Case : 021
This is Abdomen X- Ray . What is the findings ?
What are the complication ?

Peritoneal dialysis catheter

Possible complications

Early Complications

Pain. The most common pain is usually incisional or pain associated with manipulation of the catheter during the procedure. Pain associated with infusion of solution may be due to hypersensitivity to the low pH of conventional solutions, to placement of the catheter in a functional or anatomic compartment (e.g. limited by adhesions) or to position of the catheter tip against the pelvic wall, bladder or rectum. Infusion of air at the time of catheter insertion or during connections can also cause transient pain. The latter can be confirmed by resolution of the pain after moving the tip of the catheter to another location or replacing the catheter with a shorter one.

Bleeding. Bleeding can result from laceration of anterior abdominal wall vessels (i.e. inferior epigastric artery) or less frequently, puncture of intraabdominal vessels (mesenteric, inferior vena cava, aorta, iliac). Arterial bleeding from needle insertion into a blood vessel is usually easy to recognize and most of the time can be controlled by simply removing the offending instrument from the vessel. Laceration of the vessel will require immediate intervention and ligation through either laparoscopy or laparotomy. Venous bleeding may be more difficult to identify and control since veins do not have a muscularis layer. The recommended approach depends on the severity of the bleeding. Frequent exchanges and the use of intraperitoneal (i.p.) heparin to prevent clotting are generally used until the effluent clears or surgical intervention is deemed necessary.

Perforations. Perforation of an internal organ during catheter implantation should always be considered if pain, peritonitis or bleeding is observed. Paralytic ileus or obstruction, polycystic renal disease and internal herniae are predisposing factors. The diagnosis of a perforated organ is often evident immediately after the event, but unfortunately may remain silent for some time, leading to other complications. The most obvious signs of perforation are: the return of intestinal content or urine through the catheter or stylet, a hissing sound from gas release, fetid smell from fecal material, instant urge to urinate or vaginal release of peritoneal fluid. Peritoneoscopic or surgical implantation of the catheter should both reduce the incidence of perforation and provide a prompt diagnosis. Direct visualization is also helpful in deciding whether to abort the procedure and treat the patient with conservative means (antibiotic coverage and observation) or with exploratory laparotomy and repair. Through and through perforations of the small intestine or bladder after blind insertion of the catheter may remain silent for some time after the procedure and may be associated with good initial function of the catheter, making the diagnosis more elusive.

Leaks. The incidence of pericatheter leaks has been variously reported to be 0 to 40%. Pericatheter leaks may not be apparent in the immediate post insertion period unless a full (2 L in adult patients) exchange is performed. Undernourished and immunosuppressed patients, diabetics and individuals with very weak anterior abdominal walls are most prone to develop this complication. Catheter leaks can be prevented with the use of tightly secured purse string sutures at the site of entrance of the catheter into the peritoneal cavity, by precisely placing the catheter cuffs and by avoiding the use of full infusion volumes, particularly in the sitting and standing positions, until the catheter is totally healed. Many clinicians recommend a rest period of several weeks after catheter insertion whenever possible to assure optimal healing.

Joffe reported the use of fibrin glue to control catheter leaks after failure to recover with conservative therapy². The technique consisted of injecting 2 ml of the ready-made fibrin adhesive system using a concentration of thrombin of 4 IE/ml into the area of the external cuff. The success rate in a small series was 83%.

Subcutaneous fluid leaks can also migrate and cause abdominal wall or genital edema. In order to distinguish a subcutaneous fluid accumulation from a patent processus vaginalis, a scintigram or CT scan is recommended.

A leak around the internal cuff may dissect the anterior abdominal wall, causing an accumulation of fluid around the catheter incision site resembling a hernia. The diagnosis can be established by ultrasound, scintigraphy or contrast media injection into the catheter followed by drainage. The problem can be corrected by revision of the insertion site and reapplication of an effective purse string suture in proximity to the internal cuff of the catheter.

Obstruction. The most common type of obstruction is a one way or the ball-valve type caused by proximity of the distal portion of the catheter to the omentum or intestine allowing infusion of the solution, but slow or no outflow due to due to the negative pressure caused by the external obstruction. Migration of the catheter can also cause of poor outflow. Migration has been shown to be associated with poor orientation of the catheter’s tunnel resulting in misdirection of the catheter into the upper abdominal quadrants due to the catheter spatial memory^3,4. Although catheter manipulation often restores good catheter position, recurrence of migration is common and requires reinsertion with special attention to tunnel orientation. The use of a titanium weight at the end of the catheter or front-loading, or laparoscopic salvage of the catheter with reposition and securing the internal tip of the catheter in the true pelvis with a stitch can prevent or correct this complication. Omental wrapping can occur at any time after catheter insertion. Conservative therapy with enemas, change in position and ambulation often remedy this problem. Persistent obstruction may require catheter manipulation with reposition or replacement in extreme cases. Surgical laparatomy or laparoscopic epiplopexy of the greater omentum and epiploic appendices can be used in salvaging a dysfunctional catheter⁵.

Total obstruction during insertion is usually due to a catheter kink. The problem can be solved with manipulation using a flexible probe, or if persistent, by peritoneoscopic or surgical repositioning. Blood or fibrin clots following implantation should be treated with irrigations using heparinized solution. In extremes cases of a stubborn internal obstruction, direct intervention using a semi-flexible probe or brush under fluoroscopic control can be attempted.

Infections. Peritonitis as an early complication should raise the possibility of intraoperative contamination. Polymicrobial peritonitis with Gram negative organisms and/or yeasts is most suggestive of colonic perforation (see Treatment of Peritonitis). If bowel perforation is suspected, the diagnosis should be confirmed and appropriate surgical intervention with removal of the infected catheter is recommended.

Redness exceeding 13 mm in diameter and purulence with or without bloody discharge are the signs of an acute exit site infection. Swelling, erythema and tenderness over the tunnel tract are indications that the infection has extended to the tunnel between the internal and outer cuffs. The extent of the infection (abscess) can be further evaluated with a simple ultrasound of the anterior abdominal wall.

When signs of exit site infection are observed, a Gram stain and cultures should be obtained and appropriate empiric antibiotic therapy started. Warm hypertonic saline compresses may be useful and provide comfort in many cases. Failure to heal after specific antibiotic therapy based on cultures and sensitivities requires removal of the infected cuff or catheter removal and replacement. The surgical removal of the infected tissue, unroofing and cuff shaving have been practiced with some success by several experienced operators. However, replacement of the catheter to a clean site is the preferred option.

Herniae. Herniae may first appear following implantation of the catheter due to increased intraabdominal pressure. The traditionally quoted predisposing factors include malnutrition, immunosuppression, multiparity and a weak anterior abdominal wall. A recent survey including 75 U.S. and Canadian centers analyzed the data from 1864 patients⁶. Logistic regression analysis found no association between hernias and age, body surface area, PD modality, volume of dialysate, time of largest dwell (day/upright vs night/recumbent), or type of catheter used. Cystic disease conferred a 2.5-fold increase in risk for anatomic complications (p < 0.001); female gender conferred an 80% reduction in risk (p < 0.0001), and Kt/V > or = 2.0 conferred a 52% reduction in risk (p < 0.05) for hernia.

If the diagnosis is made during the procedure, it should be immediately corrected. If not, the infusion volume should be reduced and automated PD in the supine position should be favored until corrective surgery is scheduled. Incisional herniae are more common when the incision is performed over the linea alba and least frequent with paramedian insertions through the rectus muscle .

Hydrothorax. Hydrothorax typically occurs early in the course of therapy since it is frequently due to a congenital defects of muscle fibers of the diaphragm. The reported frequency varies between 1 and 10%. Diaphragmatic defects are possibly more frequent than this, but go unrecognized until fluid is present in the peritoneal cavity and intraperitoneal pressure (IAP) increases. Women are affected more commonly than men and the right side predominates. The first manifestations of hydrothorax are dyspnea or inadequate ultrafiltration. However, approximately 25% of instances are asymptomatic and diagnosed during routine physical examination of chest x-rays. The pleuro-peritoneal communication is best localized with injection of radioisotopes into the peritoneal cavity followed by scintigrams after infusion and post drainage. A low pleural fluid protein content is the most consistent biochemical finding. The available therapeutic options are: surgical closure of the communication, pleurodesis by talc insufflation, injection of oxytetracycline, autologous blood or other irritants or video-assisted thoracoscopic pleurodesis (VATS). VATS talc pleurodesis is a safe and reliable treatment that allows sustained continuation of PD with low recurrence rate⁷.

Genital edema. The most common causes of gential edema are pericatheter fluid extravasation into the preperitoneal space and a patent processus vaginalis. The latter complication frequently presents shortly after catheter insertion. The diagnosis is readily confirmed by scintigraphy, cannulography with contrast material or CT scanning. Surgical correction is most effective and allows continuation of PD in most cases.

Late Complications

Hemoperitoneum. Hemoperitoneum is a common late complication of chronic PD, but is seldom related to the catheter per se. An occasional instance of bleeding is seen after tugging and pulling of a catheter with resulting internal bleeding from and anterior abdominal wall small vessels. Immobilization and protection of the exit site is recommended for a few days after the event to prevent further irritation. No other action is necessary in most instances. Perforation of a vascular structure from pressure necrosis is also possible (spleen), but relatively rare.

Perforation. Perforations into bowel, bladder, spleen, gallbladder and pelvic wall due to pressure necrosis have been occasionally reported. Many of these perforations are asymptomatic and only recognized when the fluid drains into the bladder or vagina, effluent fluid becomes discolored with a greenish tinge from ble, or the catheter makes a surprise appearance through the anus. The most likely predisposing cause is poor position of the catheter tip or pressure due an inadequately long catheter. Therapy consists of removal of the catheter, repair of the fistulous tract, if possible, and a rest period from PD in order to reduce intraperitoneal pressure and allow healing of the tract.

Leaks. Late pericatheter leaks occur for all the same reasons as the early ones and from persistent exit site or tunnel infections. In addition, leaks from deterioration or accidental damage to the catheter should be considered. Depending on the site of the hole and the preference of the operator, the catheter can be replaced, repaired with sterile glue or simply shortened if the defect is very close to the external tip.

Most catheters are made of silicon rubber or polyurethane. Hydrolysis of the polyurethane surface and cracking of the material after exposure to polyethelene glycol or alcohol have been reported .

Obstruction. The causes, mechanisms and therapy of catheter obstruction seen during early or late complications are very similar. The recurrent or chronic production of fibrin strands causing intermittent obstruction can be partially prevented by the use of intermittent heparin i.p. One-way obstruction is almost always seen during the drain phase, but a reverse one-way obstruction (during infusion) has been described due to a fibrin clot .

Infection. In addition to all the infectious complications listed in the early complications we may encounter chronic, often indolent and fastidious to treat chronic exit site infections, cuff erosions and extrusions. Many of these chronic infections are due to Pseudomonas, Serratiae or other water-borne organisms. Aggressive and prolonged specific therapy (often with two drugs) is required for eradication (see Exit Site Infections). Due to definite association between these exit site infections and formation of biofilm, microabscess, tunnel tract infections and peritonitis, it is imperative to monitor the process closely during conservative therapy and replace the catheter if no clinical improvement is observed.

Cuff position during catheter placement is critical. If the external cuff is placed too close to the exit site (<1.5 cm) or if the exit site is too large (exceeding the diameter of the catheter), there is a high risk of cuff extrusion. Very superficial placement of the cuff, particularly in thin patients with scant subcutaneous fat, positioning the cuff directly under the belt line or repeated exit site infections can result in cuff erosion. Once again, unroofing the area, surgical debridement and shaving the external cuff can correct the problem. However, the only way of curing the problem is total or partial replacement of the catheter and selection of a new virgin exit site.

Herniae, genital edema. The mean time for developing herniae is 1 year after initiation of PD, with the risk increasing 20% per year for patients on CAPD. Thus, most of the herniae occur as late complications. The treatment is similar to that suggested for hernia early in the course of PD.

From :

http://www.advancedrenaleducation.com/AllAboutDialysis/PeritonealDialysis/DialysisAccess/ComplicationsofPDCatheters/