Emily Leshen
Golisano Children's Hospital University of Rochester
Rochester, NY
Disclosure information not submitted.
Jacob Anderson, MD, , MEd
Pediatric Critical Care Fellow
Golisano Children's Hospital University of Rochester
Rochester
Disclosure information not submitted.
Elizabeth Nocera, DO
Assistant Professor
University of Rochester Medical Center/Golisano Children's Hospital, United States
Disclosure information not submitted.
Derek Wakeman, MD
Assistant Professor
University of Rochester Medical Center/Golisano Children's Hospital, United States
Disclosure information not submitted.
Adam Dziorny, MD, PhD,
Assistant Professor
Golisano Children's Hospital University of Rochester
Rochester, NY
Disclosure information not submitted.
Title: Abdominal Compartment Syndrome Due to Perforated Gastric Ulcer in a Pediatric Patient
Case Report Body:
Introduction: Gastric ulcer perforation is a rare cause of peritonitis and pneumoperitoneum in pediatric patients. Even more rare, this may result in abdominal compartment syndrome with associated organ injury. We present a case of tension pneumoperitoneum with resulting multiple organ dysfunction and highlight rapid diagnosis and management.
Description: A 13 year-old male with a medical history of Goldenhar syndrome and tracheostomy dependence presented with one day of severe abdominal pain and distension. On exam he was in shock, with a tense abdomen and dusky, pulseless bilateral lower extremities. An abdominal radiograph demonstrated impressive pneumoperitoneum. With concern for tension physiology, his abdomen was needle decompressed, resulting in decreased abdominal distension and reperfusion of the lower extremities. He was taken to the operating room for abdominal exploration, where a gastric ulcer perforation was identified. Surgical pathology noted gastropathy with ulceration and necro-inflammatory debris. Despite abdominal decompression, he developed acute liver failure with associated coagulopathy, persistent shock requiring extended vasoactive therapy, rhabdomyolysis, and stage III acute kidney injury requiring early continuous renal replacement therapy (CRRT). He had eventual resolution of his liver failure with medical management and was able to wean off dialysis with improved renal function. He was treated empirically for presumed Helicobacter pylori with triple therapy, though he was ultimately negative for H. pylori on immunohistochemical staining of collected tissue. He was discharged home on isradipine for kidney injury associate hypertension and a low sodium and phosphorus diet, though he preferred gastrostomy tube feeds as he found his diet restrictions nonpalatable.
Discussion: This case highlights a rare etiology of abdominal compartment syndrome in a pediatric patient, which has not previously been described in the literature. His abdominal compartment syndrome resulted in persistent shock with severe end organ dysfunction, particularly hepatic and renal, fortunately not requiring long term dialysis or organ transplant. Early CRRT may have been especially useful in this setting, with concomitant rhabdomyolysis and persistent need for vasoactive medications to promote eventual recovery.