1173CHAPTER 98 Acute Abdomen unstable In addition to the transport challenges, the radiation exposure of a CT scan may pose a risk for developing malig nancies later in life, especially for children w[.]
CHAPTER 98 Acute Abdomen unstable In addition to the transport challenges, the radiation exposure of a CT scan may pose a risk for developing malignancies later in life, especially for children who receive serial radiographs.15 That risk can be reduced by using directed scans (i.e., limiting the scan to the portion of the abdomen in question) Other risks include the administration of IV contrast material that can cause anaphylaxis in those who are allergic or renal injury, especially in those who might already be hypovolemic or receiving nephrotoxic drugs.16 That risk can be minimized as well by using nonionic contrast materials or with the administration of sodium bicarbonate and N-acetylcysteine prior to the administration of the IV contrast Administration of enteral contrast can result in aspiration if there is intestinal obstruction or delayed gastric emptying with vomiting or gastroesophageal reflux The abdominal CT scan can be effective at identifying the condition of all the intraabdominal organs and retroperitoneal spaces It is being used with increasing success to assess for bowel obstruction Identification of fluid collections and their characteristics can help ascertain whether blood, bile, or pus is present and whether it can be drained percutaneously To make certain that nonopacification of fluid-filled loops of bowel is not misconstrued for pathologic collections of fluid, enteral contrast should be given as long as no contraindications exist With IV contrast and carefully timed image capture, conclusions about organ perfusion can be assessed as well Colonic and intestinal ischemia, necrotizing pancreatitis, and decreased renal perfusion can all be seen reliably Magnetic Resonance Imaging Magnetic resonance imaging (MRI) of the abdomen can be valuable, especially as the risks of radiation can be obviated, but the logistical challenges of moving an ICU patient to the MRI suite are similar to those mentioned earlier for CT scans The added challenges posed by MRI include the slower speed of the image capture, which interferes with accessing the unstable patient for interventions, as well as the restrictions for certain MRI-incompatible ICU equipment to be in the MRI scanning room Despite these issues, MRI enterography and cholangiography are now capable of generating revealing images of the GI and hepatobiliary tracts.17 Thus, if the value of the images can offset the risks of transporting a sick child to the MRI suite, it should be considered Abdominal Conditions Requiring Treatment in the Intensive Care Unit Perforated Viscera Children with perforation of the GI tract will frequently require either preoperative resuscitation or postoperative stabilization in the ICU The most common condition resulting in perforation is appendicitis Although perforated appendicitis is common, occurring in 30% to 50% of children who present to children’s hospitals with appendicitis,18 it is unusual for it to result in serious intraabdominal sepsis Nevertheless, deaths still occur in such children, related most often to septic shock with cardiovascular collapse or severe acute respiratory distress syndrome Other sites of perforation in the GI tract include gastric or proximal intestinal perforation from severe gastritis, peptic ulcer disease, gastric ischemia, or following manipulations such as insertion of gastric tubes or transpyloric feeding tubes.19 In children with chronic gastrostomies, accidental dislodgements or manipulations 1173 of the gastrostomy site can result in separation of the stomach from the abdominal wall, leading to spillage of gastric contents into the peritoneal cavity Because the acidic gastric pH results in lower bacterial counts, such perforations not usually result in serious intraabdominal sepsis However, chronically hospitalized children or children with gastroesophageal reflux on chronic acid suppression therapies may be colonized with resistant bacterial or fungal organisms such as Candida species that can lead to serious septic consequences Interestingly, some gastric formulas now contain probiotics that, if leaked into the peritoneum, can elicit a septic response Ingested foreign bodies can lead to perforation anywhere in the GI tract, with common items being sharp materials such as pins or nails, fish bones, disc batteries, and magnets.20 Magnet ingestion incidents, in particular, have dramatically risen since the early 2000s and have led to serious injury and death If more than one magnet is ingested, the magnets can pinch loops of bowel and lead to ischemia, necrosis, perforation, and death.20–22 Trauma can also result in perforation The lap portion of a seat belt can cause an abrupt and significant increase in intraabdominal pressures during motor vehicle accidents Patients may sustain intestinal perforation, organ lacerations, or significant intraabdominal hematomas requiring ICU care Abdominal injury is the second most common cause of death in abused children after head injury A punch or kick can compress the small bowel against the vertebral column, causing a jejunal perforation So characteristic is this mechanism that the intraoperative finding of a jejunal perforation in the absence of a known trauma history should prompt an evaluation by the hospital’s child abuse team.23 Sports injuries, from skateboarding to all-terrain vehicle use, can all lead to significant injury requiring resuscitation.24 Ischemia In children with intestinal malrotation, the entire intestine supplied by the superior mesenteric artery (i.e., from jejunum to right transverse colon) can twist, resulting in midgut volvulus In a somewhat similar manner, the colon alone can twist when there is sufficient redundancy in the mesocolon, typically in the cecum or the sigmoid colon In any of these situations with intestinal and mesenteric twisting, the resultant venous congestion can compromise the capillary inflow to the bowel wall, ultimately leading to irreversible ischemia if the bowel is not untwisted promptly With venous congestion as an early component of these obstructive volvulus conditions, there may be less release of lactate into systemic circulation, potentially leading to a falsely reassuring normal lactate level despite significant intestinal ischemia Volvulus of a loop of small intestine can occur when a segment of bowel, typically distal ileum, becomes entrapped beneath an omphalomesenteric remnant This particular lesion can be difficult to diagnose, as neither contrast enema radiographs nor antegrade upper GI contrast studies are likely to reach the involved area of volvulus In addition, these children will often not have impressive physical examination findings until the bowel has become ischemic At that point, systemic sepsis can occur rapidly Similar pathophysiology can develop from a twist of bowel within an internal hernia In the pediatric ICU (PICU), another cause of intestinal ischemia is low cardiac output or hypoxemia Children with congenital heart disease, particularly those with single-ventricle physiology or severe cyanotic heart disease, can develop mucosal ischemia following cardiac surgery, manifested as pneumatosis 1174 S E C T I O N X Pediatric Critical Care: Gastroenterology and Nutrition intestinalis on radiographs or ultrasonography, bloody stool, metabolic acidosis with elevated serum lactate, and sepsis Children on potent vasoactive pressors, such as epinephrine or norepinephrine, and those receiving extracorporeal support can develop ischemia as well This is a variant of necrotizing enterocolitis (NEC), which can involve the entire small intestine and, less commonly, the colon If the diminished cardiac output or hypoxemia is corrected and the ischemia is limited to the mucosa, surgical treatment may be avoided Resection is necessary if the acidosis or systemic perturbations are refractory or if perforation results Unfortunately, as this disease can involve the entire gut, the utility of resection may be limited Other causes of intestinal ischemia include small-bowel obstruction, usually from adhesions following previous laparotomies or, less commonly, related to incarcerated inguinal hernias If the bowel becomes sufficiently distended, the intraluminal pressure can exceed the intramural perfusion pressure of the microcirculation, resulting in ischemia Other less common causes of intestinal ischemia include conditions that alter the microcirculation of the bowel wall, such as vasculitis or hemolytic uremic syndrome The systemic physiologic insult of intestinal ischemia is usually proportional to the degree of ischemic tissue Thus, midgut volvulus or total intestinal involvement with NEC can be the most catastrophic of these disease states acutely and can have the most devastating long-term consequences, with short-bowel syndrome and intestinal failure a common consequence if the ischemia is irreversible Neutropenic Enterocolitis Children who have significant neutropenia, whether drug induced from chemotherapy for malignant diseases or as a primary disease, may develop inflammation of the intestinal tract The most common location is the right colon Historically, this has been termed typhlitis, but more accurately it is labeled neutropenic enterocolitis, as it can affect other portions of the intestinal tract as well It may be preceded by mucositis and enteropathy that permits the intestinal bacteria to invade the bowel wall Affected children exhibit fever, abdominal pain and tenderness, abdominal distention, ileus or diarrhea, radiographic signs of inflammation, and sometimes hemodynamic instability The diagnosis is made best by CT scan or ultrasound.25 Treatment includes early initiation of broadspectrum antibiotics, bowel rest/decompression with a nasogastric tube, fluid resuscitation, hemodynamic support if needed, serial abdominal and radiographic examinations, and a cessation of chemotherapy Surgical treatment is reserved for patients with clinical instability or deterioration after appropriate resuscitation and those with free air on CT or plain film Neutropenic enterocolitis is becoming more common with the expanding use of bone marrow transplantation as an adjunct to the treatment of many childhood diseases, including cancer.26 Additionally, the use of new, targeted immunotherapy for the treatment of childhood cancers has increased, and it is yet unclear what risk these drugs pose in the development of neutropenic enterocolitis Pancreatitis Severe pancreatitis can require intensive care in children Etiologies for pancreatitis are most often idiopathic in children, but anatomic causes—such as gallstones, pancreatic trauma, or pancreas divisum—can also be responsible Drugs and hemolytic uremic syndrome can be unusual causes of severe pancreatitis.27 In severe cases, pancreatitis can lead to significant third-space fluid losses, pleural effusions, retroperitoneal hemorrhage, abscess formation, and hypocalcemia Necrotizing pancreatitis, though rare in children, can require repeated surgical debridement to eradicate the ongoing source of sepsis Hemorrhage Intraabdominal hemorrhage can result from trauma or following surgical procedures or manipulations In blunt trauma, the spleen is the most commonly injured abdominal organ To avoid the risk of overwhelming postsplenectomy infection, nonoperative management is attempted as long as hemodynamic stability can be maintained Hospitalization in the PICU with strict bed rest is indicated when the splenic injury is grade IV or V or if there are other significant injuries.28 The risk of delayed splenic rupture following nonoperative management is extremely low If surgery is necessary, attempts to salvage the spleen with splenorrhaphy are important Before surgery, if time permits, the child should be immunized for encapsulated bacterial organisms, including Haemophilus influenza, Streptococcus pneumoniae, and meningococcus The liver is also a commonly injured organ in blunt abdominal trauma; it, too, can usually be managed nonoperatively The development of hemobilia several weeks after nonoperative management of a hepatic laceration is uncommon However, when it occurs, it can result in significant GI bleeding This can usually be managed with arteriographic embolization or endoscopic biliary stent placement,29 but it sometimes requires resection of the involved hepatic segment or lobe Other Specific Conditions Cholecystitis Gallstones are increasingly common in children, perhaps because of the increased use of parenteral nutrition with its associated risk of cholestasis or the increasing prevalence of childhood obesity.30 Gallstones can result in cholecystitis, biliary obstruction, or pancreatitis that can complicate an ICU course for a child Acalculous cholecystitis can be seen in children who are hospitalized in the ICU, particularly those who are receiving large doses of opiates that lead to biliary dyskinesia or those who have decreased perfusion of the abdominal organs because of hypotension Acalculous cholecystitis can be associated with a significant systemic inflammatory response and should be considered as a source of unexplained sepsis in a child Ultrasonographic and CT scan findings of a dilated gallbladder with a thickened gallbladder wall and pericholecystic fluid are diagnostic However, a radionuclide study, such as a hepatobiliary iminodiacetic acid scan, is the most accurate functional imaging study Empiric antibiotic coverage for common biliary pathogens— including Gram-negative organisms such as Klebsiella, Pseudomonas, or E coli—should be started immediately Cholecystectomy would be definitive therapy In critically ill children who might not tolerate a trip to the operating room, percutaneous drainage of the gallbladder, performed with ultrasound guidance in the ICU, can be an effective temporizing procedure Spontaneous Bacterial Peritonitis Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection of ascitic abdominal fluid that may present with fever, abdominal CHAPTER 98 Acute Abdomen pain, altered mental status, or persistent vomiting.31 Enteric organisms have traditionally been isolated from more than 90% of infected ascites fluid in SBP, suggesting that the GI tract is the source of bacterial contamination This is thought to be due to direct transmural migration of bacteria from an intestinal or hollow organ lumen An alternative proposed mechanism for bacterial inoculation of ascites is via hematogenous transmission in conjunction with an impaired immune system The debate continues, and the exact mechanism of bacterial displacement from the GI tract into ascites fluid remains controversial If suspected, broad-spectrum antibiotics should be initiated to cover GI flora until culture results can guide therapy further Interventional radiology–guided paracentesis can be both diagnostic and therapeutic Abdominal Compartment Syndrome Intraabdominal hypertension (IAH) is defined as intraabdominal pressure (IAP) greater than 12 mm Hg Although this is relatively uncommon in PICU patients, it can be associated with a high morbidity and mortality If the IAP reaches a point where perfusion to intraabdominal organs is compromised, a constellation of organ dysfunctions may occur, including renal insufficiency, intestinal ischemia, hepatic dysfunction, elevated diaphragms, and respiratory insufficiency.32–34 This constellation is termed abdominal compartment syndrome (ACS) Risk factors for ACS include massive fluid resuscitation for any illness, IAH, intraabdominal inflammation or infection from any cause, obesity, and tight abdominal wall closures following laparotomy Like compartment syndrome in extremities, there is no absolute pressure to define the presence of ACS; intravascular volume status, blood pressure, and systemic vascular resistance are all factors that can impact the perfusion pressure of the abdominal organs and minimize the effect of IAP An abdominal perfusion pressure (APP) can be calculated as mean arterial pressure minus IAP If the APP is greater than 60 mm Hg, a higher survival rate has been reported The diagnosis of ACS is made when there is a sustained increased IAP in combination with signs of organ dysfunction, such as decreased cardiac output, oliguria, and respiratory insufficiency Other organ systems that can be affected by IAH include the reduction of portal and mesenteric venous flow, potentially leading to hepatic dysfunction and intestinal edema, and ischemia In addition, the increased intrathoracic pressure that can result from elevated diaphragms can raise intracranial pressure When signs of IAH are evident in the setting of abdominal distention, pressure measurements can be made using nasogastric tubes, rectal catheters, bladder catheters, and peritoneal drainage tubes such as peritoneal dialysis catheters The most reliable and practical measurement can be obtained using a closed system composed of a Foley bladder catheter connected to a fluid column and a pressure measuring device, such as a tube manometer or pressure transducer Ultrasound evaluation—including Doppler imaging of renal, portal, and mesenteric blood flow—can be helpful in assessing end-organ perfusion as well as estimating intraabdominal venous pressure by assessing the caliber of the inferior vena cava (IVC) CT scans can also reveal poor perfusion of these organs and a flattened IVC as well as increased abdominal girth, especially in the anterior to posterior dimension If the diagnosis of ACS is suspected, efforts to augment perfusion must be initiated Practitioners should avoid the reverse Trendelenburg or prone positions, as these can increase IAP Effective decompression of the GI tract is important—it can be 1175 optimized by effective nasogastric tube drainage, administration of prokinetic medications, and colonic decompression by either enemas, rectal irrigation, or rectal tube Supporting renal function is also important, which includes liberal use of diuretics along with volume resuscitation If these maneuvers have not improved organ function, temporary decompression by insertion of an abdominal drain to decrease the amount of fluid in the abdomen may be necessary.35 If this does not adequately decompress the IAH, laparotomy is necessary, with placement of a sterile patch or silo that may provide sufficient compliance to reverse the ACS The morbidity of ACS is significant, and mortality rates higher than 50% have been reported, especially if treatment is delayed until multisystem organ failure develops After decompression, and once resolution of any end-organ dysfunction occurs and after the underlying causes of the IAH have abated, delayed closure of the abdomen can be considered Sometimes that closure will require abdominal wall reconstruction techniques, such as skin flap closure without fascial repair or skin grafts Primary or delayed primary fascial repair may be feasible, sometimes requiring separation and release of the muscle groups or insertion of prosthetic patches, such as synthetic mesh, Gore-Tex, or biologic sheet materials that serve as a protein matrix for tissue ingrowth Intraabdominal Abscess Intraabdominal abscesses are highly variable in presentation Patients may present with significant abdominal pain, spiking fevers, prolonged ileus after a surgical procedure, or leukocytosis Classic physical findings may be absent in a deep abscess, where the only clues may be persistent fevers, tachycardia, and mild persistent GI dysfunction Postoperative analgesics and incisional pain frequently mask abdominal findings In addition, antibiotic administration may mask abdominal tenderness, fever, and leukocytosis In patients with subphrenic abscesses, irritation of the diaphragm may lead to shoulder pain, persistent episodes of hiccups, or unexplained pleural effusions, atelectasis, or pneumonia With pelvic abscesses, frequent urination, diarrhea, or tenesmus may occur If these abscesses go unrecognized, patients may develop a significant septic response that can lead to multiple-organ failure and death Intestine as a Source of Sepsis The intestine is an organ endowed with large quantities of both lymphatic tissue and bacteria Consequently, it can be a central organ in the systemic inflammatory response in children hospitalized in the ICU The role of the gut’s immune system is not fully understood but may play a key role in some intestinal inflammatory diseases such as Crohn disease In addition, the interplay between the gut-associated lymphoid tissue and bacteria present in the bowel lumen is important in critical illness The sick child with decreased visceral blood flow and under severe stress likely has alterations in the mucosal integrity of the intestine That loss of integrity can lead to bacterial invasion of the bowel wall with subsequent entry of the bacteria/toxins into the lymphatic or portal venous circulation Once in the circulation, these bacteria/ toxins can trigger a severe systemic inflammatory response, even if the bacteria are not detectable as a bloodstream infection Use of enteral antibiotics to decrease potentially pathologic gut bacteria has proved effective in reducing intestinal sources of sepsis in some settings, whereas replacement of gut flora using probiotics or synbiotics has been used with some success in others.36 1176 S E C T I O N X Pediatric Critical Care: Gastroenterology and Nutrition Surgical Intervention The decision to perform a laparotomy or laparoscopy in a pediatric ICU patient can be challenging There are indeed times when a patient can be too sick to go to the operating room and other times when the patient is so sick that only an immediate operation will provide a chance for successful treatment With the possible exception of patients with continued IAH or ACS, delaying operative treatment with time spent on preoperative resuscitation is often valuable Induction of general anesthesia in a hypovolemic or acidotic patient with cardiogenic or septic shock can be dangerous An understanding of the differential diagnosis can be most helpful in planning the appropriate antibiotic coverage and timing of the surgical treatment Most of the conditions that require laparotomy in ICU patients have an infectious component; thus, empiric broad-spectrum antibiotics should be administered early in the resuscitation Depending on the disease, resuscitation and antibiotics alone may obviate the need for emergent laparotomy Therefore, effective communication between the surgical and ICU teams is essential To optimize the timing of the operation, the surgical team should be ready to go immediately once the preoperative resuscitation is sufficient In situations in which physical examination or radiographs not provide localization, bedside imaging can help localize the disease Image-guided drainage of localized infection may be a successful strategy in lieu of a full laparotomy with its incumbent risks37,38 or may help to improve the physiology so that a definitive operation can be more safely performed after the condition has stabilized Key References Barnes PM, Norton CM, Dunstan FD, et al Abdominal injury due to child abuse Lancet 2005;366:187-188 Carlotti APCP, Carvalho WB Abdominal compartment syndrome: a review Pediatr Crit Care Med 2009;10:115-120 Davila ML Neutropenic enterocolitis Curr Opin Gastroenterol 2006; 22:44-47 Matheson PJ, Wilson MA, Garrison RN Regulation of intestinal blood flow J Surg Res 2000;93:182-196 Tackett JJ, Muise ED, Cowles RA Malrotation: current strategies navigating the radiologic diagnosis of a surgical emergency World J Radiol 2014;6:730-736 Vieira SM, Matte U, Kieling CO, et al Infected and noninfected ascites in pediatric patients J Pediatr Gastroenterol Nutr 2005;40:289-294 The full reference list for this chapter is available at ExpertConsult.com e1 References Cheong YC, Laird SM, Li TC, et al Peritoneal healing and adhesion formation/reformation Hum Reprod Update 2001;7:556-566 Holmdahl L, Ivarsson ML The role of cytokines, coagulation, and fibrinolysis in peritoneal tissue repair Eur J Surg 1999;165:10121019 Matheson PJ, Wilson MA, Garrison RN Regulation of intestinal blood flow J Surg Res 2000;93:182-196 Zakaria ER, Li N, Garrison RN Mechanisms of direct peritoneal resuscitation-mediated splanchnic hyperperfusion following hemorrhagic shock Shock 2007;27:436-442 Mainous MR, Ertel W, Chaudry IH, Deitch EA The gut: a cytokinegenerating organ in systemic inflammation Shock 1995;4:193-199 Jakob SM The effects of mechanical ventilation on hepato-splanchnic perfusion Curr Opin Crit Care 2010;16(2):165-168 Putensen C, Wrigge H, Hering R The effects of mechanical ventilation on the gut and abdomen Curr Opin Crit Care 2006;12:160-165 Evennett NJ, Petrov MS, Mittal A, Windsor JA Systematic review and pooled estimates for the diagnostic accuracy of serological markers for intestinal ischemia World J Surg 2009;33:1374-1383 Haas SA, Lange T, Saugel B, et al Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients Intensive Care Med 2016;42:202-210 10 Weinberger E, Winters WD, Liddell R, et al Sonographic diagnosis of intestinal malrotation in infants: importance of the relative positions of the superior mesenteric artery and vein AJR Am J Roentgenol 1992;159:825-828 11 Pracros JP, Sann L, Genin G, et al Ultrasound diagnosis of midgut volvulus: the “whirlpool” sign Pediatr Radiol 1998;22:18-20 12 Tackett JJ, Muise ED, Cowles RA Malrotation: current strategies navigating the radiologic diagnosis of a surgical emergency World J Radiol 2014;6:730-736 13 Epelman M, Daneman A, Navarro OM, et al Necrotizing enterocolitis: review of state of the art imaging findings with pathologic correlation Radiographics 2007;27:285-305 14 Bohnhorst B Usefulness of abdominal ultrasound in diagnosis necrotizing enterocolitis Arch Dis Child Fetal Neonatal Ed 2013;95:445-450 15 Rice HE, Frush DP, Farmer D, Waldhausen JH Review of radiation risks from computed tomography: essentials for the pediatric surgeon J Pediatr Surg 2007;42:603-607 16 Patzer L Nephrotoxicity as a cause of acute kidney injury in children Pediatr Nephrol 2008;23:2159-2173 17 Schaefer JF, Kirschner HJ, Lichy M, et al Highly resolved freebreathing magnetic resonance cholangiopancreatography in the diagnostic workup of pancreaticobiliary diseases in infants and young children—initial experiences J Pediatr Surg 2006;41:1645-1651 18 Nelson DS, Batemen B, Bolte RG Appendiceal perforation in children diagnosed in a pediatric emergency department Pediatr Emerg Care 2000;16:233-237 19 Campwala I, Perrone E, Yanni G, et al Complications of gastrojejunal feeding tubes in children J Surg Res 2015;199:67-71 20 Shah SK, Tieu KK, Tsao K Intestinal complications of magnet ingestion in children from the pediatric surgery perspective Eur J Pediatr Surg 2009;19:334-337 21 Strickland M, Rosenfield D, Fecteau A Magnetic foreign body injuries: a large pediatric hospital experience J Pediatr 2014;165:332-335 22 Hussain SZ, Bousvaros A, Gilger M, et al Management of ingested magnets in children J Pediatr Gastroenterol Nutr 2012;55:239-242 23 Barnes PM, Norton CM, Dunstan FD, et al Abdominal injury due to child abuse Lancet 2005;366:187-188 24 Meehan WP, Mannix R A substantial portion of life-threatening injuries are sports-related Pediatr Emerg Care 2013;29:624-627 25 McCarville MB, Adelman CS, Li C, et al Typhlitis in childhood cancer Cancer 2005;104:380-387 26 Davila ML Neutropenic enterocolitis Curr Opin Gastroenterol 2006; 22:44-47 27 Suzuki M, Sai JK, Shimizu T Acute pancreatitis in children and adolescents World J Gastrointest Pathophysiol 2014;15:416-426 28 Dervan LA, King MA, Cuschieri J, et al Pediatric solid organ injury operative interventions and outcomes at Harborview Medical Center, before and after introduction of a solid organ injury pathway for pediatrics J Trauma Acute Care Surg 2015;79:215-220 29 Singh V Endoscopic management of traumatic hemobilia J Trauma 2007;62:1045-1047 30 Kaechele V, Wabitsch M, Thiere D, et al Prevalence of gallbladder stone disease in obese children and adolescents: influence of the degree of obesity, sex, and pubertal development J Pediatr Gastroenterol Nutr 2006;42:66-70 31 Vieira SM, Matte U, Kieling CO, et al Infected and noninfected ascites in pediatric patients J Pediatr Gastroenterol Nutr 2005;40:289-294 32 Malbrain M, Cheatham M, Kirkpatrick A, et al Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome I Definitions Intensive Care Med 2006;32:1722-1732 33 Carlotti APCP, Carvalho WB Abdominal compartment syndrome: a review Pediatr Crit Care Med 2009;10:115-120 34 Cheatham M, Malbrain M, Kirkpatrick A, et al Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome II Recommendations Intensive Care Med 2007;33:951-962 35 Cheatham ML, Safcsak K Percutaneous catheter decompression in the treatment of elevated intraabdominal pressure Chest 2011;140: 1428-1435 36 Doron S, Gorbach SL Probiotics: their role in the treatment and prevention of disease Expert Rev Anti Infect Ther 2006;4:261-275 37 McDanial JD, Warren MT, Pence JC, Ey EH Ultrasound guided transrectal drainage of deep pelvic abscess in children: a modified and simplified approach Pediatr Radiol 2015;45:435-438 38 Gervais DA, Brown SD, Connolly SA, et al Percutaneous imagingguided abdominal and pelvic abscess drainage in children Radiographics 2004;24:737-754 ... epinephrine or norepinephrine, and those receiving extracorporeal support can develop ischemia as well This is a variant of necrotizing enterocolitis (NEC), which can involve the entire small intestine... the acidosis or systemic perturbations are refractory or if perforation results Unfortunately, as this disease can involve the entire gut, the utility of resection may be limited Other causes of... inflammation of the intestinal tract The most common location is the right colon Historically, this has been termed typhlitis, but more accurately it is labeled neutropenic enterocolitis, as