Elevated Intra-Abdominal Pressure and Organ Failure in Abdominal Lymphoma

Abstract

Introduction: Increased intra-abdominal pressure (IAP) associated with single or multiorgan failure characterizes the abdominal compartment syndrome (ACS), most commonly seen post-operatively or in the setting of massive fluid resuscitation. Malignancy with ascites is a very unusual etiology. To alert clinicians to the spectrum and clinical relevance of this potentially catastrophic disorder, we report the rare association of diffuse abdominal lymphoma complicated by IAP, respiratory failure and sepsis. Case Report: A 71 y.o. woman was admitted with a 1 week history of abdominal discomfort and increasing abdominal girth. Past medical history included atrial fibrillation and type 1 diabetes mellitus. On exam, temp = 98.6F; BP = 141/50. Mild diffuse tenderness without signs of peritoneal irritation was present on abdominal exam. Ascites with shifting dullness was found. Pertinent lab values: Hgb. = 10.4gm% with normochromic, normocytic RBC indices; WBC = 7300; glucose = 135mg%; BUN/creatinine = 36/1.5. Abdominal CT scan:ascites, multiple low intensity soft tissue densities, suspicious for diffuse carcinomatosis of possible ovarian or GI primary site. Ultrasound-guided paracentesis: WBC = 46000 (lymphs = 96%); RBCs = 64 per cubic cm; albumin = 2.7gm%; LDH = 3420 IU; serum albumin-ascites albumin(SAAG) = 0.6. Cytology demonstrated large nucleated, basophilic lymphoid cells with irregular cytoplasm consistent with lymphoma.Over 48 hours, she developed a marked increase in both distention and ascites, then respiratory failure requiring intubation. Indirect measurement of abdominal pressure was done by instilling 50 cc of saline into the urinary bladder with measured pressure elevated at 44 mm Hg (normal to 5, elevated > 20). Her course was complicated by Staph aureus bacteremia, Candidemia and hospital death. Discussion: Current understanding of the contribution of intra-abdominal hypertension and abdominal compartment syndrome to the complex problems of acutely ill medical patients is incomplete, as in our patient. Existing data indicates that IAP developing after ICU admission is a risk factor for multi-organ failure and may contribute to increased morbidity and mortality. Abdominal pressure should be monitored in high-risk patients, including patients such as ours, who have intra-peritoneal malignancy and experience acute deterioration.