was successfully treated with computed tomography guided percutaneous intra-abdominal drainage.
Case Report
A 53 year old male was admitted and followed at a tertiary care center from December 26,2003 to January 31,2004 with severe gallstone pancreatitis. Ranson’s Criteria at 24 and 48 hours was calculated and was noted to be 2 and 5 respectively with an APACHE II score of 37. Repeat CT scans confirmed phlegmonous pancreatitis. Over the coarse of the early part of the hospitalization the patient continued to deteriorate as the bladder pressure (BP) rose to 37 cm H20 with an associated compromise in ventilatory support as indicated by a Pco2 of 55, tidal volume (TV) of 470ml on PCV 34 with a PIP of 37mmHg. Insertion of a CT guided percutaneous drain was preformed. 1200 cc of serous fluid was rapidly evacuated leading to a drop of BP to 21 cm H20. Similarly, post decompression, an associated improvement in the patient’s TV was noted (600cc), leading to a significant improvement in ventilation with a drop of the PCO2 to 42mm Hg. A change in the patient’s urine output and creatinine was not noted given the patients prolonged oliguric renal insufficiency requiring dialysis. The patients BP remained less than 20 since decompression.
Discussion
The morbidity and mortality following decompressive celiotomy for ACS remains to be an area of great concern in both the surgical and trauma literature. Although numerous authors have advocated for early celiotomy in severe pancreatitis with ACS, our case report illustrates that CT guided percutaneous drainage of the abdominal cavity is a safe alternative to laparotomy.
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