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Sclerosing encapsulating peritonitis as a complication of CAPD. (22) Axial CT image (a) and gray-scale US image (b) show large linear foci of peritoneal calcification in a 68-year-old woman. (23) Axial CT image (a) and gray-scale US image (b) show a loculated fluid collection in the pelvis of a 26-year-old woman with abdominal pain and bloody dialysate effluent. Foci of peritoneal calcification also are visible in a. (24) Axial CT image shows extensive calcification of the bowel wall and peritoneum in a 34-year-old woman (same patient as in Fig 21). (25) Axial CT image shows bowel wall thickening in a 56-year-old woman.
Source publication
Continuous ambulatory peritoneal dialysis (CAPD) is used to treat end-stage renal failure in an increasing number of patients. CAPD has an advantage over hemodialysis in that it allows patients greater freedom to perform daily activities; it also provides other clinical benefits. However, the long-term effectiveness of CAPD is limited by complicati...
Citations
... In the successive follow-ups, the patient has been followed for five month postoperatively and is doing well. Death due to liver failure 1 (5,5) Scan CT= Scan computerizd tomography. ...
... The typical age range is between 12 and 18 years; in fact, patient ages range from 6 to 79 years in the literature. However, the secondary form can be mainly secondary to chronic ambulatory peritoneal dialysis with an occurrence in around 0.9-7.3% of patients [5]. It has been associated with abdominal surgery, ventricle peritoneal shunts, retrograde menstruation, and tuberculosis peritonitis, the intake of practolol, sarcoidosis, carcinoid tumors or patients with liver cirrhosis. ...
Idiopathic sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by total or patial encasement of the intestines by a fibrocollagenous coccon-like a membrane. Early clinical features of this condition are generally non-specific and are frequently not recognized until the patient develops signs of small bowel obstruction. We report the observation of an adult patient operated for an acute bowel obstruction, in which the diagnosis of sclerosing encapsulating peritonitis (SEP) was made intraoperative. A good understanding of SEP and a better awareness of its clinical, paraclinical and therapeutic findings may aid to establish better management of this rare condition.
... Iopamidol [21][22][23][24][25] and iohexol 6,26,27 are the most frequently reported contrast agents used in performing CT peritoneography; although, iopromide 28,29 has been cited or the identities of the non-ionic agents were not stated. [30][31][32][33] The most commonly used iodine concentration is 300 mgI/mL 22,23,25,27,28,[30][31][32] ; however, 350 mgI/mL 6,26 and 370 mgI/mL 21 have also been utilised. Volume of contrast added to 2 L of dialysate is usually 100 mL, 21,23,26,27,[31][32][33] but as little as 50 mL 22 to as much as 150 mL 25 are reported. ...
... Iopamidol [21][22][23][24][25] and iohexol 6,26,27 are the most frequently reported contrast agents used in performing CT peritoneography; although, iopromide 28,29 has been cited or the identities of the non-ionic agents were not stated. [30][31][32][33] The most commonly used iodine concentration is 300 mgI/mL 22,23,25,27,28,[30][31][32] ; however, 350 mgI/mL 6,26 and 370 mgI/mL 21 have also been utilised. Volume of contrast added to 2 L of dialysate is usually 100 mL, 21,23,26,27,[31][32][33] but as little as 50 mL 22 to as much as 150 mL 25 are reported. ...
... [30][31][32][33] The most commonly used iodine concentration is 300 mgI/mL 22,23,25,27,28,[30][31][32] ; however, 350 mgI/mL 6,26 and 370 mgI/mL 21 have also been utilised. Volume of contrast added to 2 L of dialysate is usually 100 mL, 21,23,26,27,[31][32][33] but as little as 50 mL 22 to as much as 150 mL 25 are reported. While adding a fixed volume of contrast to 2 L of dialysate simplifies solution preparation, perhaps making compounding less error-prone, some clinical reports individualise the contrast-dialysate mixture to patient body weight, adding 1 mL/kg contrast solution to 30 mL/kg dialysate. ...
Abstract
Background: Computerised tomographic (CT) peritoneography is performed on peritoneal dialysis (PD) patients to
identify peritoneal boundary defects, dialysate maldistributions and loculated fluid collections. Iodinated contrast media
are added to dialysate and infused through the dialysis catheter, and CT images are obtained. Chemical compatibility of
contrast media with dialysis solutions has not been studied. In some institutions, pharmacists charged with oversight of
compounded sterile preparations have placed a moratorium on the use of contrast media-dialysate mixtures until
compatibility data become available. This study was undertaken to examine the compatibility of non-ionic iodinated
contrast agents added to PD solution for the performance of CT peritoneography.
Methods: 100 mL of three non-ionic iodinated contrast agents, iopamidol 370 mgI/mL, iohexol 300 mgI/mL and iodixanol
320 mgI/mL, were mixed with 2 L 1.5% dextrose PD solution and stored at 2–8�C, 25�C and 40�C. Observations at
predefined intervals were made over 5 days for visual appearance, turbidity, pH, drug concentration and chemical
degradation.
Results: Iopamidol, iohexol and iodixanol were stable for 5 days under study conditions. The contrast-dialysate mixture
remained clear and colourless, no turbidity changes observed, pH and drug concentrations were stable and no increase in
existing impurities or new impurities were detected.
Conclusions: The addition of commonly used non-ionic iodinated contrast agents to 1.5% dextrose dialysis solution is
chemically stable, meeting the criteria set forth in the standards and guidelines of the US Pharmacopeia and the Institute of
Safe Medication Practices. A protocol for performing CT peritoneography is recommended herein to facilitate patient
safety and diagnostic reliability of the imaging study
... Peritoneography, computed tomographic peritoneography, magnetic resonance peritoneography and peritoneal scintigraphy are traditional imaging techniques that are used for the examination of peritoneal dialysis-(PD) related complications such as catheter malfunction, leakage, hernia, peritoneal-pleural-pericardial communications [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. ...
... The catheter appears as a double binary image, the arrow indicates the catheter lumen; b the contrast agent appears in the catheter lumen (arrow), the catheter sideholes and in the peritoneal space; c the peritoneal space and the catheter lumen are filled with the contrast agent. The catheter is seen as two parallel hypoechoic lines, the arrow indicates the catheter lumen sheath formation around the catheter; d B-mode ultrasound reveals slightly hyperechoic intraluminal material (arrows); e the corresponding CEUS image shows an intraluminal stop of the contrast agent inflow caused by the intraluminal material (arrows) and outflow of the contrast agent through a sidehole proximal to the catheter occlusion the imaging aspects of CEUS in catheter malfunction are similar to those of catheter peritoneography [2][3][4]9]. ...
... Carrying out CEUS is less time-consuming than blue methylene, computed tomographic peritoneography and peritoneal scintigraphy, all of which may require a wait time of more than 120 min to maximize diagnostic capability in the presence of small diaphragmatic wall defects [8,9,15]. ...
In the field of peritoneal dialysis contrast enhanced ultrasound (CEUS) is a new add-on examination to B-mode ultrasound, but until recently it has never been systematically studied. Based on the experience of the Project Group "Integrated Imaging and Interventional Nephrology" of the Italian Society of Nephrology, CEUS is helpful for evaluating catheter malfunction, peritoneal-pleural communication, leakage, and herniation, and in particular it facilitates dynamic functional imaging of the catheter and its complications. The use of CEUS in peritoneal dialysis is simple, repeatable, safe, radiation-free, and appears to be less time-consuming and more cost-effective than other radiological imaging techniques such as peritoneography, computed tomography, magnetic resonance or peritoneal scintigraphy.
... 1,2 Hydrothorax is usually a clear transudative (mostly right-sided) pleural effusion, which should be differentiated from other sources of pleural effusion, such as heart failure or fluid overload, causing increased hydrostatic pressure in the lungs. 3 Pathogenesis of peritoneal dialysis catheter-associated hydrothorax has been reported to originate from congenital or acquired defects of the diaphragm, defective lymphatic drainage, and pleuroperitoneal communication via a fistulous tract. 4 Various tools for diagnosing hydrothorax have been evaluated with thoracentesis used to differentiate between transudative and exudative pleural fluid. ...
... CT and MR peritoneography are valuable modalities for determining whether an anatomic diaphragmatic defect is present. 3 Between CT and MR, the reference standard is CT peritoneography using intraperitoneal contrast, which has a greater spatial resolution, widespread availability, and relatively low cost capable of depicting the entire peritoneal cavity. 3,6 Primary disadvantages include namely exposure to ionizing radiation and iodinated contrast media, which pose the risk of an allergic reaction and peritonitis. ...
... 3 Between CT and MR, the reference standard is CT peritoneography using intraperitoneal contrast, which has a greater spatial resolution, widespread availability, and relatively low cost capable of depicting the entire peritoneal cavity. 3,6 Primary disadvantages include namely exposure to ionizing radiation and iodinated contrast media, which pose the risk of an allergic reaction and peritonitis. Furthermore, it has been reported that CT peritoneography shows a 33% sensitivity in identifying pleuroperitoneal leak. ...
Peritoneal scintigraphy, although rarely used, plays a vital role in the diagnosis of peritoneal dialysis catheter complications. Reported complications include spontaneous hydrothorax secondary to a pleuroperitoneal fistula, which requires the abandonment of peritoneal dialysis, given that a delay in diagnosis can lead to worsening clinical status. Previously reported peritoneal scintigraphy protocols recommended intraperitoneal instillation of radiotracer and moderate-to-large volumes of dialysate or sterile saline ranging from 350 to 2,000 mL. However, smaller volumes, in conjunction with the use of single-photon emission computed tomography/computed tomography, are not verified in patients receiving peritoneal scintigraphy imaging.
... The PD system has three essential elements: the peritoneal microcirculation; the peritoneal membrane (dialyzer); and the dialysate compartment, which includes the PD solution and the delivery instrument (9,10). In PD, the dialysate is infused into the peritoneum via an indwelling catheter with the tip positioned in the most dependent part of the peritoneal cavity, and solute diffusion occurs between the extracellular fluid compartment and the intraperitoneal dialysate across the peritoneal membrane along a concentration gradient (11,12). The unwanted waste products diffuse through the peritoneum into the dialysate, which is drained via the PD catheter (11,12). ...
... In PD, the dialysate is infused into the peritoneum via an indwelling catheter with the tip positioned in the most dependent part of the peritoneal cavity, and solute diffusion occurs between the extracellular fluid compartment and the intraperitoneal dialysate across the peritoneal membrane along a concentration gradient (11,12). The unwanted waste products diffuse through the peritoneum into the dialysate, which is drained via the PD catheter (11,12). ...
... CT can be performed with or without intraperitoneal contrast material administration (CT peritoneography) for detection of dialysate leakage, hernias, and abscesses (Fig 4) (20). Intravenous or oral contrast medium may be beneficial if there is suspicion for an intraperitoneal collection (11). CT peritoneography involves instilling 1 mL of nonionic contrast material per kilogram of body weight (300 mg/mL iodine), which is mixed with 30 mL/kg of dialysate in the peritoneal cavity (21,22). ...
Worldwide, peritoneal dialysis (PD) is the preferred renal replacement therapy option for children with end-stage renal disease who are awaiting transplantation. PD involves the instillation of a specifically formulated solution into the peritoneal cavity via a PD catheter, with two-way exchange of solutes and waste products along a concentration gradient. This exchange occurs across the peritoneal membrane. The PD catheter has intraperitoneal, abdominal wall, and external components. Enormous efforts have been directed to augment the efficiency and longevity of the peritoneum as a dialysis system by preventing PD-related infectious and noninfectious complications, which may otherwise result in technique failure and a subsequent temporary or permanent switch to hemodialysis. Imaging has an instrumental role in prompt diagnosis of PD complications and in guiding the management of these complications. The main imaging techniques used in the setting of PD complications-namely, conventional radiography, US, CT, MRI, and peritoneal scintigraphy-as well as the benefits and limitations of these modalities are reviewed. The authors also describe the frequently encountered radiologic findings of each complication. Familiarity with these features enables the radiologist to play a crucial role in early diagnosis of PD complications and aids the pediatric nephrologist in tailoring or discontinuing PD and transitioning to hemodialysis if necessary. Online supplemental material is available for this article. ©RSNA, 2022.
... (Exploration des complications non infectieuses de la dialyse péritonéale par scintigraphie) Pierre Pascal 1 , Marie-Béatrice Nogier 2 1 ...
... In the absence of any contraindication, it is often chosen by the patient after being informed on extrarenal purification techniques or is preferentially proposed in the presence of certain co-morbidities or when the creation of vascular access for hemodialysis is difficult. [1] The dialysate is injected into the peritoneal cavity via a catheter penetrating the anterior wall of the abdomen through the parietal peritoneum and its tip is ideally positioned in the pouch of Douglas. The peritoneum functions as a semi-permeable membrane that allows bidirectional exchanges between the liquid introduced into the peritoneal cavity and the blood flowing through the peritoneal capillaries, leading to diffusive and convective purification of the so-called "uremic" toxins of small molecular weight and effective water-sodium subtraction. ...
... Abdominal radiography can help detect bowel obstruction, constipation, displacement of the dialysis catheter, pneumoperitoneum and peritoneal calcifications. [1] The benchmark remains CT peritoneography, which has a high detection rate, wide availability and ease of use, thereby making it possible to explore the entire peritoneal cavity. However, it has the disadvantage of requiring exposure to ionizing radiation and the infusion of iodinated contrast agent in a 2 L bag of dialysate 30 min before CT imaging, which poses a potential risk of allergy. ...
Peritoneal dialysis (PD) is an alternative to hemodialysis that is indicated in patients with chronic end-stage disease. It has many advantages, but also complications such as dialysate leaks around the catheter insertion site, in the abdominal wall or in the pleural cavity, inguinoscrotal hernia and even intra-abdominal fluid collection.
Peritoneal scintigraphy is a simple, non-invasive, low-irradiation examination, without the risk of allergy, that allows both diagnosing and locating these complications because it allows acquiring images at the time of infusion, as well as remotely and after drainage of the dialysate. Tomoscintigraphy coupled with scanner SPECT / CT (Single Photon Emission Computed Tomography / Computed Tomography) can also help narrow the diagnosis.
The objective of this article is to clarify the value of peritoneal scintigraphy in the diagnosis of non-infectious complications of peritoneal dialysis, the conditions for performing the examination and the potential indications, as illustrated by a few cases.
... If infection occurs, dialysis fluid presents an abnormal echogenicity with multiple fine echoes due to cell debris and fibrin threads. 24 The observation of gas bubbles within dialysis fluid is mostly diagnostic of infection due to perforation. 25 Based on the study of Karahan et al, every peritonitis episode should be an indication to perform US of the catheter cuffs and the tunnel segment searching for a catheter-related origin of infection. ...
... The predominant US finding is increased thickness of the small bowel mesentery to more than 15 mm, accompanied by enlargement of the mesenteric lymph nodes and adherent bowel loops. 24 In the case of peritonitis with severe pain or hemodynamic instability, US has an unimportant diagnostic role. ...
... Furthermore, a hernia might even be a cause of leakage due to local peritoneal membrane defects ( Figure 5). 24 ...
Ultrasound is very effective in performing procedures and assessment of complications in peritoneal dialysis. The ultrasound examination can be applied for preoperative assessment, during the peritoneal catheter placement, for the detection and monitoring of infection, as well as for the evaluation of the catheter malfunction. Despite being not only a cost‐ and time‐saving technique but also a bedside procedure, ultrasonography remains an underrated clinical tool in the field of peritoneal dialysis. This publication wants to explain and reinforce the clinical utility of US in PD and to expand the diagnostic equipment for the clinician.
... Peritonitis remains a major complication in peritoneal dialysis (PD) and is associated with increased hospitalizations, technique failure, and mortality. [1][2][3][4] While imaging modalities do not play a role in the diagnosis of peritonitis, 5 abdominal imaging is often performed in the setting of peritonitis to evaluate for other concomitant intra-abdominal processes or to rule out any superimposed infectious complications. Experience in hemodialysis patients has shown that dialysis patients undergo frequent imaging with estimated radiation doses that may increase the risk of cancer. ...
... While abdominal imaging has been studied in other PD-related complications such as evaluation of PD catheter position, dialysate leaks, encapsulating sclerosing peritonitis, or other intraabdominal pathologies (hernias, diverticular disease, cholecystitis, etc), the utility of abdominal imaging in patients with PD peritonitis has never been examined. 5,7,9,10 Signs and symptoms of peritonitis may be severe and physicians who do not routinely care for PD patients may suspect other causes and thus order potentially unnecessary abdominal imaging. 11 Moreover, the presence of free air under the diaphragm on upright radiography, which suggests a perforated viscus in non-PD patients, may be seen in asymptomatic PD patients. ...
Background
Peritonitis remains a major complication in peritoneal dialysis (PD). Abdominal imaging is often performed in the setting of peritonitis to evaluate for concomitant intra-abdominal processes. However, the usefulness of this procedure is unknown.
Objective
The aim of this study was to assess the prevalence of abdominal imaging performed in the setting of PD peritonitis and to evaluate clinical parameters associated with abnormal imaging results to identify clinical situations in which radiographic examinations are informative.
Design
This is a retrospective cohort study.
Setting
The study was conducted at the Toronto General Hospital, Ontario, Canada.
Patients
We studied 166 episodes of PD peritonitis in 114 patients between January 1, 2011, and June 30, 2016.
Measurements
Baseline demographics, characteristics of PD peritonitis, and characteristics of abdominal imaging performed.
Methods
The association between relevant clinical parameters and abnormal abdominal imaging was examined using a univariate and multivariate logistic regression model.
Results
Abdominal imaging (computed tomography [CT] scan or ultrasound) was performed in 68 cases (41%). Patients were more likely to undergo imaging if they required hospitalization, were admitted to the intensive care unit (ICU), had polymicrobial or fungal organisms causing peritonitis, had relapsing/recurrent/refractory peritonitis, had an indication for hemodialysis or PD catheter removal, or presented with hypotension, tachycardia, or an elevated serum lactate. Of the imaging performed, abnormalities were found in 32 cases (47%). The most common findings were bowel obstruction, intra-abdominal collection, and biliary abnormalities. In the univariate analysis, ICU admission (43.3% vs 14.3%, P < .01) and need for temporary or permanent hemodialysis (62.5% vs 30.6%, P < .01) were associated with imaging abnormalities. Importantly, the peritonitis organism was not associated with abnormal imaging results. In a multivariate analysis, ICU admission was the only significant clinical parameter associated with imaging abnormalities with an odds ratio (OR) of 4.4 (95% confidence interval [CI]: 1.1-17.4, P = .04).
Limitations
Single-center study, small sample size, and lack of detailed information on the exact indications leading to abdominal imaging.
Conclusions
Abdominal imaging is commonly performed in the setting of PD peritonitis. Abnormalities are not infrequent and are present in almost half of the cases, with need for ICU admission being the most significant clinical parameter associated with abnormal findings. Therefore, abdominal imaging should be performed in carefully selected patients with PD peritonitis, especially if there is evidence of hemodynamic instability. While the finding of fungal or polymicrobial peritonitis was a driver for abdominal imaging, the presence of these organisms did not predict radiologic abnormalities.
... In primary peritonitis, which represents a minority of cases (1%), infection is mainly sustained by Streptococci, Pneumococci and Haemophilus influenzae and antibiotics currently employed are ceftriaxone, cefotaxime, ceftazidime as well as acylaminopenicillins. In continuous ambulatory peritoneal dialysis (CAPD) peritonitis agents more frequently involved are coagulase-negative Staphylococci and Staphylococcus aureus and empirical therapy is based on vancomycin plus gentamicin or a group 2 cephalosporin with or without ciprofloxacin [34]. ...
IntroductionPeritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care.Methods
Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis.Conclusion
This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.
... These are time consuming, require adequately trained personnel, and may be associated with complications related to intra-abdominal iodinated contrast media administration. [8] Other methods of diagnosing pleuroperitoneal leaks such as magnetic resonance peritoneography, methylene blue instillation into the peritoneal cavity, and videothoracoscopy are time consuming, expensive, and associated with risks of chemical peritonitis with methylene blue. [5,3,8] The instillation of a radionuclide into the peritoneal cavity is a technique that was 1st described in 1985 by Pecoraro et al. [9] It involves injecting a nonabsorbable radionuclide via the peritoneal dialysis catheter port. ...
... [8] Other methods of diagnosing pleuroperitoneal leaks such as magnetic resonance peritoneography, methylene blue instillation into the peritoneal cavity, and videothoracoscopy are time consuming, expensive, and associated with risks of chemical peritonitis with methylene blue. [5,3,8] The instillation of a radionuclide into the peritoneal cavity is a technique that was 1st described in 1985 by Pecoraro et al. [9] It involves injecting a nonabsorbable radionuclide via the peritoneal dialysis catheter port. The presence of this radioactivity in the pleural space and peritoneal cavity reflects a hydrothorax secondary to a communication between these 2 cavities. ...
A pleuroperitoneal leak (PPL) is a relatively rare complication of peritoneal dialysis (PD) and early diagnosis is essential.
Patients suspected of a PPL usually present with dyspnea (marked during inflow of PD fluid) and tend to have transudative high glucose pleural effusions.
The PPL scintigraphy (PPLS) is one of the methods for objectively proving a PPL. The effectiveness of PPLS as a noninvasive method of evaluating a suspected PPL and its effectiveness in the exclusion of a leak in patients with similarly presenting comorbidities was assessed.
Patients suspected to have a PPL were considered for PPLS based on clinical presentation and pleural fluid analysis. Radiopharmaceutical was administered into the peritoneum via the dialysis port with the patient lying supine and immediate dynamic followed by delayed statics were acquired.
Of the 27 scans reviewed, 70% were found to be positive with majority detected within 12 minutes of radiopharmaceutical administration with a high predominance occurring in the right chest (P < .001). In PPLS-positive patients, when both chest X-rays and planar agreed on showing the right-sided chest predominance, the highest measurements of the pleural glucose:serum glucose ratio were recorded. A statistically significant correlation between the outcome of the scan and final decision on patient management was noted (P < .01).
The PPLS is an effective diagnostic tool for assessing PPLS. However, multicenter studies investigating its added value over other conventional methods are needed to establish it as a highly relevant diagnostic tool.
