Intra-Abdominal Pressure in the Early Phase of Severe Acute Pancreatitis: Canary in a Coal Mine? Results from a Rigorous Validation Protocol

BACKGROUND/AIMS: Intra-abdominal hypertension (IAH) is being increasingly reported in patients with severe acute pancreatitis (SAP) with worsened outcomes. The present study was undertaken to evaluate intra-abdominal pressure (IAP) as a marker of severity in the entire spectrum of acute pancreatitis and to ascertain the relationship between IAP and development of complications in patients with SAP. METHODS: IAP was measured via the transvesical route by measurements performed at admission, once after controlling pain and then every 4 hours. Data were collected on the length of the hospital stay, the development of systemic inflammatory response syndrome (SIRS), multiorgan failure, the extent of necrosis, the presence of infection, pleural effusion, and mortality. RESULTS: In total, 40 patients were enrolled and followed up for 30 days. The development of IAH was exclusively associated with SAP with an APACHE II score > or =8 and/or persistent SIRS, identifying all patients who were going to develop abdominal compartment syndrome (ACS). The presence of ACS was associated with a significantly increased extent of pancreatic necrosis, multiple organ failure, and mortality. The mean admission IAP value did not differ significantly from the value obtained after pain control or the maximum IAP measured in the first 5 days. CONCLUSIONS: IAH is reliable marker of severe disease, and patients who manifest organ failure, persistent SIRS, or an Acute Physiology and Chronic health Evaluation II score > or =8 should be offered IAP surveillance. Severe pancreatitis is not a homogenous entity.

Diagnostic Dilemma in an Unusual Case of Common Bile Duct Obstruction

Biliary obstructions are rarely caused by a foreign body and have received sparse attention. We present an unusual case with pruritis and abdominal pain caused by impacted full length surgical gauze within the common bile duct. The patient had previously undergone an open cholecystectomy. Radiological investigations were inconclusive and suggestive of either a calculus or a cholangiocarcinoma. Surgical exploration revealed full length surgical gauze within the common bile duct. Because imaging modalities are often non-determinant, the possibility of biliary tract obstruction from a foreign body should be borne in mind for patients with unusual presentations, especially those who have previously undergone surgery.