Pneumoperitoneum in peritoneal dialysis patients

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

Peritoneal Dialysis with Marked Pneumoperitoneum

Pneumoperitoneum, the presence of free air within the peritoneal cavity, is often caused by the perforation of gas-containing viscus and commonly requires surgical treatment. However, in patients with peritoneal dialysis, free air is commonly seen on X-ray. We present the case of a patient with peritoneal dialysis with marked pneumoperitoneum. A 75-year-old Japanese male with end-stage renal disease due to antineutrophil cytoplasmic antigen-associated vasculitis had been receiving continuous ambulatory peritoneal dialysis for 9 years. He had a poor appetite and general malaise without abdominal pain or fever. These symptoms gradually worsened, and he was hospitalized. At the time of admission, chest X-ray revealed bilateral free air in the abdomen. Subsequent computed tomography of the abdomen revealed marked pneumoperitoneum. Peritonitis due to perforation of the digestive tract was considered; however, the absence of abdominal pain, fever, and turbidity of dialysis drainage indicated that peritonitis was unlikely. Insufficient air venting during continuous ambulatory peritoneal dialysis bag replacement was suspected. The bag was carefully changed, resulting in a gradual decrease in the free air. We encountered a patient with continuous ambulatory peritoneal dialysis who had significant free air in the abdominal cavity in the absence of peritonitis. The source of the air was determined to be the dialysis bag due to insufficient venting during replacement. This case underscores the importance of instructing patients with continuous ambulatory peritoneal dialysis on the thorough removal of air from the bag during replacement.

Long-term pneumoperitoneum in continuous ambulatory peritoneal dialysis (CAPD) caused by handling fault of Stay.Safe(R) system associated to bicaVera solution

We found chronic pneumoperitoneum in two continuous ambulatory peritoneal dialysis patients from two different hospitals. Both patients used the Stay.Safe® system and bicaVera solution, whose extension tubing is not primed with fluid but air-filled, unlike that of the conventional solution bags. This fact, together with a handling fault common to both patients, resulted in the inflow of the air in the tubing of bicaVera bags into the peritoneal cavity during every exchange. We warn of this complication, which must be specifically pointed out during training, and we recommend providing the system with a mechanic device to prevent this handling fault.

Pneumoperitoneum in peritoneal dialysis patients; one centre's experience

The pneumoperitoneum (PP) on upright chest X-ray (CXR) usually indicates a perforated viscus. As peritoneal dialysis (PD) catheter provides an additional port of air entry into the peritoneal cavity, the incidence and clinical significance of PP in PD patients has been debated in the literature (a variable incidence from 4 to 34% has been reported in previous studies). With improvement in patient training and connecting devices of PD catheters, technique-related PP is quite rare. Following a recent patient with PP, we reviewed our 3-year data to evaluate the incidence and significance of this radiological sign in PD patients.

We reviewed all upright CXRs in our PD patients from 2006 to 2008, using an electronic radiology database. Over 3 years, we had a total of 156 patients on PD. We have reviewed a total 312 upright CXRs (mean 2 X-rays per patient), which were performed for various clinical reasons during this period.

Seven PD patients had 11 CXRs showing free air under the diaphragm (total incidence of PP 4% of PD population and 3% of CXR performed in PD patients). One patient had two episodes of PP with a total of four X-rays demonstrating free air. Two patients had surgical complications of PD catheter insertion and PP was diagnosed just after the insertion of PD catheter, both of them needed laparotomy. Five patients had incidental PP, which was possibly technique related. In four of these patients with incidental PP, no definite intervention was needed. However, one of these five patients was symptomatic. We established that the cause of PP was faulty technique. Aspiration of PP with a patient in the Trendelenburg position gave her immediate symptomatic relief. We also retrained her to prevent further episodes of PP.

This review demonstrates the quite low and falling incidence of PP (<4% in a prevalent PD population) most likely due to improvement in training and technique. The air should not enter the peritoneal cavity in normal properly performed exchanges. Air under the diaphragm in a PD patient requires appropriate evaluation to exclude visceral perforation. After that, patient technique of PD exchanges should be reviewed. However, if PP persists, aspiration of air can give symptomatic relief.

Gas-forming bacterial peritonitis mimics hollow organ perforation

Acute abdomen is an emergent condition in the emergency department, and it is mandatory to evaluate it immediately and treat it without delay. Pneumoperitoneum is usually attributed to perforation of the gastrointestinal tract. However, intra-abdominal, gynecologic, urologic, and miscellaneous pathogenesis not related to a perforated gastrointestinal tract had never been described in the past. Approximately 10% of pneumoperitoneum is not associated with hollow organ perforation. There are many imitators of pneumoperitoneum including subphrenic abscess, colon volvulus, Chilaiditi syndrome, and so on. In our case, the gas-forming bacterial peritonitis accounted for the pneumoperitoneum. We presented an 85-year-old man who received laparotomy due to peritonitis, and radiographic subphrenic free air was seen. However, a large amount of ascites was found rather than perforated bowels during the surgical exploration, and the culture of ascites was positive for Pseudomonas aeruginosa.

Prolonged postlaparoscopy carbon dioxide pneumoperitoneum

In this article we report what is to our knowledge the longest published duration of postlaparoscopy CO2 pneumoperitoneum, and discuss factors that may contribute to the duration of postoperative pneumoperitoneum.

Diagnosis and management of enteric disease and abdominal catastrophe in peritoneal dialysis patients with peritonitis

Peritoneal dialysis (PD)-associated peritonitis rates have decreased significantly in recent years, especially Staphylococcus epidermidis and Staphylococcus aureus infections. Rates of gram-negative, polymicrobial, and fungal peritonitis have remained steady. The reported mortality of gram-negative and polymicrobial peritonitis varies widely (4%-50%). Most likely, the reason for this variability is that prognosis depends on the underlying etiology more than the specific microorganisms isolated. Gram-negative, polymicrobial, and fungal infection have variable association with documented visceral disease, and the highest mortality occurs in reports with the highest prevalence of intra-abdominal pathology. The odds ratio of death in PD patients with documented abdominal catastrophe and peritonitis is reported to be 20:1 compared with all other causes. Further reductions in PD-associated peritonitis mortality are likely to depend on earlier diagnosis and better management of intra-abdominal pathology. Presentation with hypotension, sepsis, lactic acidosis, and/or elevation of peritoneal fluid amylase should raise immediate concern for "surgical" peritonitis. Suspicion for visceral disease should also be high in patients with gram-negative, polymicrobial, and fungal infection or those who fail to improve rapidly as judged by clinical signs and symptoms, cell counts, and repeat cultures. Nonlocalizing physical examination and negative or nonspecific results of abdominal computed tomography do not rule out serious intra-abdominal disease. Immediate initiation of broad antibiotic coverage including for anaerobic infection is indicated when bowel pathology is suspected. Urgent surgical consultation, with active discussion and participation by the nephrologist, is advisable when visceral pathology is suspected and the patient is unstable or fails to improve rapidly.

Pneumoperitoneum: a review of nonsurgical causes

OBJECTIVE

To review causes of nonsurgical pneumoperitoneum (NSP), identify nonsurgical etiologies, and guide conservative management where appropriate.

DATA SOURCE

We conducted a computerized MEDLINE database search from 1970 to 1999 by using key words pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identified 482 articles by using these keywords and reviewed all articles. Additional articles were identified and selectively reviewed by using key words laparotomy, laparoscopy, and complications.

STUDY SELECTION

We reviewed all case reports and reviews of NSP, defined as pneumoperitoneum that was successfully managed by observation and supportive care alone or that required a nondiagnostic laparotomy.

DATA SYNTHESIS

Each unique cause of nonsurgical pneumoperitoneum was recorded. When available, data on nondiagnostic exploratory laparotomies were noted. Case reports were organized by route of introduction of air into the abdominal cavity: abdominal, thoracic, gynecologic, and idiopathic.

CONCLUSIONS

Most cases of NSP occurred as a procedural complication or as a complication of medical intervention. The most common abdominal etiology of NSP was retained postoperative air (prevalence 25% to 60%). NSP occurred frequently after peritoneal dialysis catheter placement (prevalence 10% to 34%) and after gastrointestinal endoscopic procedures (prevalence 0.3% to 25%, varying by procedure). The most common thoracic causes included mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. One hundred ninety-six case reports of NSP were recorded, of which 45 involved surgical exploration without evidence of perforated viscus. The clinician should maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum and should recognize that conservative management may be indicated in many cases.

Pneumoperitoneum caused by a perforated peptic ulcer in a peritoneal dialysis patient: difficulty in diagnosis

Peritonitis due to viscus perforation in peritoneal dialysis (PD) patients can be catastrophic. We describe the first reported case of perforated peptic ulcer (PPU) in a PD patient. This 78-year-old man presented with a 1-day history of mild abdominal pain. He had been receiving nocturnal intermittent PD for 2 years and had ischemic heart disease and cirrhosis of the liver. Pneumoperitoneum and peritonitis were documented, but the symptoms were mild. The "board-like abdomen" sign was not noted. Air inflation and contrast radiography indicated a perforation in the upper gastrointestinal tract, and laparotomy disclosed a perforation in the prepyloric great curvature. Unfortunately, the patient died during surgery. This case illustrates that the "board-like abdomen" sign may be absent in PD patients with PPU because of dilution of gastric acid by the dialysate. Free air in the abdomen, although suggestive of PPU, is also not uncommon in PD patients without viscus perforation. Because PD has to be discontinued after laparotomy and exploratory laparotomy may be fatal in high-risk patients, other diagnostic methods should be used to confirm viscus perforation before surgery. PPU, which can be proved by air inflation and contrast radiography, should be suspected in PD patients with pneumoperitoneum and peritonitis.