Abdominal Compartment Syndrome : Diagnostic and Prognostic Value of CT Findings - a Prospective Study (SCANAPIV)

Abdominal Compartment Syndrome (ACS) is a well known condition occuring in critically ill patients in intensive care units.

This syndrome features a sustained intra abdominal hypertension (IAH) above 20 mmHg and a multiple organ failure due to the raise of the intra abdominal pressure.

Several reviews described CT findings linked to these conditions, but most of them suffer an insufficient statistical method.

Furthermore, the main CT feature described as specific in ACS, Round Belly Sign (RBS), has been highly debated since.

This study is aimed to evaluate, in a prospective way, the diagnostic and prognostic value of CT findings in abdominal hypertension and abdominal compartment syndrome patients hosted in intensive care units, based on previous reviews and adding three new CT features described for the first time.

Study Overview

• Status: Unknown
• Conditions: Intra-Abdominal Hypertension; Abdominal Compartment Syndrome

Detailed Description

Abdominal compartment syndrome (ACS) is a well known condition, occurring in patients hosted in intensive care units and suffering from acute abdominal disease (such as severe acute pancreatitis, trauma, hemoperitoneum, surgery, infectious disease), large volume fluid resuscitation (over 2,5L), and systemic disease such as severe sepsis or major burns.

This syndrome features a sustained intra abdominal hypertension (IAH) above 20 mmHg, measured indirectly by intra-vesical pressure, and a multiple organ failure due to the raise of the intra abdominal pressure.

IAH, which is defined as an abdominal pressure rise above 12 mmHg, does not systematically lead to ACS, and is often successfully cured with medical therapy.

When medial management fails, or ACS is present, surgical management is appropriate and consists in a decompressive laparotomy.

CT examination is not ordered for ACS diagnostic, but radiologists should be aware of this condition and CT findings in patients with IAH, as these critically ill patients are likely to have multiple CT examinations in a diagnostic purpose for the initial condition, its complications or its surveillance.

Several radiological studies have determined CT findings of IAH and ACS. Most of them failed to establish a specific and sensitive semiology of IAH, due to weak methodology (except Al-Bahrani and al.). The diagnostic significance of the "Round Belly Sign" (RBS), first described by Pickhardt and al., has been debated since. None of these studies evaluated the prognostic value of IAH CT findings.

Some of IAH CT findings may have a prognostic value, and being statistically linked to a raised risk of ACS overcome when found in at-risk patients population, with proven IAH.

The aim of this study is to evaluate diagnostic and prognostic value of CT findings in IAH in a prospective way, with a high statistic value.

These CT findings are the ones previously described in previous reviews (round belly sign, narrowing of abdominal veins, elevation of the diaphragm, bilateral inguinal herniation, bowel wall thickening with enhancement, direct visceral compression) and the ones studied here for the first time (increase of the peritoneal/abdominal ratio, semi-lunar line distension, concavity of the upper side of the para renal fascia).

Design:

For each included patient, when an abdominal CT is ordered, an intra-abdominal pressure measure is performed simultaneously to the CT examination. Presence or absence of IAH or ACS is noted.

Two radiologists (one junior and one senior specialized in abdominal emergencies imaging) review the CT examinations and note the presence or absence of the ten CT features studied, without knowing the intra-abdominal pressure value.

Patient follow-up:

• 5 days follow-up
• intra-abdominal pressure measurements
• Incidence of ACS from the time of inclusion to 28 days after.
• Evolution of organ failures
• Vital status at 28 days
• Medical and surgical therapy applied

Analysis:

• Diagnostic value of CT findings in IAH
• Prognostic value of CT findings in IAH, defining CT features statistically linked to ACS overcome, and mortality at 28 days

Prevalence of IAH is expected to be about 40 to 50% in patients in state of shock hosted in ICU. Among them, about 20% are expected to suffer from ACS.

Sensitivity of RBS in IAH is about 80% according to Al-Bahrani and al.. To evaluate the diagnostic value of RBS with (CI = [0,68 - 0,88]), 68 cases of IAH and about 140 patients included are needed.

Based on imaging habits in our center, length of this study is expected to be about 10 months.

• Study Type: Observational
• Enrollment (Anticipated): 140

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Critically ill patients hosted in intensive care units (ICU) in state of shock requiring vasopressive drugs, mechanical ventilation, in which an abdominal CT is ordered and performed with simultaneous intra abdominal pressure measurement.

Description

Inclusion Criteria:

• Critically ill patients requiring ICU hosting
• State of shock requiring vasopressive drugs
• State of shock requiring mechanical ventilation
• Abdominal CT examination ordered
• Intra abdominal pressure measurement

Exclusion Criteria:

• Age under 18 years
• Pregnancy
• Contraindication to urethral catheter
• Decompressive laparotomy before CT examination
• Absolute contraindication to CT enhancement agent
• Cystectomy
• Trusteeship/guardianship

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Intra abdominal hypertension (HIA)	Incidence of intra-abdominal hypertension in patients included, defined by the raise above 12 mmHg of the intra-vesical pressure measured in a standardized way	Within four hours before or after the abdominal CT examination
Round Belly Sign	Increased ratio of anteroposterior/transverse diameter of the abdomen (ratio >0.80), measured at the level where left renal vein crosses the aorta, excluding subcutaneous fat.	At the time of CT examination

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Narrowing of abdomen large veins	Defined as a slit-like appearance of less than 3 mm	At the time of CT examination
Elevation of the diaphragm	Defined as dome of diaphragm reaching the 10th thoracic vertebral body or above	At the time of CT examination
Compression or displacement of solid abdominal viscera	Presence of contour deformity	At the time of CT examination
Bowel wall thickening with contrast enhancement	Defined as a thickness of 3 mm or greater with contrast enhancement	At the time of CT examination
Bilateral inguinal herniation	Bilateral inguinal herniation, if not present on a previous imaging examination	At the time of CT examination
Increase of the peritoneal/abdominal ratio	Increase of the peritoneal/abdominal height ratio (ratio > 0,5). Peritoneal compartment height is measured from posterior third duodenum wall on the median line to the abdominal anterior wall. Abdominal compartment height is measured at the same level, excluding subcutaneous fat.	At the time of CT examination
Semi lunar line distension	The longer length between transverse abdominis muscle and rectus abdominis muscle in millimeter	At the time of CT examination
Concavity of the upper side of the para renal fascia	Concave deformity of the upper side of the para renal fascia, with or without renal deformity or displacement	At the time of CT examination
Abdominal Compartment Syndrome (ACS)	Incidence of ACS in included patients, defined by a sustained intra abdominal hypertension above 20 mmHg and a multiple organ failure due to the raise of the intra abdominal pressure	From the time of inclusion to 28 days after

Collaborators and Investigators

• Sponsor: Centre Hospitalier Universitaire de Besançon

Publications and helpful links

General Publications

• Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K, Johansson K, Kolkman K, Wilmer A. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. Intensive Care Med. 2006 Nov;32(11):1722-32. doi: 10.1007/s00134-006-0349-5. Epub 2006 Sep 12.
• Luckianow GM, Ellis M, Governale D, Kaplan LJ. Abdominal compartment syndrome: risk factors, diagnosis, and current therapy. Crit Care Res Pract. 2012;2012:908169. doi: 10.1155/2012/908169. Epub 2012 Jun 7.
• Malbrain ML, De Keulenaer BL, Oda J, De Laet I, De Waele JJ, Roberts DJ, Kirkpatrick AW, Kimball E, Ivatury R. Intra-abdominal hypertension and abdominal compartment syndrome in burns, obesity, pregnancy, and general medicine. Anaesthesiol Intensive Ther. 2015;47(3):228-40. doi: 10.5603/AIT.a2015.0021. Epub 2015 May 14.
• Patel A, Lall CG, Jennings SG, Sandrasegaran K. Abdominal compartment syndrome. AJR Am J Roentgenol. 2007 Nov;189(5):1037-43. doi: 10.2214/AJR.07.2092.
• Epelman M, Soudack M, Engel A, Halberthal M, Beck R. Abdominal compartment syndrome in children: CT findings. Pediatr Radiol. 2002 May;32(5):319-22. doi: 10.1007/s00247-001-0569-3. Epub 2002 Feb 15.
• Al-Bahrani AZ, Abid GH, Sahgal E, O'shea S, Lee S, Ammori BJ. A prospective evaluation of CT features predictive of intra-abdominal hypertension and abdominal compartment syndrome in critically ill surgical patients. Clin Radiol. 2007 Jul;62(7):676-82. doi: 10.1016/j.crad.2006.11.006. Epub 2007 May 2.
• Malbrain ML, Chiumello D, Cesana BM, Reintam Blaser A, Starkopf J, Sugrue M, Pelosi P, Severgnini P, Hernandez G, Brienza N, Kirkpatrick AW, Schachtrupp A, Kempchen J, Estenssoro E, Vidal MG, De Laet I, De Keulenaer BL; WAKE-Up! Investigators. A systematic review and individual patient data meta-analysis on intra-abdominal hypertension in critically ill patients: the wake-up project. World initiative on Abdominal Hypertension Epidemiology, a Unifying Project (WAKE-Up!). Minerva Anestesiol. 2014 Mar;80(3):293-306. Epub 2013 Dec 12.
• Atema JJ, van Buijtenen JM, Lamme B, Boermeester MA. Clinical studies on intra-abdominal hypertension and abdominal compartment syndrome. J Trauma Acute Care Surg. 2014 Jan;76(1):234-40. doi: 10.1097/TA.0b013e3182a85f59. No abstract available.
• Wu J, Zhu Q, Zhu W, Chen W, Wang S. [Computed tomographic features of abdominal compartment syndrome complicated by severe acute pancreatitis]. Zhonghua Yi Xue Za Zhi. 2014 Nov 25;94(43):3378-81. Chinese.
• Iyer D, Rastogi P, Aneman A, D'Amours S. Early screening to identify patients at risk of developing intra-abdominal hypertension and abdominal compartment syndrome. Acta Anaesthesiol Scand. 2014 Nov;58(10):1267-75. doi: 10.1111/aas.12409.
• De Waele JJ, Ejike JC, Leppaniemi A, De Keulenaer BL, De Laet I, Kirkpatrick AW, Roberts DJ, Kimball E, Ivatury R, Malbrain ML. Intra-abdominal hypertension and abdominal compartment syndrome in pancreatitis, paediatrics, and trauma. Anaesthesiol Intensive Ther. 2015;47(3):219-27. doi: 10.5603/AIT.a2015.0027. Epub 2015 May 14.
• Wachsberg RH, Sebastiano LL, Levine CD. Narrowing of the upper abdominal inferior vena cava in patients with elevated intraabdominal pressure. Abdom Imaging. 1998 Jan-Feb;23(1):99-102. doi: 10.1007/s002619900295.
• Hong JJ, Cohn SM, Perez JM, Dolich MO, Brown M, McKenney MG. Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg. 2002 May;89(5):591-6. doi: 10.1046/j.1365-2168.2002.02072.x.
• Holodinsky JK, Roberts DJ, Ball CG, Blaser AR, Starkopf J, Zygun DA, Stelfox HT, Malbrain ML, Jaeschke RC, Kirkpatrick AW. Risk factors for intra-abdominal hypertension and abdominal compartment syndrome among adult intensive care unit patients: a systematic review and meta-analysis. Crit Care. 2013 Oct 21;17(5):R249. doi: 10.1186/cc13075.

Study record dates

Study Major Dates

• Study Start: July 1, 2016
• Primary Completion (Anticipated): July 1, 2016
• Study Completion (Anticipated): July 1, 2017

Study Registration Dates

• First Submitted: June 16, 2016
• First Submitted That Met QC Criteria: June 23, 2016
• First Posted (Estimate): June 28, 2016

Study Record Updates

• Last Update Posted (Estimate): July 21, 2016
• Last Update Submitted That Met QC Criteria: July 20, 2016
• Last Verified: July 1, 2016

More Information

Terms related to this study

• Keywords: Radiology; Intensive Care; Abdominal Compartment Syndrome; Intra-Abdominal Hypertension; Round Belly Sign; CT findings
• Additional Relevant MeSH Terms: Pathologic Processes; Cardiovascular Diseases; Vascular Diseases; Disease; Musculoskeletal Diseases; Muscular Diseases; Hypertension; Syndrome; Compartment Syndromes; Intra-Abdominal Hypertension
• Other Study ID Numbers: P/2016/298

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No