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Diagnosis of Peritonitis Diagnosis of Peritonitis in PD in PD Common symptoms include Common symptoms include Fever (53%) Fever (53%) Abdominal Pain (79%) Abdominal Pain (79%) Nausea (31%) Nausea (31%) Diarrhea (7%) Diarrhea (7%) Lab findings Lab findings Increase in WBC > 100 cells/mm3 Increase in WBC > 100 cells/mm3 Neutrophilic predominance Neutrophilic predominance Microbiology Microbiology About half of infections are gram positive About half of infections are gram positive 15% are gram negative 15% are gram negative Approx. 20 % are culture negative Approx. 20 % are culture negative 2% are polymicorobial 2% are polymicorobial 2% are fungal 2% are fungal

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Diagnosis of Peritonitis in PDDiagnosis of Peritonitis in PD

Common symptoms includeCommon symptoms include– Fever (53%)Fever (53%)– Abdominal Pain (79%)Abdominal Pain (79%)– Nausea (31%)Nausea (31%)– Diarrhea (7%)Diarrhea (7%)

Lab findingsLab findings– Increase in WBC > 100 cells/mm3Increase in WBC > 100 cells/mm3– Neutrophilic predominanceNeutrophilic predominance

MicrobiologyMicrobiology– About half of infections are gram positiveAbout half of infections are gram positive– 15% are gram negative15% are gram negative– Approx. 20 % are culture negativeApprox. 20 % are culture negative– 2% are polymicorobial2% are polymicorobial– 2% are fungal2% are fungal

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Fungal Infections in PDFungal Infections in PD

MicrobiologyMicrobiology– Candida 79%Candida 79%– Cryptococcus 6%Cryptococcus 6%

Risk FactorsRisk Factors– breaks in sterile technique when connecting peritoneal catheters breaks in sterile technique when connecting peritoneal catheters

to bags of dialysate. to bags of dialysate. – infections at the cutaneous siteinfections at the cutaneous site– intestinal perforationintestinal perforation– peritoneovaginal fistulae peritoneovaginal fistulae – transmigration of fungi across the bowel wall into the transmigration of fungi across the bowel wall into the

peritoneum. peritoneum.

WBC are almost always greater than 200 cells/mm3WBC are almost always greater than 200 cells/mm3

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Noninfectious Complications of PDNoninfectious Complications of PD

GERD and gastric emptyingGERD and gastric emptying– Nausea, vomiting, a sensation of fullness, and Nausea, vomiting, a sensation of fullness, and

epigastric discomfort occur in 20 percent of patientepigastric discomfort occur in 20 percent of patient– 14 percent of patient with PD have frequent vomitting14 percent of patient with PD have frequent vomitting

Pleural EffusionPleural EffusionElectrolyte abnormalitiesElectrolyte abnormalities– HypokalemiaHypokalemia

Cellular uptake of potassium, prompted by the intraperitoneal Cellular uptake of potassium, prompted by the intraperitoneal glucose load with subsequent insulin release, and glucose load with subsequent insulin release, and Bowel losses may play a role in the hypokalemiaBowel losses may play a role in the hypokalemia

– HypermagnesiumiaHypermagnesiumiaPositive magnesium balance resulting from renal failure and Positive magnesium balance resulting from renal failure and the relatively high dialysate magnesium concentration. the relatively high dialysate magnesium concentration.

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Acute Mesenteric IschemiaAcute Mesenteric Ischemia

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CausesCauses

ArterialArterial– Embolus, thrombosisEmbolus, thrombosis– Mortality rate > 60%Mortality rate > 60%

VenousVenous– Thrombosis, strangulationThrombosis, strangulation

Non-occlusive Mesenteric IschemiaNon-occlusive Mesenteric Ischemia– Hypoperfusion in sclerotic vesselsHypoperfusion in sclerotic vessels

Dehydration, MI, arrhythmia, shock, pressorsDehydration, MI, arrhythmia, shock, pressors

Risk Factors -> atherosclerosis, arrhythmias, Risk Factors -> atherosclerosis, arrhythmias, severe valvular disease, CHF, hypercoaguabilitysevere valvular disease, CHF, hypercoaguability

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Mesenteric Vascular SupplyMesenteric Vascular Supply

Celiac ArteryCeliac Artery– Gives off common hepatic, splenic and left gastric Gives off common hepatic, splenic and left gastric

arteriesarteries

Superior Mesenteric ArterySuperior Mesenteric Artery– Gives off pancreaticoduodenal, jejunal, ileal, middle Gives off pancreaticoduodenal, jejunal, ileal, middle

and right colic arteriesand right colic arteries– Feeds majority of the bowel from distal duodenum to Feeds majority of the bowel from distal duodenum to

middle colonmiddle colon

Inferior Mesenteric ArteryInferior Mesenteric Artery– Supplies distal colon, rectumSupplies distal colon, rectum

Rarely involved in embolic ischemia due to small ostiumRarely involved in embolic ischemia due to small ostium

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Intestinal PhysiologyIntestinal Physiology

Intestines have high tolerance for ischemiaIntestines have high tolerance for ischemia– Extensive collateral circulationExtensive collateral circulation– Numerous vascular control mechanisms by Numerous vascular control mechanisms by

which arteries can dilate and constrict as which arteries can dilate and constrict as neededneeded

– Can accommodate 75% reduction in Can accommodate 75% reduction in perfusion for up to 12 hoursperfusion for up to 12 hours

With complete occlusion or prolonged With complete occlusion or prolonged ischemia (and secondary vasoconstriction) ischemia (and secondary vasoconstriction) infarction occursinfarction occurs

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SMA EmbolismSMA Embolism

Accounts for 50% of all cases of acute Accounts for 50% of all cases of acute mesenteric ischemiamesenteric ischemia

SMA is predisposed due to it’s large SMA is predisposed due to it’s large caliber ostium caliber ostium

Embolus usually lodges distal to middle Embolus usually lodges distal to middle colic artery (~3-10cm in)colic artery (~3-10cm in)

Jejunum most often affected as it is most Jejunum most often affected as it is most distal from celiac and IMA collateralsdistal from celiac and IMA collaterals

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PresentationPresentation

Rapid onset of periumbilical abdominal Rapid onset of periumbilical abdominal pain, out of proportion to what is elicited pain, out of proportion to what is elicited on abdominal examon abdominal exam

Nausea, vomitingNausea, vomiting

Forceful bowel evacuationForceful bowel evacuation

Normal abdominal examNormal abdominal exam

Occult blood in stoolOccult blood in stool

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PresentationPresentation

As ischemia progresses to infarctionAs ischemia progresses to infarction– Abdominal distensionAbdominal distension– Absent bowel soundsAbsent bowel sounds– Peritoneal signsPeritoneal signs

As compared with the small bowel, colonic As compared with the small bowel, colonic ischemia tends to be less painful, lower in ischemia tends to be less painful, lower in abdomen and is more frequently assoc abdomen and is more frequently assoc with hematocheziawith hematochezia

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WorkupWorkupLabs -> leukocytosis, hemoconcentration, Labs -> leukocytosis, hemoconcentration, metabolic acidosismetabolic acidosis

Arterial lactate almost always elevatedArterial lactate almost always elevated

ImagingImaging– Plain filmPlain film

Distended loops, wall thickening, pneumatosis intestinalisDistended loops, wall thickening, pneumatosis intestinalis

– CT angiogramCT angiogram As above + arterial occlusionsAs above + arterial occlusions

– MRAMRA– Mesenteric AngiographyMesenteric Angiography

Gold standardGold standard

Need A/P and lateral views to assess arterial take-off pointsNeed A/P and lateral views to assess arterial take-off points

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TreatmentTreatment

Hemodynamic supportHemodynamic supportAntibioticsAntibioticsGI decompression with NGT/suctioningGI decompression with NGT/suctioningAvoid vasoconstricting agentsAvoid vasoconstricting agents– To increase forward flow -> dobutamine, milrinone, dopamine To increase forward flow -> dobutamine, milrinone, dopamine

(preserve mesenteric perfusion)(preserve mesenteric perfusion)

Anticoagulation (unless overt bleeding)Anticoagulation (unless overt bleeding)Papaverine infusionPapaverine infusion– VasodilaterVasodilater– Effective for relieving mesenteric arterial vasospasmEffective for relieving mesenteric arterial vasospasm

Local thrombolysis effective for embolic diseaseLocal thrombolysis effective for embolic diseaseSurgery Surgery