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KEY POINTS
Causes of acute abdominal pathology in the intensive care unit (ICU) patient include acute acalculous cholecystitis (AAC), severe acute pancreatitis, feeding intolerance, paralytic ileus and diarrhea, and abdominal compartment syndrome (ACS).
An emergent bedside laparotomy may be indicated for patients with a high suspicion for intra-abdominal pathology; however, this is a high-risk procedure, requires substantial resources to be mobilized, and has a risk of mortality.
Modern management of pancreatic necrosis and infected necrosis, known as the “step-up” approach, consists of initial medical management with fluid resuscitation and antibiotic administration, followed by percutaneous catheters for drainage of infected fluid.
Feeding intolerance in the critically ill patient can be attributable to the patient's critical illness, medications, intra-abdominal pathology, or underlying disease.
Treatment and management of ACS consists of serial monitoring of intra-abdominal pressures (IAP); optimization of systemic perfusion and organ function in the presence of intra-abdominal hypertension (IAH); institution of medical procedures to decrease IAP and reduce end-organ dysfunction; and prompt surgical decompression for refractory IAH or ACS.
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Critically ill patients are susceptible to a variety of causes and manifestations of abdominal dysfunction. However, the diagnosis and treatment of these conditions can be challenging secondary to nonspecific clinical findings, concurrent complex disease processes, and altered mental status. The purpose of this chapter is to discuss select causes of abdominal dysfunction in the critically ill patient, including evaluation for acute abdominal pathology in the critically ill patient, AAC, severe acute pancreatitis, feeding intolerance, paralytic ileus and diarrhea, ACS, and care of the long-term open abdomen.
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Evaluation for Acute Abdominal Pathology in the Intensive Care Unit
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Critically ill patients are susceptible to acute abdominal pathology, including bowel perforation, biliary tract disease, pancreatitis, ischemia, and hemorrhage. Acute abdominal pathology may be the patient's initial insult, or the patient may develop abdominal dysfunction as a complication of critical illness. Patients with recent surgery may manifest intra-abdominal complications such as anastomotic leak or abscess, or may develop iatrogenic abdominal complications such as bowel perforation from paracentesis, or pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). Critically ill patients may pose a diagnostic dilemma, as some patients may be challenging to evaluate due to concomitant critical illness; even patients with evaluable mental status may have unreliable clinical examinations. Steroid use and immunosuppression may blunt a patient's clinical examination even in the presence of an intra-abdominal catastrophe. Evaluation of the patient with suspicion for acute abdominal pathology should occur expeditiously; failure to consider the abdomen as a potential source of sepsis or hemorrhage can lead to missed diagnoses and poor outcomes.
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Although physical examination findings in this population can be nonspecific, patients with unexplained sepsis or abdominal pain (if they can communicate same) should undergo a thorough physical examination to evaluate for abdominal distension, tenderness, and inspection of all wounds and incisions. Laboratory findings will be nonspecific as well, but may provide ...