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KEY POINTS

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  • The acute abdomen presents in unusual ways in the intensive care unit (ICU).

  • Successful management depends on prompt diagnosis and management; the intensivist, surgeon, gastroenterologist, and radiologist must collaborate effectively.

  • Computed tomography (CT) and ultrasonography should be used liberally to evaluate abdominal conditions.

  • Complications occur frequently in the postsurgical ICU patient; “stable vital signs” does not imply clinical stability.

  • Postoperative residual or recurrent intra-abdominal sepsis may not be obvious clinically or radiographically; cardiorespiratory or other organ dysfunction should prompt a search for the source that will require resuscitation, antibiotics, and source control

  • The treatment of the febrile postsurgical patient is not simply the administration of antibiotics.

  • Acalculous cholecystitis is a treacherous disease that requires urgent treatment; definitive diagnosis is not always possible or necessary before treatment.

  • Abdominal wall tissue loss or tension may preclude fascial closure at laparotomy. ICU staff must understand and manage postoperatively techniques to protect intestinal integrity and cardiopulmonary function, such as temporary closure and vacuum dressings.

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Patients with an “acute abdomen” present challenging problems for surgeons and intensivists. The term acute abdomen refers to a patient whose chief presenting symptom is the acute onset of abdominal pain. The majority of these patients present in the emergency department and need operation but do not require treatment in an ICU. However, the small percentage of patients who require ICU admission constitute a significant fraction of the surgical ICU patients in most general hospitals. Furthermore, the intensivist must be aware that an ICU patient may develop an acute abdominal emergency while being treated for another condition.

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In this chapter, we will first discuss the approach to the ICU patient who develops abdominal pain while undergoing treatment for some other disorder. The bulk of the chapter, however, will be directed to the patient with known intra-abdominal sepsis (IAS) who requires intensive care. Emphasis will be placed on the early diagnosis of intra-abdominal septic complications.

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EVALUATION OF ACUTE ABDOMINAL PAIN IN THE INTENSIVE CARE UNIT PATIENT

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The diagnosis of abdominal pain depends heavily on an accurate history and a complete physical examination.1 Both of these sources of data may be severely limited in the ICU patient. History may be unobtainable because of intubation or a decreased level of consciousness. Physical examination is made difficult by cannulas and dressings, and compromised further by the effects of medications such as analgesics and corticosteroids. Abdominal pain itself may be masked by narcotics or other painful disease processes. Some physical signs, such as the absence of bowel sounds, which would be considered significant in an otherwise well patient, may not be significant in an ICU patient, in whom multiple extra-abdominal causes of ileus may be present. Hence, in the ICU setting, it is rare that an abdominal complaint comes to light because the patient complains of abdominal pain; rather, the physician usually must infer its presence on the basis of nonspecific findings ...

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