Tisherman – Abdominal Catastrophes in the ICU

[x_text]Master teacher & master clinician Dr. Sam Tisherman is back to discuss abdominal disasters that can present in the ICU. This is a great case-based discussion of a few of the can’t miss diagnoses that can quickly cause your patient to crash and burn.[/x_text]

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Clinical Pearls

1. Peritoneal signs: In the critically ill patient: Stop pressing and shake the bed. If the patient grimaces with simple motion – there’s something bad going on.
2. Rigler’s sign: Visualization of free intraperitoneal air on a supine film, where air is present on both the intra- & extra-luminal surfaces of the bowel.
3. In the critically-ill, ICU patient, always include ischemic bowel, perforation, c. diff colitis, and acalculous cholecystitis in your differential of the acute abdomen. Remember – ileus and intra-abdominal abscesses are signs of another process, and not a true diagnosis!
4. Mild amylase/lipase elevations can often be seen in mesenteric ischemia & bowel perforations.
5. Acalculous Cholecystitis: Caused by low blood flow to the gallbladder during a low flow state. Start with ultrasound, but if inconclusive – get the HIDA scan!
6. Remember recent procedures and clinical change in proximity to abdominal procedures.
7. For the septic shock patient with a surgical source – rule of thumb is aggressive resuscitation first, then definitive management. Pre-operative management & optimization his one of the most important steps in preventing peri-anesthetic arrest.
8. Surgical drains: If a drain stops, either there’s nothing left to drain or the drain ain’t working.
9. For the critically ill patient with c. diff – get your surgeon involved early. There are new surgical techniques that can dramatically decrease mortality.
10. Diverting loop ileostomy & colonic lavage. Significantly reduced  mortality with preservation of the colon. [Neal MD, Alverdy JC et al, 2011]

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[x_text]Suggested Reading

1. Sise MJ. Acute mesenteric ischemia. Surg Clin North Am. 2014;94(1):165-81. [PubMed Link]
2. Carr JA. Abdominal compartment syndrome: a decade of progress. J Am Coll Surg. 2013;216(1):135-46. [PubMed Link]
3. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2):133-64. [PubMed Link]

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