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  • Abdominal pathology presents in unusual ways in the intensive care unit (ICU).

  • Prompt diagnosis requires frequent physical exam and attention to subtle changes in patient status.

  • Optimal investigation and management depend on close collaboration between the intensivist, surgeon, gastroenterologist, and radiologist.

  • Computed tomography (CT) and ultrasonography should be used liberally to evaluate abdominal conditions in accordance with the expected differential diagnosis.

  • Operative, interventional radiological, or endoscopic treatment may be appropriate depending on the pathology encountered and the severity of critical illness.

  • Complications occur frequently in the postsurgical ICU patient; clinical status, wound characteristics, and drain output can be helpful diagnostic adjuncts.

  • Postoperative residual or recurrent intra-abdominal sepsis may not be obvious clinically or radiographically; cardiorespiratory or other organ dysfunction may be the first signs of abdominal pathology.

  • The treatment of the febrile postsurgical patient is not simply the administration of antibiotics; a source of sepsis must be sought and removed if present.

  • Acalculous cholecystitis is a treacherous disease that requires urgent treatment; definitive diagnosis is not always possible or necessary before treatment.

  • Technical restraints or abdominal pathology may preclude fascial closure at laparotomy, and the intensivist must be capable of managing temporary abdominal closure and vacuum-assisted abdominal closure devices.


The acute abdomen is often a source of confusion as it describes a clinical presentation with a wide breadth of possible etiologies, required treatments, and outcomes. We will seek to clarify this terminology and provide an approach and understanding to the related problems suitable for intensive care physicians of all backgrounds. The term acute abdomen refers specifically to the acute onset of severe abdominal pain, often associated with related clinical findings such as peritonitis on physical exam, and in most cases arising from an underlying diagnosis requiring emergent surgical, radiological, or endoscopic management.1

Peritonitis describes a constellation of clinical findings indicating severe inflammation of the peritoneum lining the abdominal cavity.1 The chief physical findings of peritonitis are severe abdominal tenderness, rigidity secondary to spastic contraction of the abdominal musculature, rebound tenderness, and guarding. Although physical examination and the identification of any or all of these findings is crucial in the assessment of patients with suspected intra-abdominal pathology, it is important to remember that many of these findings may be diminished or entirely masked in critically ill or immunosuppressed patients. For this reason, maintaining a high suspicion for an intra-abdominal cause in a deteriorating patient is critical to the early identification of these pathological processes.

This chapter will focus on life-threatening intra-abdominal pathologies encountered commonly in the ICU, often presenting with an acute abdomen or peritonitis. Furthermore, we must also note that, although many patients present with a primary intra-abdominal pathology, others will develop a life-threatening intra-abdominal condition as a direct or indirect consequence of an unrelated critical illness. This adds additional complexity to an already challenging problem. Some of the common and ...

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