Evaluation of impact of intra- abdominal hypertension on outcome in patients of acute pancreatitis and comparative study between step up approach and simultaneous approach for management of reduction of IAP in patients of acute pancreatitis with IAH: A randomised control study

Patients with SAP tend to have elevated intra- abdominal pressure (IAP), which can lead to intra- abdominal hypertension (IAH)  and subsequently to abdominal compartment syndrome (ACS). About 11–40 % of SAP patients suffer from complications of ACS. Incidence of IAH in patients of SAP varies from 60- 80%. The degree of IAP in patients with SAP seems to correlate with the degree of organ dysfunction, the severity of the disease, the length of the stay at hospital and mortality.  We have established in our previous studies that IAH is a poor outcome predictor and that reduction of IAP improves survival. Moreover, we have also established that failure of early reduction of IAP can lead to deleterious outcomes. Thus early detection and rapid treatment of IAH is key to improve outcome in AP patients with IAH. Interestingly, the key factors contributing to the development of IAH in AP include paralytic ileus leading to bowel distension, ascites, peripancreatic fluid collections, mesenteric inflammation, and abdominal pain in various combinations. The current strategy involves step wise intervention to address these factors in the form of minimally invasive techniques such as Ryle’s tube insertion and flatus tube insertion to start with and insertion of percutaneous catheter drain at a later phase in cases of non-improvement. However, it is imperative to note that time is key to obtain highest benefit from interventions to reduce IAP, as pointed above. Whether all the interventions applied simultaneously would benefit earlier or have better synergistic effects in reducing the IAP has not been studied.  Hence we planned this study to monitor IAP in patients of acute pancreatitis and to compare the two strategies of conventional step-up approach and a simultaneous approach for management of IAH in patients of acute pancreatitis in a randomised control trial.