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Critical care board review
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Acute&Abdomen,&Pancrea00s,&&&Abdominal&Compartment&Syndrome&
Ben&deBoisblanc,&MD,&FACP,&FCCP,&FCCM&
LSU&Health&Sciences&Center&
New&Orleans,&LA&!
Disclosures&&No&poten0al&conflicts&of&interest&to&disclose.&
&Objec0ves&&1)&Iden0fy&risk&factors&for&and&management&
of&severe&pancrea00s,&ischemic&coli0s,&acalculous&cholecys00s,&&&C.#difficile#coli0s.&&2)&Recall&diagnos0c&criteria&for&and&
management&of&abdominal&compartment&syndrome.&3)&Differen0ate&bowel&obstruc0on&syndromes.&&
Differen0al&Dx&of&Acute&Abdomen&• Appendici0s&
• PUD&
• Cholecys00s&&
• Pancrea00s&pancrea00s&
• Intes0nal&ischemia&
• DKA&&
• Diver0culi0s&
• Ectopic&
pregnancy&
• Perforated&viscus&
• Ureteral&colic&
• Biliary&colic&
• Volvulus&
• Pyelonephri0s&
• Biliary&colic&
• Adrenal&crisis&
Case&45&y/o&woman&with´&pancrea00s.&Which&of&
following&are&true®arding&nutri0on?&
a. She&should&receive&TPN&un0l&she&has&bowel&sounds&
b. She&should&be&fed&via&PEJ&c. &She&should&be&held&NPO&
un0l&her&pain&resolves&
d. She&should&be&fed&a&low&fat&diet&
e. She&may&be&fed&p.o.&ad&lib&
Case&48&y/o&alcoholic&with&severe&epigastric&pain.&&BP&100/60,&P&138,&Hct&
55%,&lactate&3&mmol,&lipase&1925.&&CT&boggy&pancreas.&Aber&15&L&
of&crystalloid&BP&90/50,&P&135,&Hct&38%,&lactate&4&mmol,&lipase&
1500,&P/F&390,&Pplat&60&with&Vt&500&ml.&The&next&most&
appropriate&step&would&be:&
a. Reduce&VT&b. Transfuse&2&U&PRBC&c. CTA&of&chest&with&PE&protocol&
d. Measure&intravesicular&pressure&
e. Echocardiography&
Predictors&of&Mortality&
• Shock&• ALI&• AKI&• GI&bleeding&• Necrosis/abscess&• APACHE&II&>&8&• CRP&>&6&at&24&hrs&• Stones&• Dynamic&CT&Grade&
Infected&Necro0zing&Pancrea00s&
• Usually&aber&1st&week&• Risk&propor0onal&to&CT&&grade:&&
• A&g&Normal&• B&–&Enlargement&• C&–&Peripancrea0c&
inflamma0on&• D&g&Single&fluid&collec0on&• E&–&Mul0ple&collec0ons&
• Prophylac0c&Abx:&– No&if&A,&B&
– Perhaps&if&&>30%&necrosis&by&
dynamic&CT&
• Imipenem&
Necro0zing&Pancrea00s:&Tx&
• Serial&CT,&US,&or&EUSgaspira0on&for&culture&dx&
– Gg&60%,&G+&50%,&fungi&25%&
• NG&or&NJ&feedings&if&tolerated&
• ERCP&for&stone&
• Surgical&&drainage&for&abscess&
• IR&or&EUS&drainage&if&poor&opera0ve&candidate&
Abdominal&Compartment&Syndrome&• Intragabdominal&HTN&+&
organ&dysfunc0on&
– Renal,&hemodynamic,&splanchnic,&pulmonary,&CNS,&skin&
• Mortality&10g70%&• Risks:&&
– >5&L/24&hr&resuscita0on&– intragabdominal&trauma&– cirrhosis,&pancrea00s,&peritoneal&dialysis,&AAA&
– lower&with&“damage&control&laparotomy”&
ACS:&Dx&• Suspect&in&high&risk&pt&
• Organ&dysfunc0on&+&IAH&&
• Measure&Bladder&pressure&• Normal&<&10&
• Grade&I&=&10g15&• Grade&II&=&16g25&• Grade&III&=&26g35&• Grade&IV&=&>35&
mid+axilla#_____#
ACS:&Tx& • Grade&IIgIII&&– gut&decompression&muscle&relaxants&&&observa0on&
• Grade&IV&
– Surgical&decompression&with&delayed&fascial&closure&
– Monitor&for&hyperkalemia,&lac0c&acidosis&
Case&19&y/o&Type&1&diabe0c&man&with&3&day&hx&N&V&&&epigastric&pain.&&
ABG&pH&7.10,&pCO2&20,&HCO3g&6,&serum&ketones&posi0ve.&&Aber&6&
L&crystalloid,&intravenous&insulin,&&&electrolyte&replacement&pH&
7.35,&pCO2&35,&HCO3g&19,&however&he&con0nues&to&complain&of&
abdominal&pain.&&U/S&of&abdomen&is&ordered.&
Your&next&step&should&be:&
a. ERCP&b. Trial&of&IV&somatosta0n&
c. Surgical&consulta0on&
d. HIDA&scan&e. Observa0on&
Acalculous&Cholecys00s&
• 5g10%&of&all´&cholecys00s&
• Common&to&cri0cal&illness,&HIV,&EBV,&&&TPN&>3&months&&&
• Pathogenesis&– SIRS&+&biliary&stasis&+&increased&lithogenicity&+&ischemia&
• 40g60%&incidence&of&gangrene&&&perfora0on&
Acalculous&Cholecys00s&
• Imaging&CT&&&U/S:&– distension&– thickening&of&wall&– pericholecys0c&fluid&– intramural&gas&– mucosal&sloughing&&&sludging&
• HIDA&scan&NPV<25%&• Tx:&percutaneous&cholecystostomy&or&cholecystectomy&
Case&24&y/0&with&chest&&&abdominal&pain&aber&using&cocaine.&
EKG&shows&anterolateral&ST∆&but&normalizes&over&20&
min.&&His&abdomen&diffusely&tender.&Next&day&he&
passes&small&amount&of&BRB&per&rectum.&&A&
colonoscopy&is&ordered.&&Treatment&might&include:&
a. IV&vasopressin&b. Proton&pump&inhibitor&
c. Oral&vancomycin&
d. Papaverine&e. IV&fluids&&&observa0on&
Mesenteric&Ischemia&
• Severe&pain,&distension,&fecal&occult&blood&
• Splenic&flexure&or&transverse&colon&• E0ology:&– 30%&embolic&(cardiac)&
– 30%&atheromatous&
– 30%&nonocclusive&(shock,&CHF,&hypovolemia,&cocaine,&digitalis,&midodrine)&
– Rarely&mesenteric&vein&thrombosis&(thrombophilia,&portal&HTN,&pancrea00s,&CA)&
Mesenteric&Ischemia&• Dx:&• CTA&~&70%&sensi0ve:&thrombus,&mesenteric&venous&gas,&pneumatosis&intes0nalis,&bowel&thickening/dilata0on,&fat&stranding,&ascites&
• Colonoscopy&• Tx:&Normalize&
circula0on,&papaverine,&embolectomy,&an0coagula0on&
Case&80&y/0&with&progressive&lethargy&over&6&mos&is&admised&to&ICU&for&
respiratory&failure&due&to&CHF.&BP&90/60,&P&38/min&(sinus),&T&
35oC.&LVEF&10%.&His&abdomen&is&distended,&tympanic,&
hypoac0ve&BS,&nongtender.&The&most&appropriate&treatment&for&
this&pa0ent&is:&
a. Egmycin&
b. Milrinone&
c. Enteral&feedings&
d. Neos0gmine&
e. Thyroid&hormone&
Bowel&Obstruc0on&Syndromes&• Arrested&Peristalsis&– Gastroparesis&– Small&bowel&ileus&– Colonic&pseudogobstruc0on&
• Mechanical&obstruc0on&– Adhesions&– Volvulus&– Intussuscep0on&– Tumors&– Fecal&impac0on&
Mechanical&SBO&• Colicky&pain,&copious&vomi0ng,&
abdominal&disten0on,&high&
pitched&BS&&
• Compromise&of&venous&blood&flow&
g&bowel&ischemia&&&necrosis&
• Late&:&silent&abd,&tenderness,&leukocytosis,&hypotension,&
tachycardia&
• Tx:&– 85%&resolve&with&NG&suc0on&,&IVFs&– Early&surgery&for&infarc0on&
Small&Bowel&Ileus&&&Colonic&PseudogObstruc0on&(Ogilvie’s)& • Risk&factors:&
– GI&surgery&– Cri0cal&Illness&– Electrolytes&– Opiates,&an0cholinergics&– Hypothyroidism&– Elderly&&&debilitated&
• Tx:&– NPO?&– Tube&decompression&– Fluids&vs&fluid&restric0on?&– Correct&electrolytes&– Avoid&precipita0ng&drugs&– Egmycin,&neos0gmine,&lactulose&
• PEJ/Cecostomy&for&refractory&cases&
Case&80&y/o&admised&to&ICU&from&rehab&ward.&Previously&healthy,&she&
fell&on&cruise&ship&&&sustained&a&hip&Fx&for&which&she&had&a&THR.&&
5&days&postgop&she&developed&diarrhea&&&abdominal&pain.&&BP&
88/48,&P120,&T38.9oC.&Her&abdomen&is&now&tense,&silent,&&&she&
has&rebound&tenderness.&&Blood&cultures&growing&2&GNRs.&
Possible&Tx&&includes:&
a. IV&vancomycin&
b. Total&colectomy&
c. Soapsuds&enemas&
d. Neos0gmine&
e. Loperamide&
Severe&C.#difficile#Coli0s&
• BI/NAP1,&ribotype&027&– More&virulent,&toxic&megacolon&– Increased&Toxin&A&&&B,&binary&toxin,&more&sporula0on&
– Sep0c&shock,&culture&neg&or&polymicrobial&
– Mortality&~&20%&– Eliza&sensi0vity&75%&
• Risk&factors:&– Epidemics,&age,&PPI,&feeding&tube,&prior&flouroquinolone&
• Tx:&– Oral&vancomycin&preferred?&– Colectomy&&&ileostomy&for&severe&disease&