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# Abdominal compartment syndrome

Pressure inside the belly rises so high that it squeezes the organs and blood vessels, causing [kidney](https://durgical.com/en/anatomy/kidney/), lung and heart problems. It needs urgent care.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Rectus abdominis](https://durgical.com/en/anatomy/rectus-abdominis-muscle/)
- [Peritoneum](https://durgical.com/en/anatomy/peritoneum/)
- [Kidneys](https://durgical.com/en/anatomy/kidney/)
- [Urinary bladder](https://durgical.com/en/anatomy/urinary-bladder/)
- [Diaphragm](https://durgical.com/en/anatomy/diaphragm/)
- [Inferior vena cava](https://durgical.com/en/anatomy/inferior-vena-cava/)
- [Linea alba](https://durgical.com/en/anatomy/linea-alba/)
- [Transversus abdominis](https://durgical.com/en/anatomy/transversus-abdominis-muscle/)
- [External oblique](https://durgical.com/en/anatomy/external-abdominal-oblique-muscle/)
- [Jejunum](https://durgical.com/en/anatomy/jejunum/)
- [Ileum](https://durgical.com/en/anatomy/ileum/)
- [Liver](https://durgical.com/en/anatomy/liver/)
- [Left renal vein](https://durgical.com/en/anatomy/right-renal-vein/)

## Why it happens

- [Venous return and the Guyton curves](https://durgical.com/en/physiology/venous-return-and-the-guyton-curves/)
- [Cardiac output and what sets it](https://durgical.com/en/physiology/cardiac-output-and-what-sets-it/)
- [Lung and chest wall compliance](https://durgical.com/en/physiology/lung-and-chest-wall-compliance/)
- [Glomerular filtration: the barrier and its determinants](https://durgical.com/en/physiology/glomerular-filtration-the-barrier-and-its-determinants/)

## What it is

Organ dysfunction caused by a sustained rise in intra-abdominal pressure. By international consensus (WSACS), intra-abdominal hypertension is a sustained pressure of 12 mmHg or more, and abdominal compartment syndrome is a sustained pressure above 20 mmHg with new organ dysfunction or failure.

## Who gets it

Mostly seen in intensive care, after major trauma, emergency abdominal surgery, severe acute pancreatitis, major burns and massive fluid resuscitation. Intra-abdominal hypertension is common in critically ill patients; full abdominal compartment syndrome is less frequent but has high mortality. In Colombia and Latin America, trauma from road crashes and violence, severe pancreatitis and burns are relevant settings.

## Causes

- Primary: abdominal or pelvic injury or disease (haemoperitoneum, damage-control surgery, ruptured abdominal aortic aneurysm, severe pancreatitis)
- Secondary: conditions outside the abdomen that need massive fluid resuscitation (sepsis, major burns, shock)
- Ileus, bowel obstruction or colonic distension
- Tense ascites or large intra-abdominal haematoma
- Abdominal closure under tension or tight dressings

## Risk factors

- Massive fluid or blood transfusion and positive fluid balance
- Shock, acidosis, hypothermia and coagulopathy
- Major burns, especially of the trunk
- Severe acute pancreatitis
- Obesity and prone positioning
- Mechanical ventilation with high airway pressures

## Pathophysiology

The abdomen behaves like a closed box with limited compliance. As pressure rises, venous return through the inferior vena cava falls and cardiac output drops. The [diaphragm](https://durgical.com/en/anatomy/diaphragm/) is pushed up, raising airway pressures and impairing ventilation. Renal vein and parenchymal compression reduce kidney perfusion, causing oliguria. Gut perfusion falls, promoting ischaemia, bacterial translocation and more oedema, a vicious cycle. Intracranial pressure can also rise. Abdominal perfusion pressure equals mean arterial pressure minus intra-abdominal pressure.

## Classification

- Intra-abdominal hypertension grade I: 12–15 mmHg
- Grade II: 16–20 mmHg
- Grade III: 21–25 mmHg
- Grade IV: above 25 mmHg
- Primary, secondary or recurrent abdominal compartment syndrome

## Symptoms and signs

- Tense, distended abdomen
- Falling urine output despite fluids
- Rising peak airway pressures and worsening oxygenation in ventilated patients
- Hypotension and tachycardia
- Abdominal pain and difficulty breathing in awake patients

## Red flags

- Oliguria or anuria in a critically ill patient with a distended abdomen
- Bladder pressure above 20 mmHg
- Sudden rise in ventilator pressures or hypercapnia
- Hypotension that worsens with more fluids
- Rising lactate suggesting gut ischaemia

## Diagnosis

**Clinical**
Abdominal examination is unreliable for estimating pressure; measurement is required in at-risk patients. Suspect it when organ dysfunction appears together with a tense [abdomen](https://durgical.com/en/anatomy/region/abdomen/) and risk factors.

**Tests**
Intravesical (bladder) pressure is the reference method: measured at end-expiration, supine, with the transducer zeroed at the mid-axillary line and a small saline instillation. Creatinine, urine output, blood gases and lactate assess organ dysfunction.

**Imaging**
Imaging is supportive: CT may show a round-belly sign, compressed [inferior vena cava](https://durgical.com/en/anatomy/inferior-vena-cava/), bowel wall thickening or fluid collections; ultrasound guides drainage of ascites or collections.

## Differential diagnosis

- Hypovolaemic or septic shock without raised abdominal pressure
- Acute kidney injury from other causes
- Acute mesenteric ischaemia
- Tension pneumothorax (rising airway pressures with hypotension)
- Bowel obstruction without organ failure

## Goal of treatment

Lower intra-abdominal pressure and restore organ perfusion, keeping abdominal perfusion pressure adequate, while treating the underlying cause.

## Treatment

**Follow-up**
Serial bladder pressure measurements in patients at risk; nursing priorities include correct measurement technique, urine output, ventilator pressures, haemodynamics and fluid balance.

**Conservative**
Evacuate intraluminal contents with nasogastric and rectal tubes, avoid head-up positions that raise pressure, loosen tight dressings, and avoid a positive fluid balance after initial resuscitation.

**Medical**
Adequate analgesia and sedation, short trials of neuromuscular blockade, prokinetics for ileus, and blood-product ratios that limit crystalloids in massive haemorrhage.

**Procedure**
Percutaneous catheter drainage of ascites, blood or other free fluid when feasible.

**Surgical**
Decompressive laparotomy with temporary abdominal closure (open abdomen, negative-pressure dressings) for established abdominal compartment syndrome that does not respond to other measures.

## Complications

- Acute kidney injury
- Respiratory failure
- Low cardiac output and shock
- Bowel ischaemia and sepsis
- Multiple organ failure and death
- Open-abdomen complications: fistula, ventral hernia

## Prognosis

Untreated abdominal compartment syndrome has very high mortality. Early recognition and decompression improve organ function, but survivors of an open abdomen often need later abdominal wall reconstruction.

## Prevention

- Restrictive, goal-directed fluid resuscitation after the initial phase
- Routine bladder pressure monitoring in high-risk ICU patients
- Considering leaving the abdomen open after damage-control surgery

## Test yourself

Think of the answer, then tap the question to see it.

## How is abdominal compartment syndrome defined by the WSACS consensus?

A sustained intra-abdominal pressure above 20 mmHg, with or without abdominal perfusion pressure below 60 mmHg, associated with new organ dysfunction or failure.

## What is the reference method to measure intra-abdominal pressure?

Intravesical (bladder) pressure, at end-expiration, supine, zeroed at the mid-axillary line.

## How is abdominal perfusion pressure calculated?

Mean arterial pressure minus intra-abdominal pressure.

## What is the definitive treatment of refractory abdominal compartment syndrome?

Decompressive laparotomy with temporary abdominal closure (open abdomen).

## Why does urine output fall in abdominal compartment syndrome?

Raised pressure compresses the renal veins and parenchyma and reduces cardiac output, lowering kidney perfusion.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/abdominal-compartment-syndrome/)

## Related conditions

- [Acute pancreatitis](https://durgical.com/en/conditions/acute-pancreatitis/)
- [Burns (thermal, chemical, electrical; inhalation injury)](https://durgical.com/en/conditions/burns/)
- [Blunt abdominal trauma](https://durgical.com/en/conditions/blunt-abdominal-trauma/)
- [Major trauma (polytrauma): ATLS primary survey](https://durgical.com/en/conditions/major-trauma-atls-primary-survey/)
- [Acute kidney injury](https://durgical.com/en/conditions/acute-kidney-injury/)
- [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/)
- [Hypovolaemic shock](https://durgical.com/en/conditions/hypovolaemic-shock/)
- [Abdominal aortic aneurysm](https://durgical.com/en/conditions/abdominal-aortic-aneurysm/)
- [Acute compartment syndrome](https://durgical.com/en/conditions/acute-compartment-syndrome/)
- [Acute mesenteric ischaemia](https://durgical.com/en/conditions/acute-mesenteric-ischaemia/)
- [Postoperative ileus](https://durgical.com/en/conditions/postoperative-ileus/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome](https://pmc.ncbi.nlm.nih.gov/articles/PMC3680657/) (Intensive Care Medicine, 2013).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/abdominal-compartment-syndrome/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/abdominal-compartment-syndrome/