- Email: [email protected]
Bowel Perforation During Peritoneal Dialysis Catheter Placement
Imaging Teaching Case Bowel Perforation During Peritoneal Dialysis Catheter Placement Kenneth Abreo, MD, and Adrian Sequeira, MD Interventional nephrologists and radiologists place peritoneal dialysis catheters using the percutaneous fluoroscopic technique in both the inpatient and outpatient setting. Nephrologists caring for such patients may have to diagnose and manage the complications resulting from these procedures. Abdominal pain can occur following peritoneal dialysis catheter placement when the local and systemic analgesia wears off. However, abdominal pain with hypotension is suggestive of a serious complication. Bleeding into the abdomen and perforation of the colon or bladder should be considered in the differential diagnosis. In the case reported here, the peritoneogram showed contrast in the bowel, and correct interpretation by the interventionist would have prevented this complication. The characteristic pattern of peritoneogram images in this case will guide interventionists to avoid this complication, and the discussion of the differential diagnosis and management will assist nephrologists in taking care of such patients. Am J Kidney Dis. -(-):---. ª 2016 by the National Kidney Foundation, Inc. INDEX WORDS: Bowel; perforation; peritoneogram images; fluoroscopic patterns; catheter; peritoneal dialysis (PD); catheter placement; complication.
INTRODUCTION Peritoneal dialysis (PD) catheters are placed in the abdomen using fluoroscopy by interventional nephrologists and interventional radiologists. The procedure is straightforward, yet has the potential for complications. It is important to know how to prevent these complications, recognize them early, and manage them when they occur. The 3 major complications of the fluoroscopic method of PD catheter placement are bleeding, colon perforation, and bladder perforation. In this report, we describe the case of a patient who developed abdominal pain and hypotension following fluoroscopic placement of a PD catheter.
CASE REPORT Clinical History and Initial Laboratory Data A 69-year-old man with a long history of hypertension, type 2 diabetes mellitus, and end-stage renal disease was admitted for fluoroscopic percutaneous placement of a PD catheter. The patient had an immature left upper-extremity brachiocephalic arteriovenous fistula. He had nonischemic cardiomyopathy with ejection fraction of 5% to 10%. The arteriovenous fistula was ligated to minimize shunt volume and improve heart failure symptoms. He received hemodialysis through a right femoral vein tunneled dialysis catheter. He did not tolerate hemodialysis because of persistent hypotension. He was a poor surgical candidate because of his cardiac condition. Three months prior to presentation, he underwent a laparoscopic cholecystectomy that was complicated by bleeding and required a laparotomy. On abdominal examination, he had a well-healed right-upper-quadrant scar from the laparotomy. Body mass index was 25 kg/m2. A decision to place a percutaneous PD catheter was therefore made. Laboratory tests on the day of the procedure showed the following values: white blood cell count, 8.4 3 103/mL; hemoglobin, 12 g/dL; platelet count, 189 3 103/mL; prothrombin time, 16.2 (reference range, 11.3-15.2) seconds; international normalized ratio, 1.42; serum creatinine, 7.5 mg/dL, corresponding to an estimated glomerular filtration rate of 9 mL/min/1.73 m2 (as Am J Kidney Dis. 2016;-(-):---
calculated by the 4-variable MDRD [Modification of Diet in Renal Disease] Study equation); serum urea nitrogen, 38 mg/dL; serum sodium, 137 mEq/L; serum potassium, 4.4 mEq/L; serum chloride, 99 mEq/L; serum bicarbonate, 28 mEq/L; serum glucose, 95 mg/ dL; and serum albumin, 3 g/dL. X-ray of the abdomen showed a nonspecific nonobstructive bowel gas pattern, cholecystectomy clips over the right upper quadrant, and a right femoral venous catheter for hemodialysis. One day prior to the procedure, the patient was given polyethylene glycol 3350 (17 g in 4 oz of water) for constipation. For procedural sedation, the patient received midazolam, 1 mg, intravenously, and fentanyl, 50 mg, intravenously. A blunt 18-gauge needle was used to gain entry into the peritoneal cavity using ultrasound and fluoroscopic guidance. The patient was asked to tense and lift his abdomen during needle entry. Contrast was injected through the needle and the pattern on the peritoneogram indicated that the needle tip was in the peritoneal cavity. A 150-cm glide wire was inserted into the peritoneal cavity and the PD catheter was inserted using the Seldinger technique. PD catheter placement was uneventful, with the pigtail tip of the catheter located in the pelvic cavity (Fig 1). One liter of normal saline solution was instilled in the abdominal cavity through the PD catheter, with brisk return of clear fluid. The patient did not report abdominal pain. Postprocedure, the patient was clinically stable and in no distress. Nine hours later, he developed nausea, vomiting, severe abdominal pain, and hypotension. There was diffuse abdominal tenderness on examination. The patient was transferred to the intensive care unit, where vasopressors and broad-spectrum antibiotics were administered. Complete blood cell count showed hemoglobin level of 12.4 g/dL, white blood cell count of
From the Division of Nephrology and Hypertension, LSU Health Shreveport School of Medicine, Shreveport, LA. Received October 10, 2015. Accepted in revised form January 11, 2016. Address correspondence to Kenneth Abreo, MD, Division of Nephrology and Hypertension, LSU Health Shreveport School of Medicine, 1501 Kings Hwy, Shreveport, LA 71130. E-mail: [email protected] 2016 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2016.01.010 1
Abreo and Sequeira contrast resulted in a circular collection of contrast within the bowel. The needle then pierced the bowel wall again, and injection of contrast showed it to outline the bowel wall. Thus, there was contrast within and outside the bowel.
Diagnosis Through-and-through perforation of the transverse colon by the PD catheter.
Clinical Follow-up A laparotomy was done, which found tangential transverse colon perforation with the PD catheter at 2 sites with minimal peritoneal contamination along with a large amount of bloody PD effluent. The PD catheter was removed and the 5-mm defects in the colon were repaired. No adhesions were noted. In the days following surgery, the patient developed septic shock and the family requested to stop all life-sustaining measures.
DISCUSSION Figure 1. Fluoroscopic image shows the peritoneal dialysis catheter positioned appropriately within the pelvic cavity (straight arrow). The bent arrow points to the right femoral-tunneled dialysis catheter.
8.35 3 103/mL, and platelet count of 190 3 103/mL. A surgical consultation was requested and a noncontrast computed tomographic scan of the abdomen was obtained.
Imaging Studies The computed tomographic scan showed a large amount of free intraperitoneal gas post–catheter placement with additional foci of soft-tissue stranding. The catheter’s coiled tip was located in the right lower abdominal quadrant, but appeared to traverse the inferior wall of the transverse colon (Fig 2). A moderate volume of fluid noted in the pelvic peritoneal cavity represented either blood or PD fluid. Due to these findings, the images taken during fluoroscopic placement of the catheter were reviewed, which showed a circular blob of contrast within the transverse colon (Fig 3B). The 18-gauge blunt needle had pierced the bowel wall, and injection of
Hollow viscus perforation (bowel and bladder) is a recognized complication of PD catheter placement.1,2 The incidence of procedure-related bowel perforation is about 0.7% to 2.6%.1,3-5 Because this is a blind technique, perforation may not be recognized during the procedure.6 Prior to catheter placement, certain precautions have been advocated to minimize the risk for hollow viscus perforation. Specifically, the bladder is emptied with a Foley catheter (the day of the procedure) if there is suspicion of abnormal voiding and the bowel is evacuated the prior evening with laxatives.7 Bowel distention and the presence of abdominal wall adhesions are risk factors for bowel perforation, whereas incomplete bladder evacuation as a result of diabetic cystopathy or outlet obstruction are risk factors for bladder perforation. Some interventionalists do not recommend prophylactic laxatives, instead relying on ultrasound to guide and prevent bowel perforation.
Figure 2. Computed tomographic images show the catheter perforating the wall of the transverse colon. (A) Coronal section: transcolonic passage of the catheter (arrow). (B) Sagittal section: catheter passing through the wall of the bowel (arrow). 2
Am J Kidney Dis. 2016;-(-):---
Complications of PD Catheter Placement
Figure 3. Fluoroscopic patterns following intraperitoneal contrast injection (peritoneogram). (A) Characteristic smudge of contrast in the preperitoneal plane (bent arrow). (B) Bowel outline (straight arrow) as contrast distributes itself within the spaces around bowel loops, and contrast sitting within the loop of the bowel (bent arrow). (C) An example of a fluoroscopic pattern of contrast within the bowel: the micropuncture needle (*) as it entered the bowel, the wall of the bowel with its scalloped margins (bent arrow), and radiopaque stool within the bowel (straight arrow). In this example, fecal matter was aspirated on removal of the needle.
Using this technique, Abdel-Aal et al1 still encountered bowel perforation in 2 patients. Sigel et al8 described an ultrasound technique to map abdominal wall adhesions. “Visceral slide” is the observed movement of the bowel under ultrasound. This movement is restricted by adhesions. Another potential source of bowel injury is the procedural use of a sharp 21-gauge micropuncture needle to penetrate the abdominal wall. Using a blunt 18-gauge Hawkins needle or a Veress needle minimizes this risk, though bowel perforation can still occur with the latter.3,6,9 Fecal peritonitis is associated with significant morbidity and mortality,10,11 and therefore bowel perforation must be recognized early. When needle entry is gained into the peritoneal cavity, contrast is injected. Under fluoroscopy, the contrast should spread out in the spaces between the bowel loops, thereby outlining the bowel walls (Fig 3B). If a localized smudge of contrast is noted, it is likely that the needle is in the preperitoneal space (Fig 3A). If the bowel is punctured, contrast outlines either the mucosal folds of the small intestine or the haustral folds of the large bowel.12 Further, in the presence of fecal matter, the resulting fluoroscopic image has a central white radiopaque area surrounded by dark radiolucent contrast media (Fig 3C). Besides this, aspiration of fecal matter or a hissing sound from gas release, as well as a positive sniff test, which is the detection of a foul-smelling odor on needle withdrawal, may be noted. If these initial checks are nondiagnostic and the catheter is inserted into the bowel, the patient may experience an urge to have a bowel movement or diarrhea while PD is attempted. This is different from a pressure sensation over the rectum that some patients may perceive while instilling PD fluid in a nonperforated scenario. In Am J Kidney Dis. 2016;-(-):---
addition, the returning effluent is malodorous and feculent, or there is failure of dialysate to drain.13 In the event of a through-and-through wall perforation, these tests may be inconclusive. Bloody dialysate return or prolonged postoperative pain may be the only clues to such an event. With a history of abdominal surgery, our patient was at risk for bowel perforation. In hindsight, the initial clue to bowel perforation was missed. The blob of contrast noted in Fig 3B (bent arrow) was thought to be preperitoneal layering of contrast. Further, the patient did not report pain when the perforation occurred during the procedure. The lack of an initial bloody, feculent, or malodorous PD effluent also hinted against bowel perforation. When a PD catheter is placed in the bowel or bladder, infusion of fluid through the catheter causes diarrhea or diuresis as the fluid exits the rectum or Foley catheter, respectively. Because this was a through-and-through perforation, the tip of the catheter was located in the pelvis and fluid return was clear and complete. In the immediate postoperative period, the patient was alert and clinically stable. His condition deteriorated 9 hours later, thereby reminding us that such events can be clinically silent for an interval before manifesting floridly. The decrease in blood pressure was also not accompanied by a decrease in hemoglobin level. If a peritoneal exchange were performed at this time, the bloody effluent drained would have provided another clue (similar to a diagnostic lavage). A bloody effluent would indicate either organ perforation or bleeding from vessel rupture. In this case, if the interventionalist had appropriately interpreted the initial peritoneogram, the procedure could have been abandoned, the 18-gauge needle withdrawn, and the patient managed conservatively 3
Abreo and Sequeira
with bowel rest and antibiotics that cover gut flora, specifically Gram-negative bacteria and anaerobes.4 These microperforations seal spontaneously,13 and in most cases, surgery is not needed.
ACKNOWLEDGEMENTS Support: None. Financial Disclosure: The authors declare that they have no relevant financial interests. Peer Review: Evaluated by 3 external peer reviewers, the Feature Editor, the Education Editor, and the Editor-in-Chief.
REFERENCES 1. Abdel-Aal AK, Joshi AK, Saddekni S, Maya ID. Fluoroscopic and sonographic guidance to place peritoneal catheters: how we do it. AJR Am J Roentgenol. 2009;192(4):1085-1089. 2. Moreiras M, Cuina L, Rguez Goyanes G, Sobrado JA, Gil P. Inadvertent placement of a Tenckhoff catheter into the urinary bladder. Nephrol Dial Transplant. 1997;12(4):818-820. 3. Napoli M, Russo F, Mastrangelo F. Placement of peritoneal dialysis catheter by percutaneous method with the Veress needle. Adv Perit Dial. 2000;16:165-169. 4. Asif A, Byers P, Vieira CF, et al. Peritoneoscopic placement of peritoneal dialysis catheter and bowel perforation: experience of an interventional nephrology program. Am J Kidney Dis. 2003;42(6):1270-1274. 5. Maher E, Wolley MJ, Abbas SA, Hawkins SP, Marshall MR. Fluoroscopic versus laparoscopic implantation of
4
peritoneal dialysis catheters: a retrospective cohort study. J Vasc Interv Radiol. 2014;25(6):895-903. 6. Jacobs IG, Gray RR, Elliott DS, Grosman H. Radiologic placement of peritoneal dialysis catheters: preliminary experience. Radiology. 1992;182(1):251-255. 7. Flanigan M, Gokal R. Peritoneal catheters and exit-site practices toward optimum peritoneal access: a review of current developments. Perit Dial Int. 2005;25(2):132-139. 8. Sigel B, Golub RM, Loiacono LA, et al. Technique of ultrasonic detection and mapping of abdominal wall adhesions. Surg Endosc. 1991;5(4):161-165. 9. Toro A, Mannino M, Cappello G, Di Stefano A, Di Carlo I. Comparison of two entry methods for laparoscopic port entry: technical point of view. Diagn Ther Endosc. 2012;2012: 305428. 10. Wakeen MJ, Zimmerman SW, Bidwell D. Viscus perforation in peritoneal dialysis patients: diagnosis and outcome. Perit Dial Int. 1994;14(4):371-377. 11. Van der Reijden H, Struijk D, Van Ketel R, Kox C, Krediet R, Arisz L. Fecal peritonitis in patients on continuous ambulatory peritoneal dialysis, an end-point in CAPD. Adv CAPD. 1988;4:198-203. 12. Abdel-Aal AK, Dybbro P, Hathaway P, Guest S, Neuwirth M, Krishnamurthy V. Best practices consensus protocol for peritoneal dialysis catheter placement by interventional radiologists. Perit Dial Int. 2014;34(5):481-493. 13. Simkin EP, Wright FK. Perforating injuries of the bowel complicating peritoneal catheter insertion. Lancet. 1968;1(7533): 64-66.
Am J Kidney Dis. 2016;-(-):---
INTRODUCTION Peritoneal dialysis (PD) catheters are placed in the abdomen using fluoroscopy by interventional nephrologists and interventional radiologists. The procedure is straightforward, yet has the potential for complications. It is important to know how to prevent these complications, recognize them early, and manage them when they occur. The 3 major complications of the fluoroscopic method of PD catheter placement are bleeding, colon perforation, and bladder perforation. In this report, we describe the case of a patient who developed abdominal pain and hypotension following fluoroscopic placement of a PD catheter.
CASE REPORT Clinical History and Initial Laboratory Data A 69-year-old man with a long history of hypertension, type 2 diabetes mellitus, and end-stage renal disease was admitted for fluoroscopic percutaneous placement of a PD catheter. The patient had an immature left upper-extremity brachiocephalic arteriovenous fistula. He had nonischemic cardiomyopathy with ejection fraction of 5% to 10%. The arteriovenous fistula was ligated to minimize shunt volume and improve heart failure symptoms. He received hemodialysis through a right femoral vein tunneled dialysis catheter. He did not tolerate hemodialysis because of persistent hypotension. He was a poor surgical candidate because of his cardiac condition. Three months prior to presentation, he underwent a laparoscopic cholecystectomy that was complicated by bleeding and required a laparotomy. On abdominal examination, he had a well-healed right-upper-quadrant scar from the laparotomy. Body mass index was 25 kg/m2. A decision to place a percutaneous PD catheter was therefore made. Laboratory tests on the day of the procedure showed the following values: white blood cell count, 8.4 3 103/mL; hemoglobin, 12 g/dL; platelet count, 189 3 103/mL; prothrombin time, 16.2 (reference range, 11.3-15.2) seconds; international normalized ratio, 1.42; serum creatinine, 7.5 mg/dL, corresponding to an estimated glomerular filtration rate of 9 mL/min/1.73 m2 (as Am J Kidney Dis. 2016;-(-):---
calculated by the 4-variable MDRD [Modification of Diet in Renal Disease] Study equation); serum urea nitrogen, 38 mg/dL; serum sodium, 137 mEq/L; serum potassium, 4.4 mEq/L; serum chloride, 99 mEq/L; serum bicarbonate, 28 mEq/L; serum glucose, 95 mg/ dL; and serum albumin, 3 g/dL. X-ray of the abdomen showed a nonspecific nonobstructive bowel gas pattern, cholecystectomy clips over the right upper quadrant, and a right femoral venous catheter for hemodialysis. One day prior to the procedure, the patient was given polyethylene glycol 3350 (17 g in 4 oz of water) for constipation. For procedural sedation, the patient received midazolam, 1 mg, intravenously, and fentanyl, 50 mg, intravenously. A blunt 18-gauge needle was used to gain entry into the peritoneal cavity using ultrasound and fluoroscopic guidance. The patient was asked to tense and lift his abdomen during needle entry. Contrast was injected through the needle and the pattern on the peritoneogram indicated that the needle tip was in the peritoneal cavity. A 150-cm glide wire was inserted into the peritoneal cavity and the PD catheter was inserted using the Seldinger technique. PD catheter placement was uneventful, with the pigtail tip of the catheter located in the pelvic cavity (Fig 1). One liter of normal saline solution was instilled in the abdominal cavity through the PD catheter, with brisk return of clear fluid. The patient did not report abdominal pain. Postprocedure, the patient was clinically stable and in no distress. Nine hours later, he developed nausea, vomiting, severe abdominal pain, and hypotension. There was diffuse abdominal tenderness on examination. The patient was transferred to the intensive care unit, where vasopressors and broad-spectrum antibiotics were administered. Complete blood cell count showed hemoglobin level of 12.4 g/dL, white blood cell count of
From the Division of Nephrology and Hypertension, LSU Health Shreveport School of Medicine, Shreveport, LA. Received October 10, 2015. Accepted in revised form January 11, 2016. Address correspondence to Kenneth Abreo, MD, Division of Nephrology and Hypertension, LSU Health Shreveport School of Medicine, 1501 Kings Hwy, Shreveport, LA 71130. E-mail: [email protected] 2016 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2016.01.010 1
Abreo and Sequeira contrast resulted in a circular collection of contrast within the bowel. The needle then pierced the bowel wall again, and injection of contrast showed it to outline the bowel wall. Thus, there was contrast within and outside the bowel.
Diagnosis Through-and-through perforation of the transverse colon by the PD catheter.
Clinical Follow-up A laparotomy was done, which found tangential transverse colon perforation with the PD catheter at 2 sites with minimal peritoneal contamination along with a large amount of bloody PD effluent. The PD catheter was removed and the 5-mm defects in the colon were repaired. No adhesions were noted. In the days following surgery, the patient developed septic shock and the family requested to stop all life-sustaining measures.
DISCUSSION Figure 1. Fluoroscopic image shows the peritoneal dialysis catheter positioned appropriately within the pelvic cavity (straight arrow). The bent arrow points to the right femoral-tunneled dialysis catheter.
8.35 3 103/mL, and platelet count of 190 3 103/mL. A surgical consultation was requested and a noncontrast computed tomographic scan of the abdomen was obtained.
Imaging Studies The computed tomographic scan showed a large amount of free intraperitoneal gas post–catheter placement with additional foci of soft-tissue stranding. The catheter’s coiled tip was located in the right lower abdominal quadrant, but appeared to traverse the inferior wall of the transverse colon (Fig 2). A moderate volume of fluid noted in the pelvic peritoneal cavity represented either blood or PD fluid. Due to these findings, the images taken during fluoroscopic placement of the catheter were reviewed, which showed a circular blob of contrast within the transverse colon (Fig 3B). The 18-gauge blunt needle had pierced the bowel wall, and injection of
Hollow viscus perforation (bowel and bladder) is a recognized complication of PD catheter placement.1,2 The incidence of procedure-related bowel perforation is about 0.7% to 2.6%.1,3-5 Because this is a blind technique, perforation may not be recognized during the procedure.6 Prior to catheter placement, certain precautions have been advocated to minimize the risk for hollow viscus perforation. Specifically, the bladder is emptied with a Foley catheter (the day of the procedure) if there is suspicion of abnormal voiding and the bowel is evacuated the prior evening with laxatives.7 Bowel distention and the presence of abdominal wall adhesions are risk factors for bowel perforation, whereas incomplete bladder evacuation as a result of diabetic cystopathy or outlet obstruction are risk factors for bladder perforation. Some interventionalists do not recommend prophylactic laxatives, instead relying on ultrasound to guide and prevent bowel perforation.
Figure 2. Computed tomographic images show the catheter perforating the wall of the transverse colon. (A) Coronal section: transcolonic passage of the catheter (arrow). (B) Sagittal section: catheter passing through the wall of the bowel (arrow). 2
Am J Kidney Dis. 2016;-(-):---
Complications of PD Catheter Placement
Figure 3. Fluoroscopic patterns following intraperitoneal contrast injection (peritoneogram). (A) Characteristic smudge of contrast in the preperitoneal plane (bent arrow). (B) Bowel outline (straight arrow) as contrast distributes itself within the spaces around bowel loops, and contrast sitting within the loop of the bowel (bent arrow). (C) An example of a fluoroscopic pattern of contrast within the bowel: the micropuncture needle (*) as it entered the bowel, the wall of the bowel with its scalloped margins (bent arrow), and radiopaque stool within the bowel (straight arrow). In this example, fecal matter was aspirated on removal of the needle.
Using this technique, Abdel-Aal et al1 still encountered bowel perforation in 2 patients. Sigel et al8 described an ultrasound technique to map abdominal wall adhesions. “Visceral slide” is the observed movement of the bowel under ultrasound. This movement is restricted by adhesions. Another potential source of bowel injury is the procedural use of a sharp 21-gauge micropuncture needle to penetrate the abdominal wall. Using a blunt 18-gauge Hawkins needle or a Veress needle minimizes this risk, though bowel perforation can still occur with the latter.3,6,9 Fecal peritonitis is associated with significant morbidity and mortality,10,11 and therefore bowel perforation must be recognized early. When needle entry is gained into the peritoneal cavity, contrast is injected. Under fluoroscopy, the contrast should spread out in the spaces between the bowel loops, thereby outlining the bowel walls (Fig 3B). If a localized smudge of contrast is noted, it is likely that the needle is in the preperitoneal space (Fig 3A). If the bowel is punctured, contrast outlines either the mucosal folds of the small intestine or the haustral folds of the large bowel.12 Further, in the presence of fecal matter, the resulting fluoroscopic image has a central white radiopaque area surrounded by dark radiolucent contrast media (Fig 3C). Besides this, aspiration of fecal matter or a hissing sound from gas release, as well as a positive sniff test, which is the detection of a foul-smelling odor on needle withdrawal, may be noted. If these initial checks are nondiagnostic and the catheter is inserted into the bowel, the patient may experience an urge to have a bowel movement or diarrhea while PD is attempted. This is different from a pressure sensation over the rectum that some patients may perceive while instilling PD fluid in a nonperforated scenario. In Am J Kidney Dis. 2016;-(-):---
addition, the returning effluent is malodorous and feculent, or there is failure of dialysate to drain.13 In the event of a through-and-through wall perforation, these tests may be inconclusive. Bloody dialysate return or prolonged postoperative pain may be the only clues to such an event. With a history of abdominal surgery, our patient was at risk for bowel perforation. In hindsight, the initial clue to bowel perforation was missed. The blob of contrast noted in Fig 3B (bent arrow) was thought to be preperitoneal layering of contrast. Further, the patient did not report pain when the perforation occurred during the procedure. The lack of an initial bloody, feculent, or malodorous PD effluent also hinted against bowel perforation. When a PD catheter is placed in the bowel or bladder, infusion of fluid through the catheter causes diarrhea or diuresis as the fluid exits the rectum or Foley catheter, respectively. Because this was a through-and-through perforation, the tip of the catheter was located in the pelvis and fluid return was clear and complete. In the immediate postoperative period, the patient was alert and clinically stable. His condition deteriorated 9 hours later, thereby reminding us that such events can be clinically silent for an interval before manifesting floridly. The decrease in blood pressure was also not accompanied by a decrease in hemoglobin level. If a peritoneal exchange were performed at this time, the bloody effluent drained would have provided another clue (similar to a diagnostic lavage). A bloody effluent would indicate either organ perforation or bleeding from vessel rupture. In this case, if the interventionalist had appropriately interpreted the initial peritoneogram, the procedure could have been abandoned, the 18-gauge needle withdrawn, and the patient managed conservatively 3
Abreo and Sequeira
with bowel rest and antibiotics that cover gut flora, specifically Gram-negative bacteria and anaerobes.4 These microperforations seal spontaneously,13 and in most cases, surgery is not needed.
ACKNOWLEDGEMENTS Support: None. Financial Disclosure: The authors declare that they have no relevant financial interests. Peer Review: Evaluated by 3 external peer reviewers, the Feature Editor, the Education Editor, and the Editor-in-Chief.
REFERENCES 1. Abdel-Aal AK, Joshi AK, Saddekni S, Maya ID. Fluoroscopic and sonographic guidance to place peritoneal catheters: how we do it. AJR Am J Roentgenol. 2009;192(4):1085-1089. 2. Moreiras M, Cuina L, Rguez Goyanes G, Sobrado JA, Gil P. Inadvertent placement of a Tenckhoff catheter into the urinary bladder. Nephrol Dial Transplant. 1997;12(4):818-820. 3. Napoli M, Russo F, Mastrangelo F. Placement of peritoneal dialysis catheter by percutaneous method with the Veress needle. Adv Perit Dial. 2000;16:165-169. 4. Asif A, Byers P, Vieira CF, et al. Peritoneoscopic placement of peritoneal dialysis catheter and bowel perforation: experience of an interventional nephrology program. Am J Kidney Dis. 2003;42(6):1270-1274. 5. Maher E, Wolley MJ, Abbas SA, Hawkins SP, Marshall MR. Fluoroscopic versus laparoscopic implantation of
4
peritoneal dialysis catheters: a retrospective cohort study. J Vasc Interv Radiol. 2014;25(6):895-903. 6. Jacobs IG, Gray RR, Elliott DS, Grosman H. Radiologic placement of peritoneal dialysis catheters: preliminary experience. Radiology. 1992;182(1):251-255. 7. Flanigan M, Gokal R. Peritoneal catheters and exit-site practices toward optimum peritoneal access: a review of current developments. Perit Dial Int. 2005;25(2):132-139. 8. Sigel B, Golub RM, Loiacono LA, et al. Technique of ultrasonic detection and mapping of abdominal wall adhesions. Surg Endosc. 1991;5(4):161-165. 9. Toro A, Mannino M, Cappello G, Di Stefano A, Di Carlo I. Comparison of two entry methods for laparoscopic port entry: technical point of view. Diagn Ther Endosc. 2012;2012: 305428. 10. Wakeen MJ, Zimmerman SW, Bidwell D. Viscus perforation in peritoneal dialysis patients: diagnosis and outcome. Perit Dial Int. 1994;14(4):371-377. 11. Van der Reijden H, Struijk D, Van Ketel R, Kox C, Krediet R, Arisz L. Fecal peritonitis in patients on continuous ambulatory peritoneal dialysis, an end-point in CAPD. Adv CAPD. 1988;4:198-203. 12. Abdel-Aal AK, Dybbro P, Hathaway P, Guest S, Neuwirth M, Krishnamurthy V. Best practices consensus protocol for peritoneal dialysis catheter placement by interventional radiologists. Perit Dial Int. 2014;34(5):481-493. 13. Simkin EP, Wright FK. Perforating injuries of the bowel complicating peritoneal catheter insertion. Lancet. 1968;1(7533): 64-66.
Am J Kidney Dis. 2016;-(-):---