Acute by Sree from Callroom

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Acute by Sree from Callroom

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

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