abdominal compartment syndrome due to psychogenic polyphagia is extremely rare . increased intra - abdominal pressure impairs venous return and arterial inflow . abdominal decompression is essential in its management , but ischemia - reperfusion injury may occur as a complication of decompression . we present a rare case of abdominal compartment syndrome caused by a bulimic attack in an anorexia - bulimia patient . a 19-year - old female patient visited our emergency room with the chief complaint of abdominal fullness and pain for 4 hours . four hours before visiting our hospital , she ate large amounts of food . during the previous 2 years , she had a tendency to ingest large amounts of food and vomit ( binge and purge ) . the patient 's vital signs were normal but she appeared to be in discomfort and both legs were pale . on physical examination , her abdomen was markedly distended with mild tenderness and tension . bowel sound was absent , both pulses of dorsalis pedis were absent , and both femoral pulses were weak . the complete blood count was normal , whereas the base excess negatively increased to -8.4 meq / l . was immediately obtained , which revealed a severe distended stomach with large amounts of food materials occupying the abdominal cavity entirely from the diaphragm to the pelvis . the esophagogastric junction was shifted towards the right , and the aorta and major branch vessels had collapsed due to the dilated stomach . ct showed infarctions of the left kidney , spleen , body and tail of pancreas , left hepatic lobe , small bowel , transverse colon and descending colon ( fig . a nasogastric tube for drainage was inserted for decompression but failed , possibly due to the tube having twisted in the esophagogastric junction . therefore , we attempted to insert a gastric lavage tube , but the lavage tube failed to advance over 40 cm . immediately after the failure in decompression with the nasogastric tube and lavage tube , the patient was taken to the operation room , where cyanosis was noted in the feet ( fig . when inserting foley catheter , the amount of urine collected was only 30 ml . during operation , there was no urination . under general anesthesia , we inserted an 18-gauge needle into the mid - abdomen through the skin , after which a large amount of airs were released . 4 ) , and evacuated over 5,000 ml of food materials and fluids . after that , the abdomen became soft and flat , and both dosalis pedis pulsations recovered . at that time , her blood pressure dropped continuously to 70/40 mmhg and her pulse rate increased to 160 beats / min . we inserted a jp ( jackson - pratt ) drain in the peritoneal cavity and performed tube gastrostomy using a foley catheter . twelve hours after the operation , the patient died due to refractory hypovolemic shock from uncontrolled gastric mucosal and intra - peritoneal bleeding following decompression of abdominal compartment syndrome . there are 12 case reports on gastric necrosis or perforation caused by a bulimic attack using medline search between 1968 and 1998 . through emergency operation , however , it is thought that the cause of death in our case is refractory hypovolemic shock caused by ischemia - reperfusion injury . previous cases associated with bulimic patients showed problems related to the stomach , but our patient showed general visceral problems , as well as stomach problems , indicating abdominal compartment syndrome . generally , when over 3 l of intraluminal fluid abruptly distends the stomach , increased pressure of the stomach wall can lead to ischemia of the stomach wall due to venous insufficiency . rupture can occur with intragastric pressures of more than 120 mmhg ( corresponding to approximately 4 l of fluid ) . chronic distension of the stomach in eating disorders , such as polyphagia and bulimia , increases the capacity of the stomach to the point where distension of over 15 l may be tolerable . we believe that in our case , distension of the stomach over 4 l occurred without necrosis , so abdominal compartment syndrome occurred before gastric rupture . although measurement of intra - abdominal pressure was not taken , physical examination and ct implied abdominal compartment syndrome . ct showed the portal vein , mesenteric artery and renal perfusion were insufficient and anuria occurred . bailey and shapiro   reported that when intra - abdominal pressure is above 30 mmhg , anuria progresses . severe progressive reduction in mesenteric blood flow has been shown with graded elevation in intra - abdominal pressure from approximately 70% baseline at 20 mmhg , to 30% at 40 mmhg . according to their report , we assumed that the intra - abdominal pressure of our case was above 40 mmhg , which was grade iv according to the abdominal compartment grading system . according to parsak and sakman , mortality in grade sudden expansion in abdominal and pelvic veins occurs , and reperfusion syndrome such as hypotension , asystoly attack and supraventricular arrhythmia happen . when gut ischemia occurs , inflammatory mediators , expression of cell adhesion molecules on endothelial and immune cell surface are generated and the pro - coagulatory properties of the vascular endothelial surface is increased . during reperfusion , gut injury may be amplified by increased production of free oxygen radicals and exhaustion of the endogenous antioxidant defense mechanism . the author recommended a prophylactic solution with mannitol and sodium bicarbonate to prevent the systemic reperfusion injury . according to a report by mccord . , when ischemia occurs in cats , the mucosal lesions are characterized by extensive lifting of the epithelium from the villi , epithelial necrosis , disintegration of the lamina propria , hemorrhage , and ulceration due to free radicals . in our case , during early decompression , there was no bleeding . but when the reperfusion was made after decompression through gastrotomy , bleeding occurred in the gastric and peritoneal cavity . however , we did not find the source of bleeding specifically . we assume this bleeding was due to intestinal damage of the ischemia - reperfusion injury . we also believe that dic occurred due to continuous bleeding , which was not possible to control . guan et al .   showed that using in vivo microscope imaging of mouse jejunal mucosa , after long ischemia ( 40 to 50 minutes ) with subsequent reperfusion , jejunal tissue suffered irreversible damage . kato et al .   showed that when experimental rats underwent selective portal vein occlusion for 75 minutes , all of the rats died within 60 minutes from unclamping . the mortality rate from selective portal vein occlusion in rats increased with a longer duration of ischemia and death occurred earlier for a long period ( 30 minutes ) of ischemia rather than for a short periods ( 25 minutes ) . although these results came from an animal lab , we assumed that in humans , ischemic time of the intestine is very important for resuscitation . in our case , the ischemic time from ct to decompression was about 3 hours , which may be critical and irreversible . it has been suggested that this may be due to the occlusion of the gastroesophageal junction by the distended fundus , which angulates the esophagus against the right crus of the diaphragm , producing a one - way valve . in our case , the patient could not vomit food material , the nasogastric tube was not able to enter the gastroesophageal junction , the gastric lavage tube could not advance over 40 cm from the mouth . we thought that the esophagogastric junction became angled and closed , thus decompression using the nasogastric tube or gastric lavage tube failed . in conclusion , we present a case of abdominal compartment syndrome due to bulimic attack . clinicians should be aware that binge - eating habits in patients with bulimic nervosa could cause abdominal compartment syndrome due to gastric distension and this may be a potentially fatal condition . at decompression , if ischemic time is long , clinicians should consider the possibility of critical ischemia - reperfusion injury . a prophylactic solution with mannitol and sodium bicarbonate may be able to help minimize reperfusion injury .
we present a rare case of abdominal compartment syndrome due to a bulimic attack in a 19-year - old female patient with bulimia nervosa . 
 she was admitted to our emergency room with complaints of progressive abdominal pain following bulimia . 
 computed tomography showed dilated stomach with food and air pressed other visceral organs and major abdominal vessels . 
 decompression using nasogastric tube or gastric lavage tube failed . at laparotomy , 
 we performed gastrotomy and decompression was performed . 
 after decompression , she fell into hypovolemic shock due to bleeding in the intra - gastric and peritoneal cavity . 
 twelve hours after the operation , the patient died due to refractory hypovolemic shock from uncontrolled bleeding following decompression of abdominal compartment . 
 it should keep in mind that binge - eating habits in patients with bulimic nervosa could cause abdominal compartment syndrome due to gastric distension and this may be a potentially fatal condition .