Abdominal Compartment Syndrome in Critical Illness: A Critical Narrative Review of Definitions, Pathophysiology, Recognition and Management

Abstract

Abdominal compartment syndrome is the clinical culmination of sustained pathological intra-abdominal pressure accompanied by new organ dysfunction. Although the syndrome is now recognised across trauma, emergency surgery, severe acute pancreatitis and medical intensive care, its detection and management remain difficult because pressure, abdominal compliance, intrathoracic pressure, perfusion and organ reserve interact dynamically. This critical narrative review evaluates the evolution and current validity of definitions, measurement standards, epidemiological estimates, pathophysiological models, monitoring approaches and therapeutic strategies in adults. Literature published from 1980 through 11 June 2026 was considered, with focused PubMed/MEDLINE searching and citation-chain review of verified consensus statements, systematic reviews and clinically influential studies. The evidence supports transvesical pressure measurement as the practical reference technique and confirms that intra-abdominal hypertension is common in selected critically ill populations, whereas overt abdominal compartment syndrome is less frequent but associated with substantial morbidity and mortality. Important limitations qualify these observations: epidemiological studies use heterogeneous monitoring schedules, pressure thresholds are operational rather than universal biological cut-offs, and associations with death are strongly confounded by illness severity, fluid accumulation, shock and mechanical ventilation. Renal dysfunction appears particularly pressure-sensitive, while cardiovascular, respiratory, splanchnic and neurological effects reflect coupled abdominal-thoracic-organ interactions. Treatment should therefore target reversible pressure-generating mechanisms before irreversible organ failure develops. Sedation optimisation, gastrointestinal decompression, drainage of accessible intraperitoneal fluid and fluid stewardship are physiologically coherent but supported mainly by observational evidence and expert consensus. Decompressive laparotomy reliably lowers intra-abdominal pressure and can improve organ function, yet comparative outcome evidence is weak and the open abdomen creates major downstream morbidity. Acute pancreatitis, cirrhosis and extracorporeal support illustrate clinically distinct phenotypes that challenge a single threshold-based model. Future progress requires prospective phenotype-based monitoring studies, validated pressure-duration and compliance metrics, pragmatic intervention trials, clearer decompression triggers and implementation research capable of translating consensus into reliable bedside practice.