ACS exists when Intra-abdominal Hypertension(IAH) is associated with clinically observed organ dysfunction. ACS adversely affects multiple organ systems. Normal Intraabdominal pressure(IAP) is atmospheric or subatmospheric. Subclincial organ effects progress to overt clinically manifest organ dysfunction beginning with IAH > 10 mm Hg. Pre-renal effects and Direct Renal Parencymal compression are the mechanism of renal failure. Direct ureteral compression is not implicated in renal dysfunction even with IAP∼40mm Hg.(5) Lovenox(LMWH) is infrequently reported (<1%) to cause spontaneous retroperitoneal bleeding and rarely caused ACS(3).
49 year old female with Refractory Stage IV Large B-cell Non-Hodgkin’s Lymphoma(NHL), DVT in left lower extremity 2 months ago and receiving Lovenox 80 mg SQ BID developed increasing abdominal pain with wall distension and hematoma over a day. The patient developed progressive hypotension, syncope and decreased urine output, progressing from oliguria to anuria. Bladder pressure measured in the supine position via the Foley’s cathether revealed a pressure of 24 mm Hg. Pertinent Physical : T 98, BP 90/50 on Levophed, RR 20, HR 115 Abdomen Anterior abdominal wall distension, Ecchymosis and tenderness over both the lower quadrants, hard to palpation Rectal Exam : Guaic Negative Brown Stools Ext : cool Labs : ( change over 24-48 hours) Hb : decreased from 10 to 6.7 Cr increased from 0.6 to 1.7 PT: 17 INR 1.6 PTT 31 Pan-cultures : Negative CT Abdomen and Pelvis : 09/16/03 : Large organizing hematoma 15 x 15 x 13 cm extending in the anterior abdomen upto the level of umbilicus. Compression of the bladder and ureters bilaterally with hydronephrosis 09/19/03 : Increase in size; Resolution of the previously seen bilateral hydronephrosis after ureteral stents. Day # 1 : Anuria despite aggressive crystalloid resuscitation. Cytoscopy and Retrograde Pyleogram reveals Bilateral Hydronephosis. Bilateral Ureteral Stenting performed. Day 2 & 3 : Oliguria Day 4 and 5 : UO increases by 1000 cc/day.
Incremental reductions in GFR and renal plasma flow are observed with graded elevations in the IAP. Oliguria at IAP of 15 mm Hg progressing to Anuria at IAP > 30 mm Hg has been reported. Direct ureteral compression does not seem to play a significant role. In animal models, where IAH was induced by implating inflatable bags in the peritoneum, ureteral stents had no impact on renal function and excretory urograms have shown no obstruction(5). Neurogenic Bladder, Bladder Trauma or Compression from a pelvic hematoma may yield inaccurate bladder estimates of the IAP. The bladder pressure in this case may inaccurately overestimate the true IAP from direct bladder compression by the overlying pelvic hematoma. In such settings, other indirect, albeit less preferred methods of IAP measurement via the nasogastric tube may be more accurately reflective of the true IAP. Hydronephrosis has not been reported to occur alongwith ACS. This patient’s de novo hydronephrosis is attributable from direct compression of the bladder and both the ureters. Hydronephrosis can co-exist with ACS; and does not imply a cause-effect relation to the IAP. Unlike the animal models with uniform elevation of the IAP, the obstrutive uropathy here is caused by the predominant pelvic component of retroperitoneal bleeding.
ACS can occur as a complication of abdominal bleeding with LMWH. Retroperitoneal bleeding with a predominant pelvic component can cause hydronephrosis and can co-exist with IAH/ACS. Ureteral stents in this subset of patients with ACS with hydronephrosis may improve the renal dysfunction.
S.J. Hansalia, None.