Acute abdominal compartment syndrome can be an elusive clinical diagnosis for which critical care physicians must exercise a high index of suspicion in the differential diagnosis of hemodynamic compromise and hemorrhagic shock. The purpose of these Rounds is to describe a case of abdominal compartment syndrome and to summarize the pathophysiology, differential diagnosis, etiology, and treatment of this entity. The Research Ethics Committee of the Montreal Heart Institute granted approval for use of the related images for publication purposes.A middle-aged male was admitted to the intensive care unit (ICU) for management of lower gastro-intestinal bleeding and hemorrhagic shock. His medical history was remarkable for cirrhosis (Child-Pugh Stage C) secondary to hepatitis C, with previous ligature of esophageal varices. He also had undergone a colonoscopy with a cecal polyp resection five days earlier. The initial blood work-up showed a 6.0 g decrease in hemoglobin. The patient was mechanically ventilated and transfused with six units of packed red blood cells. Despite blood transfusion and aggressive resuscitation with crystalloids, noradrenaline was required at an infusion rate of 15 lg Á min -1 to maintain a mean arterial pressure (MAP) [65 mmHg. Esophagogastric endoscopy showed no active bleeding. A colonoscopy was planned, and 4 L of an oral preparation (Golytely) were to be administered via a nasogastric tube (NGT). After 30 min and 1 L of the oral preparation had been administered, the patient's blood pressure decreased to 50 mmHg and the noradrenaline infusion was increased to 53 lg Á min -1 (Fig. 1a). The patient's abdomen became increasingly tense and he developed anuria. His intravesical pressure at this time was 28 mmHg (Fig. 1b). A diagnosis of acute compartment syndrome (ACS) was made, and ultrasound-guided paracentesis (Figs. 2 and 3a, b) and nasogastric aspiration were performed. Two and one-half litres of ascitic fluid and 1 L of the enteral solution were removed through aspiration. Shortly after this intervention, the noradrenaline requirements decreased to 10 lg Á min -1 to maintain the MAP [65 mmHg. On angiography, an intracecal bleeding site was identified and the cecal artery was embolized. The bleeding stopped and the patient later stabilized. A review of computed tomography scans of the abdomen performed one week prior to this acute event revealed signs of liver cirrhosis with portal hypertension and ascitis (Fig. 4 [videos #1 and #2 online at www.springerlink.com]). Note was made of the fact that the inferior vena cava was significantly narrowed in its intrahepatic portion.Abdominal compartment syndrome is defined as a sustained abdominal pressure [20 mmHg with evidence of organ dysfunction relieved by abdominal decompression. 1 Electronic supplementary material The online version of this article (

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Objective and background: The need for surgical resection of breast lesions of uncertain malignant potential diagnosed by core-needle biopsy (CNB) is not well established. Our study sought to determine the incidence of these lesions at CNB and to find the rate of pathologic upgrade at surgery. and during clinical follow-up. Method: A retrospective review of CNBs performed at our hospital covering the period from November 1999 to December 2008 was undertaken. In those patients diagnosed with lobular neoplasia (atypical lobular neoplasia (ALH) and lobular carcinoma in situ (LCIS)), atypical ductal hyperplasia (ADH) and radial scar (RS) the rates of pathologic upgrade at subsequent surgery were determined. Results: 9325 breast CNBs were performed during the period under review. There were 36 diagnoses of ALH (0.4%), 20 of LCIS (0.2%), 110 of ADH (1.2%) and 60 of RS (0.6%). Regarding lobular neoplasia, ALH surgical resection was performed with subsequent pathologic upgrade in only 1/31 patients (3.2%). 85% of LCIS diagnoses were followed by surgical resection with pathologic upgrade in 5/17 cases (29%). For patients with ADH, 51% (56/110) had surgical resection with an upgrade rate of 20% (11/56). 9/54 patients (17%) who did not undergo surgical resection subsequently developed a cancer at the biopsy site. Regarding RS, in 58% (35/60) of cases surgical resection was undertaken with a pathologic upgrade rate of 8% (3/35). In all three cases with an upgrade the biopsy had been performed on a hypoechogenic lesion. Conclusion: We conclude that the significant rate of pathologic upgrade in LCIS and ADH mandates a surgical excision when these lesions are found at CNB. The low rate of pathologic upgrade in RS in the absence of a hypoechogenic lesion and ALH may allow these cases to be observed.