Paediatric abdominal compartment syndrome and shock associated with gastric volvulus improved rapidly by gastric suction in the emergency department

Abstract

Abdominal compartment syndrome (ACS) is not rare and has a high mortality in the paediatric intensive care unit. However, there are few reports about this in the emergency department (ED). We report an 8 month-old male patient with ACS in shock associated with gastric volvulus who improved rapidly by a simple procedure in the ED. He had congenital comorbidities, including multiple cranial anomalies and was transferred because of decreased mental status. He had compensated shock with cold and mottled skin of the lower extremities, paediatric Glasgow Coma Scale of E3V5M6 and prominence of the left upper abdomen. The abdominal X-ray showed a considerably distended stomach. Soon after aspiration of gastric contents, shock and mental status improved. Physicians should consider ACS in the differential diagnosis of shock with abdominal distention. ACS may be ameliorated by gastric suction. Gastric volvulus can induce shock and decreased mental status, particularly in patients with comorbidities.

Background

Abdominal compartment syndrome (ACS) in children is defined as a sustained elevation in intra-abdominal pressure (IAP) >10 mm Hg and new or worsening organ dysfunction associated with elevated IAP.¹ Measurement of IAP requires readily available devices, such as a urinary catheter and pressure transducer. Management of ACS includes removal of intra-abdominal contents, improvement of abdominal wall compliance, optimisation of fluid administration, optimisation of perfusion and ultimately, surgical abdominal decompression.

ACS is not rare and has a high mortality in the paediatric intensive care unit; the incidence and mortality rate are 0.6%–4.7% and 16%–86%, respectively.² Although physicians should recognise and intervene rapidly in paediatric ACS cases, previous reports revealed that awareness of it was not sufficient.^{3 4} There are few reports about recognition and intervention for paediatric ACS in the emergency department (ED).

ACS associated with gastric volvulus can lead to death.⁵ However, there are few reports that reveal the association of ACS and gastric volvulus.

We report a child with ACS and shock which might have been associated with gastric volvulus who improved rapidly by a simple procedure in the ED.

Case presentation

An 8 month-old male patient with comorbidities, including multiple cranial anomalies (hypertelorism, saddle nose, forehead creases and cleft lip), laryngomalacia and multicystic dysplastic kidney, was transferred to our hospital because of decreased mental status persisting for about 2 hours. He had been receiving home oxygen therapy on 0.5 L/min of oxygen via nasal cannula. He did not have emesis, diarrhoea, poor enteral feeding or fever. On arrival at the ED, the following data were obtained: body weight, 8 kg; respiratory rate, 27 breaths/min; oxygen saturation, 100% on 1 L/min of oxygen via nasal cannula; heart rate, 114 beats/min; systolic blood pressure, 90 mm Hg; paediatric Glasgow Coma Scale, E3V5M6; axillary temperature, 36.0°C. Physical examination revealed weakly palpable radial arteries, cold and mottled skin of the lower extremities, hypotonia of the extremities and prominence of the left upper abdomen. To prevent vomiting and consequent respiratory distress, we placed a gastric tube and aspirated 120 mL of milk. Point of care ultrasound revealed a left ventricular ejection fraction of 79%, collapse of the inferior vena cava and a large cyst in the left upper abdomen. We assumed that the cause of shock was not cardiogenic. Therefore, we infused isotonic crystalloid in a 20 mL/kg bolus for compensated shock. However, the fluid bolus did not resolve the shock. From the presence of an abdominal cyst, we considered bowel strangulation in the differential diagnosis of the shock and performed an abdominal X-ray about 5 min after the bolus administration. The supine abdominal X-ray showed a considerably distended stomach (figure 1). We aspirated gastric contents via a gastric tube again, which reduced the abdominal prominence (figure 2). Immediately, shock, relative bradycardia, mental status and hypotonia improved. We clinically diagnosed the patient’s condition as ACS associated with gastric volvulus because the abdominal X-ray implied gastric volvulus and the hypoperfusion to the lower extremities was resolved soon after reduction of gastric dilatation. He was admitted to a general ward for close observation.

Figure 1.

Supine abdominal X-ray of an 8-month-old male patient with ACS with shock associated with gastric volvulus before gastric suction.

Figure 2.

Supine abdominal X-ray of the same patient after gastric suction.

On the day of admission, an upper gastrointestinal contrast series showed intestinal malrotation and no findings of gastric volvulus. After admission, feeding did not pass through the stomach. Seven days after admission, another upper gastrointestinal contrast series identified mixed-type gastric volvulus (figure 3), intestinal malrotation and gastro-oesophageal reflux. We refined the diagnosis to acute primary mixed-type gastric volvulus. Thirteen days after admission, we performed laparoscopic gastrostomy, gastropexy and the Ladd procedure.

Figure 3.

Upper gastrointestinal contrast series revealing mixed-type gastric volvulus.

Outcome and follow-up

He was discharged 36 days after admission without sequelae from shock. After hospital discharge, GPC3 gene mutation was detected by a genetic test. He did not have recurrence of gastric volvulus within the 8-month follow-up after hospital discharge.

Discussion

Although paediatric ACS has high mortality, the awareness of it is not sufficient. We should recognise and intervene rapidly in cases of paediatric ACS in the ED.

We encountered an 8-month-old male patient with ACS in shock which might have been associated with gastric volvulus who improved rapidly by a gastric suction procedure in the ED. There are two important clinical issues regarding this patient. First, physicians should consider ACS in the differential diagnosis of shock with abdominal distention. ACS may be treated by a simple procedure, such as gastric suction, in the ED, even before admission to the intensive care unit. Soon after this procedure, our patient recovered from ACS and shock which might have been associated with gastric volvulus, although the shock did not respond to the fluid bolus. We assumed two pathophysiological mechanisms in this patient. One mechanism is that his dilated stomach raised the IAP, resulting in decreasing preload. This led to systemic hypoperfusion, including weakly palpable radial arteries and decreased mental status. Another is that his dilated stomach compressed the descending aorta, resulting in cold and mottled skin of his lower extremities. Although the diagnosis of ACS requires measurement of IAP,² the IAP in this patient was not measured. When physicians clinically suspect ACS and as it requires time and readily available devices to measure IAP, they should not delay intervention for ACS. Rapid intervention may ameliorate ACS, as in this patient, but delayed recognition of ACS associated with gastric volvulus can lead to death.⁵ A previous report showed that ACS associated with gastric dilatation was improved by gastric suction in an adult patient,⁶ although there has apparently been no report concerning a paediatric patient. ACS associated with gastric dilatation may be treated rapidly by gastric suction. Therefore, physicians should consider gastric suction in addition to general resuscitation in children with shock and abdominal distention.

Second, gastric volvulus may be associated with ACS. Physicians should consider gastric volvulus in the differential diagnosis of respiratory distress, shock and decreased mental status, particularly in patients with comorbidities, such as multiple congenital anomalies. This patient had multiple comorbidities and suffered from ACS which might have been associated with gastric volvulus. There are few reports of paediatric ACS due to this.⁵ Besides ACS, gastric volvulus could progress to other critical conditions, including apnoea, cyanosis, respiratory distress and acute epigastric distention.⁷ A previous study reported that the mortality of acute gastric volvulus was 6.7%.⁷ The present patient had decreased mental status. Besides cerebral hypoperfusion from shock, we assumed another pathophysiological mechanism for decreased mental status, which is intestinal hypoperfusion from increased IAP. Although the underlying mechanism is not clear, intestinal hypoperfusion, such as from intussusception and bowel strangulation, can induce decreased mental status.⁸ Sixty-nine per cent of patients with acute gastric volvulus have an associated abnormality.⁷ Therefore, physicians should consider gastric volvulus in the differential diagnosis of respiratory distress, shock and decreased mental status in patients with comorbidities, such as multiple congenital anomalies.

Learning points.

• Physicians should consider abdominal compartment syndrome in the differential diagnosis of shock with abdominal distention.

• Abdominal compartment syndrome may be treated by a simple procedure, such as gastric suction, in the emergency department.

• Gastric volvulus may be associated with abdominal compartment syndrome.

• Physicians should consider gastric volvulus in the differential diagnosis of respiratory distress, shock and decreased mental status, particularly in patients with comorbidities, such as multiple congenital anomalies.