Silent Pressure: Hidden Abdominal Hypertension Strikes Nearly Half of ICU Patients in Ghana

Inside every human abdomen, a quiet pressure war is constantly underway. The organs packed into the abdominal cavity — stomach, intestines, liver, spleen, kidneys — exert a measurable force on their surroundings and on each other. In healthy adults, this intra-abdominal pressure (IAP) typically sits between 5 and 7 mmHg, rising to around 10 mmHg in critically ill patients. But when that pressure climbs and stays above 12 mmHg, a dangerous condition called intra-abdominal hypertension (IAH) takes hold, squeezing blood vessels, compressing organs, and quietly sabotaging the body’s ability to perfuse tissue and sustain organ function. Now, a landmark prospective study from Ghana’s largest northern referral hospital has revealed just how common — and how deadly — this hidden threat is among critically ill patients in West Africa.

Researchers at Komfo Anokye Teaching Hospital (KATH) in Kumasi, the capital of the Ashanti Region, conducted a prospective observational study of a mixed intensive care unit (ICU) population between 1 May and 30 November 2023. Their findings, published in Frontiers in Anesthesiology, show that nearly half of all critically ill patients admitted to the unit developed IAH within the first 48 hours of admission — and that the vast majority of cases emerged within just the first 24 hours. For a condition that has historically been under-recognised in resource-limited settings, the results carry profound implications for how intensive care is delivered across sub-Saharan Africa and beyond.

The study enrolled 89 consecutive patients aged 16 years or older admitted to KATH’s main ICU, an eight-bed mixed surgical-medical unit with six regular beds and two isolation beds. The hospital itself is a giant of Ghanaian healthcare: a 1,250-bed public referral facility serving approximately 300,000 patients annually, with an ICU that typically handles between 100 and 150 admissions per year. Staffing included two intensivists and 21 anaesthesia and intensive care specialists, supported by a nurse-patient ratio of 1:1 during the day and 1:2 at night. The patient cohort had a median age of 43 years (interquartile range 29–58), and 55.1% were female. Critically, 77.6% of patients were admitted for postoperative critical care or circulatory failure, while 31.5% had an underlying malignancy.

What makes this study technically remarkable is the rigour of its measurement protocol. The research team used the modified Kron’s technique — the gold-standard method for IAP assessment — which involves instilling 25 mL of normal saline into the urinary bladder via a latex Foley catheter connected to a pressure transducer. The transducer was placed at the level of the iliac crest, zeroed for accuracy, and readings were taken 30 to 60 seconds after saline instillation, allowing the detrusor muscles to relax. Measurements were recorded at end-expiration with the patient in a completely supine position, and two readings were averaged at each timepoint. IAP was assessed upon admission and then every 6 hours for the first 48 hours, or until diagnosis of IAH, discharge, or death. This serial monitoring approach, combined with standardised World Society of the Abdominal Compartment Syndrome (WSACS) grading criteria, places the study among the first prospective investigations from West Africa to apply such methodological precision to IAH epidemiology.

The results are striking. Of the 89 patients studied, 42 — a full 47.2% — developed intra-abdominal hypertension. Grade I IAH (12–15 mmHg) was the most prevalent, affecting 27 patients (64.3% of those with IAH), followed by Grade II (16–20 mmHg) in 13 patients (31.0%). Two patients (4.7%) progressed to Grade III IAH, which corresponds to abdominal compartment syndrome (ACS) — the most severe manifestation, defined as sustained IAP exceeding 20 mmHg with new-onset organ failure. Even more alarming was the timing: 39 of the 42 patients who developed IAH (92.9%) did so within the first 24 hours of ICU admission, suggesting that the pathological process often begins before or immediately upon arrival at the critical care unit.

The researchers also identified a powerful predictor of who would develop the condition. Nearly all patients (88 of 89, or 98.9%) had at least one identifiable risk factor for IAH, with 31 patients (39.7%) having one risk factor, 22 (28.2%) having two, and 25 (32.1%) having three or more concurrent risk factors. The most prevalent risk factor was capillary leak or fluid resuscitation, present in 69 patients (78.4%) and predominantly attributed to a positive fluid balance in 67 cases. Diminished abdominal wall compliance was the second most common, identified in 48 patients (54.6%), with mechanical ventilation accounting for 23 of those cases. In the multivariate analysis, having a higher number of predefined risk factors was independently associated with IAH development after adjustment for age, with an odds ratio of 11.37 (95% CI 3.84–33.66, p < 0.001) — meaning patients with multiple risk factors faced more than an eleven-fold increase in the odds of developing the condition.

The clinical consequences of IAH were severe and measurable. Patients who developed IAH had significantly higher Sequential Organ Failure Assessment (SOFA) scores throughout the first 7 days of ICU admission compared to those with normal IAP. On Day 1, the mean SOFA score was 8.42 in the IAH group versus 6.25 in the normal-IAP group (p < 0.01); by Day 7, the gap persisted at 6.09 versus 3.27 (p < 0.02). Patients with IAH also had significantly fewer ventilator-free days — 13.5 compared to 21.3 days (p < 0.001) — indicating prolonged dependence on mechanical ventilation. Most sobering of all, the mortality rate among patients diagnosed with IAH exceeded 40%, compared to 20.9% in those with normal intra-abdominal pressure (p < 0.01). Interestingly, the duration of ICU stay was comparable between the two groups, averaging 9.19 days versus 7.23 days (p = 0.70), suggesting that IAH’s impact manifests more through organ dysfunction and survival than through prolonged hospitalisation alone.

Mechanistically, the study’s findings align with established pathophysiology. Elevated IAP exerts direct mechanical effects that disrupt tissue perfusion, potentially leading to circulatory alterations and progressive organ dysfunction or failure. The abdominal cavity behaves like a closed compartment with limited compliance — when fluid, blood, or swollen organs accumulate, pressure rises and transmits forces across the diaphragm, the retroperitoneum, and the pelvic floor, compromising renal, respiratory, cardiovascular, and neurological function simultaneously. The SOFA score, which evaluates respiratory, cardiovascular, renal, coagulation, liver, and neurological function, proved a sensitive instrument for tracking this deterioration, and its simplicity makes it particularly attractive for resource-limited environments where more complex scoring systems may be impractical.

Perhaps the most provocative implication of the study is its challenge to the traditional view of IAH as a predominantly surgical or post-laparotomy phenomenon. Historically, the condition was associated with patients undergoing abdominal surgery for acute pancreatitis, ileus, hollow viscus perforation, or polytrauma. However, the Ghanaian cohort demonstrated that the majority of IAH cases occurred in patients with non-abdominal critical illnesses, including malignancy, trauma, subdural haematoma, severe hypertension, diabetes, cerebrovascular accidents, and life-threatening infections such as pneumonia, cerebral malaria, cerebral abscess, and urosepsis. This reframing positions IAH as a systemic complication of critical illness itself, rather than a niche concern of abdominal surgeons.

The authors argue that their findings support targeted intra-abdominal pressure surveillance among high-risk ICU patients in resource-limited settings. Practical interventions highlighted in the discussion include judicious use of sedatives to improve respiratory drive assessment, daily spontaneous awakening and breathing trials to accelerate ventilator weaning, conservative fluid strategies guided by monitoring of stroke volume variation, cardiac output, lactate levels, and urine output, and the use of vasopressors in the absence of fluid responsiveness to prevent unnecessary interstitial fluid accumulation. While the study’s single-centre design and relatively small sample size limit external validity, and the 48-hour monitoring window may miss late-onset cases, the research represents a crucial step toward recognising IAH as a common but under-acknowledged driver of mortality in African critical care. The authors call for further multicentre studies to determine whether routine IAP surveillance should be incorporated into standard ICU practice — a question that could reshape survival outcomes for thousands of critically ill patients across the region.

Subject of Research: Prevalence, risk factors, and clinical outcomes of intra-abdominal hypertension among critically ill patients in a Ghanaian intensive care unit

Article Title: Intra-abdominal hypertension among critically ill patients in an intensive care unit in Ghana

Article References: Bandoh, I., Antwi-Kusi, A., Amo-Antwi, K., Addison, W., Sam-Awortwi, W., Kumah-Ametepey, I., Antwi-Kusi, K., & Agyeman-Gyebi, S. N. P. (2026). Intra-abdominal hypertension among critically ill patients in an intensive care unit in Ghana. Frontiers in Anesthesiology, 5, Article 1575313. https://doi.org/10.3389/fanes.2026.1575313

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1575313

Keywords: intra-abdominal hypertension, intra-abdominal pressure, intensive care unit, abdominal compartment syndrome, SOFA score, critical illness, Ghana, mechanical ventilation, fluid resuscitation, organ dysfunction, Kron's technique, resource-limited settings