(P87) Abdominal Compartment Syndrome: Nonspecific Abdominal Pain to Cardiac Arrest

Chief Complaint : Abdominal Pain

History of Present Illness : Patient was a 13-year-old female with a past medical history of developmental delay, dysmorphic facial features, and possible Genetic Syndrome who presented to the pediatric emergency room for abdominal pain and nausea for 1 day. Patient was non-verbal and unable to elaborate further, but able to nod her head yes/no and point to her abdomen. The history was mainly obtained from the mother at bedside who stated that the patient pointed to her abdomen the evening prior to the ED presentation and refused oral intake. The last bowel movement recorded was two days prior with multiple episodes of retching without emesis. No fevers, chills, diarrhea, urinary complaints, syncope, or rash.

Pertinent Physical Exam: Upon arrival to the ED, vital signs were within normal limits. Patient appeared well without any significant distress. Abdominal exam notable for soft abdomen with distension. Mild tenderness to palpation in left upper quadrant without rebound or guarding.

Pertinent Laboratory Data: WBC 7.87, Hgb 13.7, Anion Gap 16.6, Sodium 147, Potassium 4.4, BUN/Cr 19/0.4. COVID positive. Abdominal X-ray: initially read as non-obstructive bowel gas pattern.

Case Discussion: Given the limited history and initial x-ray read, an enema was given without relief in symptoms. An addendum to the abdominal x-ray indicated severe dilation of the stomach containing air-fluid level and possible gastric outlet obstruction. The patient remained hemodynamically stable and continued to mentate well, while a nasogastric tube was inserted by the general surgery team. There was minimal output of clear liquid from the nasogastric tube after 10 minutes and the patient self-removed the tube. CT of the abdomen and pelvis was obtained with findings emergently communicated to the ED reporting tension pneumoperitoneum likely from gastric perforation, with associated compression of aorta, abdominal organs, and bowel with extensive air in the venous system. Upon return from CT, the patient suddenly became hypoxic, cyanotic, and pulseless. Multiple rounds of PALS were initiated with successful needle decompression of the thoracic cavity and return of spontaneous circulation. The patient was emergently taken to the operating room for exploratory laparotomy and decompressive laparotomy. Decompressive laparotomy incision resulted in immediate expulsion of air, with noted large amount of coffee ground gastric contents and gastric perforation.
Abdominal compartment syndrome (ACS) is a rare pediatric surgical emergency that can quickly lead to hemodynamic collapse. There are two types of ACS: primary and secondary. Primary ACS, as seen in this patient, is due to a primary intra-abdominal pathology causing a steep rise in intra-abdominal pressures and thereby significantly decreasing organ perfusion. Secondary ACS is seen in pathologies originating outside of the abdomen but also increasing intra-abdominal pressures thereby causing decreased perfusion. The gastric perforation noted in this case likely introduced large amounts of free air and gastric contents into the abdominal cavity. The resultant sharp increase of intra-abdominal pressure led to compression of the aorta, decreased intra-abdominal organ perfusion, and hemodynamic collapse.

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