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Acute by Sree from Callroom

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  • 1. Diagnosis of Peritonitis in PD
    • Common symptoms include
      • Fever (53%)
      • Abdominal Pain (79%)
      • Nausea (31%)
      • Diarrhea (7%)
    • Lab findings
      • Increase in WBC > 100 cells/mm3
      • Neutrophilic predominance
    • Microbiology
      • About half of infections are gram positive
      • 15% are gram negative
      • Approx. 20 % are culture negative
      • 2% are polymicorobial
      • 2% are fungal
  • 2. Fungal Infections in PD
    • Microbiology
      • Candida 79%
      • Cryptococcus 6%
    • Risk Factors
      • breaks in sterile technique when connecting peritoneal catheters to bags of dialysate.
      • infections at the cutaneous site
      • intestinal perforation
      • peritoneovaginal fistulae
      • transmigration of fungi across the bowel wall into the peritoneum.
    • WBC are almost always greater than 200 cells/mm3
  • 3. Noninfectious Complications of PD
    • GERD and gastric emptying
      • Nausea, vomiting, a sensation of fullness, and epigastric discomfort occur in 20 percent of patient
      • 14 percent of patient with PD have frequent vomitting
    • Pleural Effusion
    • Electrolyte abnormalities
      • Hypokalemia
        • Cellular uptake of potassium, prompted by the intraperitoneal glucose load with subsequent insulin release, and
        • Bowel losses may play a role in the hypokalemia
      • Hypermagnesiumia
        • Positive magnesium balance resulting from renal failure and the relatively high dialysate magnesium concentration.
  • 4. Acute Mesenteric Ischemia
  • 5. Causes
    • Arterial
      • Embolus, thrombosis
      • Mortality rate > 60%
    • Venous
      • Thrombosis, strangulation
    • Non-occlusive Mesenteric Ischemia
      • Hypoperfusion in sclerotic vessels
        • Dehydration, MI, arrhythmia, shock, pressors
    • Risk Factors -> atherosclerosis, arrhythmias, severe valvular disease, CHF, hypercoaguability
  • 6. Mesenteric Vascular Supply
    • Celiac Artery
      • Gives off common hepatic, splenic and left gastric arteries
    • Superior Mesenteric Artery
      • Gives off pancreaticoduodenal, jejunal, ileal, middle and right colic arteries
      • Feeds majority of the bowel from distal duodenum to middle colon
    • Inferior Mesenteric Artery
      • Supplies distal colon, rectum
        • Rarely involved in embolic ischemia due to small ostium
  • 7.  
  • 8.  
  • 9.  
  • 10.  
  • 11. Intestinal Physiology
    • Intestines have high tolerance for ischemia
      • Extensive collateral circulation
      • Numerous vascular control mechanisms by which arteries can dilate and constrict as needed
      • Can accommodate 75% reduction in perfusion for up to 12 hours
    • With complete occlusion or prolonged ischemia (and secondary vasoconstriction) infarction occurs
  • 12. SMA Embolism
    • Accounts for 50% of all cases of acute mesenteric ischemia
    • SMA is predisposed due to it’s large caliber ostium
    • Embolus usually lodges distal to middle colic artery (~3-10cm in)
    • Jejunum most often affected as it is most distal from celiac and IMA collaterals
  • 13. Presentation
    • Rapid onset of periumbilical abdominal pain, out of proportion to what is elicited on abdominal exam
    • Nausea, vomiting
    • Forceful bowel evacuation
    • Normal abdominal exam
    • Occult blood in stool
  • 14. Presentation
    • As ischemia progresses to infarction
      • Abdominal distension
      • Absent bowel sounds
      • Peritoneal signs
    • As compared with the small bowel, colonic ischemia tends to be less painful, lower in abdomen and is more frequently assoc with hematochezia
  • 15.  
  • 16.  
  • 17.  
  • 18. Workup
    • Labs -> leukocytosis, hemoconcentration, metabolic acidosis
        • Arterial lactate almost always elevated
    • Imaging
      • Plain film
        • Distended loops, wall thickening, pneumatosis intestinalis
      • CT angiogram
        • As above + arterial occlusions
      • MRA
      • Mesenteric Angiography
        • Gold standard
        • Need A/P and lateral views to assess arterial take-off points
  • 19. Treatment
    • Hemodynamic support
    • Antibiotics
    • GI decompression with NGT/suctioning
    • Avoid vasoconstricting agents
      • To increase forward flow -> dobutamine, milrinone, dopamine (preserve mesenteric perfusion)
    • Anticoagulation (unless overt bleeding)
    • Papaverine infusion
      • Vasodilater
      • Effective for relieving mesenteric arterial vasospasm
    • Local thrombolysis effective for embolic disease
    • Surgery