Case Report

Perforated peptic ulcer associated with Abdominal compartment syndrome

Abstract

Abdominal compartment syndrome (ACS) is defined as an increased intra-abdominal pressure with adverse Physiologic consequences. Abdominal compartment syndrome caused by perforated peptic ulcer is rare owing to early diagnosis and management. Delayed recognition of perforated peptic ulcer with pneumoperitoneum, bowel distension, and decreased abdominal wall compliance can make up a vicious circle and lead to ACS. We report a case of perforated peptic ulcer associated with ACS. A 74-year-old man with old stroke and dementia history was found to have distended abdomen, edema of bilateral legs, and cyanosis. Laboratory tests revealed deterioration of liver and kidney function. Abdom- inal compartment syndrome was suspected, and image study was arranged to find the cause. The study showed pneumo- peritoneum, contrast stasis in heart with decreased caliber of vessels below the abdominal aortic level, and diffuse lymphedema at the abdominal walls. Emergent laparotomy was performed. Perforated peptic ulcer was noted and the gastrorrhaphy was done. The symptoms, and liver and kidney function improved right after emergent operation.

Compartment syndrome is defined as an elevation of the pressure in a closed space with compromised circulation and ischemic tissue damage. The damage starts from the distal part of the tissue and with low oxygen tolerance. The abdomen is a closed space bound by the relatively nonexpansible fascia of abdominal musculature and is susceptible to cause compart- ment syndrome. Abdominal compartment syndrome (ACS) is thus characterized by an increase of intra-abdominal pressure leading to several adverse physiologic consequences [1,2]. Abdominal compartment syndrome caused by perforated peptic ulcer is rare owing to early diagnosis and management. Delayed recognition of a perforated peptic ulcer with pneumoperitoneum, bowel distension, and decreased abdom- inal compliance led to ACS. We report a case of perforated peptic ulcer associated with acute ACS.

A 74-year-old man presented to our emergency department with edema of bilateral legs and cyanosis for 1 day. He had medical history of senile dementia, chronic obstructive lung

disease, and old stroke with the sequela of right hemiplegia. He had been bed-ridden in a nursing home for many years. According to his caregiver, he complained of chest and abdominal discomfort in recent days. Progressive abdominal distension, poor oral intake, decreased stool passage, and urine output were also mentioned. He was then brought to our hospital. On the arrival, he was alert and afebrile but with low blood pressure (95/73 mm Hg). Physical examinations disclosed edematous and distended abdomen with muscle guarding (Fig. 1). Both legs were cold, edematous, and cyanotic (Fig. 2). The patient had no associated dyspnea, orthopnea, vomiting, or diarrhea. Complete blood count showed normal amount of white blood cells (8800/uL) with predominant neutrophils (89%). Other blood tests revealed an aspartate aminotransferase level of 1214 U/L, an alanine aminotransferase level of 1377 U/L, a blood urine nitrogen level of 92 mg/dL, and a creatinine level of 2.7 mg/dL. The chest-abdomen computed tomography (CT) scan was soon arranged to rule out abdominal great vascular insults. The images of CT scan revealed pneumoperitoneum, contrast stasis in heart with decreased caliber of vessels below the abdominal aortic level, and diffuse lymph edema at the abdominal walls and gluteal region (Fig. 3). hollow organ perforation with ACS was suspected. The patient collapsed immediately after CT scan. Cardiopulmonary cerebral resuscitation was applied. Return of spontaneous circulation

Fig. 1 The abdomen is edematous and distended.

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Fig. 2 Cold bilateral legs with cyanotic change and nonPitting edema.

was achieved and emergent laparotomy was performed. A 0.6-cm perforation at prepyloric area was found and gastrorrhaphy was done. The patient’s condition improved with recovery from cyanotic toes and normalized liver and kidney function after surgery. Further peripheral vascular Duplex test showed normal result. The patient was transferred to the respiratory care ward 1 month later.

Intra-abdominal hypertension can occur in ileus, abdom- inal tumors, intra-Abdominal hemorrhage, and in some morbid conditions such as obesity, hepatic cirrhosis with ascites, pregnancy, trauma, massive fluid resuscitation, pancreatitis, and pneumoperitoneum [1,3]. Abdominal compartment syndrome is defined as an intra-abdominal pressure higher than 20 mm Hg measured indirectly via the urinary bladder using Foley catheter with evidence of Multiple organ dysfunction [4]. The findings of a tensely distended abdomen, progressive oliguria despite adequate cardiac output, or hypoxia with increasing airway pressure are sufficient to justify abdominal decompression [5]. Abdominal compartment syndrome affects mainly the respiratory, cardiovascular, renal, gastrointestinal, and cen-

tral nervous systems [6]. It will result in hemodynamic change related to compromised venous return and increased arterial resistance [2]. Because of its high mortality, emergent decompression should be considered [7].

Abdominal compartment syndrome caused by perforated peptic ulcer is rare owing to early diagnosis and management. In our case, the patient could not express his discomfort well due to the dementia and the sequelae of old stroke, which delayed his visiting. The perforated peptic ulcer resulted in pneumoperitoneum and bowel distension. The progressive elevation of intra-abdominal pressure with blockage of lymph and venous return then caused diffuse lymph edema of abdominal walls. Decreased abdominal compliance due to edema made the intra-abdominal pressure to elevate even more rapidly as a vicious cycle, which eventually led to ACS. Elevated intra-abdominal pressure with abdominal tampo- nade compromised the blood circulation with initial pre- sentations of distended abdomen, edema of the lower legs, and cyanosis and deterioration of function of the intra- abdominal organs. Emergent laparotomy was indicated to break down the vicious cycle, release the pressure, and repair the perforated bowel. The symptoms, and liver and kidney function improved right after emergent operation, which further confirmed our diagnosis.

This case reminds us of the clinical presentations of ACS and its rare cause.

Jiun-Jen Lynn MD Yi-Ming Weng MD

Department of Emergency Medicine Chang Gung Memorial Hospital Taoyuan Hsien, Taiwan 333, ROC

E-mail address: [email protected]

Chia-sui Weng MD

Department of Obstetrics and Gynecology

Mackay Memorial Hospital Taipei, Taiwan 333, ROC

doi:10.1016/j.ajem.2008.03.047

Fig. 3 The abdominal CT scan showing pneumoperitoneum, decreased caliber of vessels below the abdominal aortic level, and diffuse lymph edema at the abdominal walls.

Case Report

References

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