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Hôpital Lapeyronie 34295 Montpellier, Cedex 5, France
Abdominal compartment syndrome is a life-threatening condition resulting from abnormal elevation of intraabdominal pressure [1, 2]. Although well known by surgeons and intensive care physicians, it is often unfamiliar to radiologists. Its appearances on CT have been reported in only one report; Pickhardt et al. [3] described an increased ratio of anteroposterior-to-transverse abdominal diameter with a cutoff value superior to 1:0.80 accurate to diagnose an abdominal compartment syndrome. We report an abdominal compartment syndrome complicating a liver trauma with an abrupt increase of the ratio of anteroposterior-to-transverse abdominal diameter.
A 15-year-old boy was admitted for trauma with a liver fracture and a biliary fistula treated by a surgical peritoneal drainage without liver resection. The recovery was unremarkable, but 3 weeks after the hospitalization, the patient presented with sudden right abdominal pain, tachycardia, and marked hypotension. Laboratory findings revealed a fall of hemoglobin from 8.2 to 4.4 g/dL. CT (Fig. 4A) showed hemoperitoneum and active extravasation due to a hepatic arterial lesion confirmed by angiography and treated by selective embolization with resorbable particles and coils. At this time, the ratio of anteroposterior-to-transverse diameter was equal to 1:0.64. Although hemodynamic parameters including cardiac frequency, arterial pressure, and hemoglobin were normalized, after embolization, the patient treated with mechanical ventilation developed progressive anuria and increased airway pressure. A CT scan performed 48 hr after the embolization (Fig. 4B) did not show any increase of the hemoperitoneum but revealed a rounded appearance of the belly with the ratio of anteroposterior-to-transverse diameter increased to 1:0.76. The measurement of intravesical pressure at 20 cm H2O confirmed the diagnosis of abdominal compartment syndrome. A decompressive laparotomy permitted a rapid response with prompt diuresis and decreased peak airway pressures.
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Abdominal compartment syndrome is theoretically diagnosed clinically. However, in an intensive care unit population, other conditions may affect pulmonary, renal, or cardiovascular systems. CT, by showing a positive "round belly" sign with a ratio of anteroposterior-to-transverse diameter superior to 1:0.80, could be a useful finding both sensitive and specific for abdominal compartment syndrome [3]. However, as noted by Zissin [4], peritoneal diseases, acute pancreatitis, large amounts of ascites, or bowel obstruction may increase this ratio, without abdominal compartment syndrome. Additionally, our patient shows that abdominal compartment syndrome may be present with a ratio of anteroposterior-to-transverse diameter inferior to 1:0.80. More than an absolute value for this ratio, the occurrence of an acute increase, without any explanation for it such as the development of ascites or a bowel obstruction, may give additional support for the diagnosis of abdominal compartment syndrome.
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  A. Patel, C. G. Lall, S. G. Jennings, and K. Sandrasegaran Abdominal Compartment Syndrome Am. J. Roentgenol., November 1, 2007; 189(5): 1037 - 1043. [Abstract] [Full Text] [PDF]
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