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    Testing again Testing again Presentation Transcript

    • 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
    • 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
    • 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.
    • Acute Mesenteric Ischemia
    • 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
    • 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
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    • 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
    • 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
    • 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
    • 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
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    • 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
    • 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