Post-ercp severe necrotizing pancreatitis with abdominal compartment syndrome: a series of unfortunate events, a case report

SESSION TITLE: Critical Care Case Report Posters 73 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Abdominal compartment syndrome (ACS) is defined as a sustained intra-abdominal pressure > 20 mmHg which is associated with new-onset organ failure. ACS can occur in 15% of patients with severe acute necrotizing pancreatitis, increasing the mortality rate. ACS carries a poor prognosis for such patients and is often missed in critically ill patients. Treatment is generally supportive, and decompressive laparotomy should be utilized promptly in select cases to prevent further decompensation. CASE PRESENTATION: An 83-year-old male with hypertension and hyperlipidemia presented to the emergency department with sudden-onset severe post-prandial abdominal pain associated with diaphoresis and bloating. Vitals were within normal limits, and laboratory workup was only significant for AST 181, and ALT 83. Ultrasound, CT abdomen, and pelvis, and eventually MRCP showed marked distention of the gallbladder, intrahepatic, common bile duct (Figure-A), and proximal pancreatic duct (Figure-B). The patient was admitted for symptomatic management. On the 3rd day of admission general surgery and gastroenterology were consulted given the worsening abdominal pain. The patient underwent ERCP the next day given biliary tree dilation on imaging, which revealed dilated pancreatic duct with an abrupt cutoff and unsuccessful cannulation of the bile duct. Overnight, the patient developed acute abdominal pain, not well controlled with IV pain medication. Labs were significant for elevated AST 69, ALT 141, and Lipase 6558. He was started on medical management of acute pancreatitis with IV fluids and supportive care. During the next 24 hours, the patient's condition deteriorated; he became altered, and later hypotensive and in respiratory distress requiring oxygen. He eventually required intubation and vasopressor support. The patient's abdomen was very distended despite orogastric decompression. He was paralyzed and intra-abdominal pressure (trans-bladder) was measured at 18 mmHg. Over the course of the day, his ventilator settings increased to FiO2 100%, PEEP 12 alongside his vasopressor requirements, and decreased his urine output. Trans-bladder pressure increased to 22mmHg. Given concerns for abdominal compartment syndrome (ACS), the patient underwent bedside decompressive laparotomy, which showed a large amount of bilious ascites, dusky small bowel and colon, severely edematous retroperitoneum, and friable and necrotic pancreas. His abdomen was temporarily closed until his hemodynamics stabilized. The patient's pressors requirement continued to increase during the following 12 hours, and after a discussion with the family, they elected to go for comfort-oriented care. The patient passed on the 6th day of admission. DISCUSSION: Severe acute necrotizing pancreatitis has been observed to result in persistent organ failure, including acute respiratory distress syndrome (ARDS), acute kidney failure, and abdominal compartment syndrome (ACS). The early diagnosis and management of these complications are of critical importance to improve patient outcomes. In this case, we have highlighted the significance of timely identification and management of ACS, however unfortunately our patient did not survive. CONCLUSIONS: In conclusion, acute severe pancreatitis can have severe consequences, such as abdominal compartment syndrome (ACS), that can significantly impact patient outcomes. However, early and serial intra-abdominal pressure monitoring is crucial in identifying and managing ACS in critically ill patients. REFERENCE #1: van Brunschot S, Schut AJ, Bouwense SA, et al. Abdominal compartment syndrome in acute pancreatitis: a systematic review. Pancreas. 2014;43(5):665-674. doi:10.1097/MPA.0000000000000108 REFERENCE #2: Jaipuria J, Bhandari V, Chawla AS, Singh M. Intra-abdominal pressure: Time ripe to revise management guidelines of acute pancreatitis?. World J Gastrointest Pathophysiol. 2016;7(1):186-198. doi:10.4291/wjgp.v7.i1.186 REFERENCE #3: Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013;39(7):1190-1206. doi:10.1007/s00134-013-2906-z DISCLOSURES: No relevant relationships by Iuliia Kovalenko No relevant relationships by Navitha Ramesh No relevant relationships by Seema Sharma Gautam No relevant relationships by Bosky Soni No relevant relationships by Nima Zarandi