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Complications of Peritoneal
Dialysis
Hany Bahouth
In some regions of the world, up to half of end-stage renal disease patients are
maintained on peritoneal dialysis (PD). The curled and straight silicon Tenckhoff
catheters still enjoy wide use and are considered to be the standard of care for PD
use. But, as with any foreign body chronically implanted into the human body, these
catheters tend to cause complications. And, it is you—the general surgeon who may
or may not have inserted the catheter—who must now deal with these problems.
Early Complications of PD Catheters
Early complications of PD catheters that occur within 30 days of insertion
are mainly technical.
Wound infection/hematoma. Treat as any other surgical wound infection
with drainage and local care (but add antibiotics because of the proximity of the
drain).
Exit site infection. The main pathogens are Staphylococcus aureus and
Gram-negative bacteria (Pseudomonas). If the presentation is in the form of
erythema without purulent discharge, treat the exit site with your topical agent
of choice. If it is accompanied by purulent discharge, then systemic antibiotics
should be prescribed, guided by Gram stain and cultures. Withhold PD until
recovery. In the absence of improvement after 2 weeks of treatment, the catheter
should be removed.
Leakage. Usually, this begins early after commencing PD. You may see fluid
leaking at the exit site, subcutaneous swelling, or subcutaneous edema without
signs of infection or any abdominal complaints. Ultrasound (US) can help in
confirming the diagnosis by detecting fluid surrounding the tunnel and cuffs of
the catheter. Computed tomographic (CT) scan with contrast medium injected
32
Hany Bahouth
Department of Surgery B, Rambam Health Care Campus, Haifa, Israel
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_32, © Springer-Verlag Berlin Heidelberg 2010
343
344 Hany Bahouth
with the dialysate can also make the diagnosis. This should be managed by holding PD for around 1–2 weeks. If leakage recurs after two or three trials, the cath-
eter should be replaced by a new one, preferably through a new exit site.
Malposition. You might be called for localized abdominal pain that starts
shortly after the initiation of PD. If this is associated with a slow inflow of dialysate
and with local swelling but without signs of local peritonitis or infection, then this
may be a sign of malposition of the catheter (e.g., preperitoneal placement). This
should be treated by removal of the catheter and reinsertion at another site.
Vascular injury. Minor bleeding almost always settles spontaneously, but
major hemorrhage signified by gross bloody effluent may need resuscitation and
laparotomy to find and treat the source of bleeding. Whether to reinsert a new
PD catheter depends on the general condition of the patient. Generally, our aim
is to complete the job at the same session.
Bowel perforation. Together with large vessel injury, this is the most feared
complication. This is diagnosed by the appearance of gas and feces in the effluent
or “osmotic” watery diarrhea if the dyalisate enters the bowel. There may be signs
of systemic infection, various degrees of abdominal pain and tenderness, or generalized peritonitis. If the patient is septic or suffers diffuse peritonitis, an urgent
laparotomy is mandatory for source control. Leave the catheter in place to guide you
to the perforation site. Delay PD for 2–3 weeks after surgical repair (obviously, a
new PD catheter will be needed). In the absence of diffuse peritonitis or sepsis and
after ruling out an intra-abdominal abscess by CT scan or US, you may manage the
situation nonoperatively. The rationale is that this is a limited injury to the bowel
by the PD catheter and can heal spontaneously when managed like any “controlled”
intestinal fistula. Keep the patient receiving nothing by mouth, start parenteral nutrition and broad-spectrum antibiotics, and stop PD. If fecal effluent continues for
more than 2–3 weeks, this suggests that the catheter may be intraluminal. CT or
injection of contrast under fluoroscopy will confirm this. In this case, gradually
withdraw the catheter over a few days to allow for the creation of a controlled tract
of the fistula until its complete removal. Then, treat this as any other fistula.
Urinary bladder injury. The suspicion rises with the appearance of polyuria
and glycosuria and perhaps slow inflow. This should be treated with early laparotomy for repair of the urinary bladder. Normally, you do not need more than one
or two stitches to the wall of the bladder, and you do not have to call the urologist
for that!
Late Complications of PD Catheters
Complications developing more than a month after the insertion of the catheter are related to chronic catheter use. The most common is peritonitis. The usual
catheter-related peritonitis is considered as primary (see > Chap. 12) but do not
32 Complications of Peritoneal Dialysis 345
forget that these patients can develop secondary peritonitis as well (e.g., appendi-
citis or perforated bowel).
The causative organisms of primary peritonitis are mainly Gram-positive
(Staphylococci) but Gram-negative organisms and fungi are occasionally responsible. The most common symptom is abdominal pain, which is diffuse and ill
defined. Fever and leukocytosis may be present as well. Cloudy peritoneal effluent is a common finding. Send the fluid for analysis; a white cell count of more
than 100/cc3 (with more than 50% neutrophils) and positive Gram stain for bacteria will confirm the diagnosis.
The management is nonoperative and consists of appropriate intravenous
antibiotics (obviously, adjusted for renal function or dysfunction), cessation of
PD through the catheter, and close observation.
When to remove the catheter?
Refractory peritonitis. Defined as peritonitis treated with appropriate anti-
biotics for more than 5 days without resolution. In such cases, US or CT scan
of the abdomen is indicated to rule out another source of intra-abdominal
pathology (i.e., secondary peritonitis).
Relapsing peritonitis. Peritonitis with the same organism within 4 weeks
of stopping antimicrobial therapy. In cases of relapsing infection with
Pseudomonas, removal of the catheter is highly recommended.
Peritonitis with catheter obstruction.
Fungal peritonitis. Candida is the most common species.
Secondary peritonitis (discussed in the next paragraph).
Mycobacterial infection.
We wish to stress again that you cannot ignore the possibility of secondary
peritonitis. Careful history, abdominal examination, and a high index of aware-
ness are needed to rule out secondary peritonitis. Analysis of the effluent fluid
might disclose multiple enteric organisms. Judicious use of imaging modalities
can help to proceed to the right diagnosis. When operating for source control,
removal of the catheter is mandatory.
Other less-frequent late complications that may require urgent attention
include pericatheter or pre-existent abdominal wall hernias that become symptomatic and gradually enlarge after the initiation of PD. These may produce
painful bulges, scrotal edema, and abdominal pain during PD. Normally, you
have to stop PD and evaluate for possible incarceration. If this is ruled out, then
repair is scheduled on a semi-elective basis. In this case, you have to allow for
adequate healing before gradually resuming PD (usually 2–3 weeks).
346 Hany Bahouth
The main message of this chapter could be summarized in a few words: “Treat
infection and remove the catheter” (> F ig. 32.1). But of course, whenever you stop
PD or remove the catheter the patient has to be placed on hemodialysis.—
[The Editors]
Fig. 32.1. “Gosh, they are all coming out of your tube; we’ll have to remove it.”
Gynecological Emergencies
Bernard Cristalli · Moshe Schein
Have you ever seen a gynecologist who is convinced that the “acute abdomen” is
gynecological in origin, and not due to acute appendicitis? (MS)
Have you ever seen a surgeon who is convinced that the “pelvic acute abdomen” in
a woman is surgical and not due to a gynecological affliction? (B. Cristalli)
The famous English writer and physician Somerset Maugham (1874–1965)
wrote: “Woman is an animal that micturates once a day, defecates once a week,
menstruates once a month, parturates once a year and copulates whenever she has
the opportunity.” One could not pen such a politically incorrect statement today,
but if allowed, we might have added to it some comment about “lower abdominal
pain”…
In most locales, general surgeons are not expected to deliver babies, but
you are likely to face a gynecological emergency that you should know how to
handle. Acute abdominal pain is very common in women during their reproductive years. Such pain is as likely to be gynecological as it is to be “surgical.”
Your gynecological colleagues (excluding of course Dr. Cristalli) are generally
good folk but typically possess a vision limited by the boundaries of the bony
pelvis (> Fig. 33.1). Consequently, they are often reluctant to diagnose any
acute condition as “gynecological” unless you have ruled out acute appendicitis. Occasionally, you operate for what you think is acute appendicitis, and the
findings are gynecological. You should know how to deal with this. Another
situation that provides you with the pleasure of interacting with gynecologistsobstetricians is dealing with the pregnant patient. As you know, pregnancy itself may be the cause of abdominal pain; at the same time, it may modify the
presentation of common surgical disorders, making diagnosis difficult. It may
also pose considerable challenges in the injured patient. For this edition, we
have collaborated with a gynecologist and obstetrician—Dr. Berni Cristalli of
Paris–and are happy to present a revised and much expanded version of this
chapter.—[The Editors]
33
Acute pelvic emergencies are extremely common, and both surgeon and
gynecologist must be able to understand what is going on and determine whether
it is the former or the latter who will be in charge. If you happen to be on call and
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_33, © Springer-Verlag Berlin Heidelberg 2010
347
348 Bernard Cristalli · Moshe Schein
Fig. 33.1. “Call the general surgeon!”
see women, whether referred directly or via your friendly gynecologist, you will
encounter mainly two kinds of syndrome: pain and bleeding. These two conditions may present alone or be associated with other symptoms, such as fever,
vaginal discharge, and others. We are not going to address painless bleeding,
which is the bread and butter of the gynecological practice.
The age of the woman is an important consideration as the gynecological
pathology you are likely to encounter differs markedly among the following
groups: premenstrual, menstrual-fertile, pregnant, menopausal—each group
with its typical disease profile and consequently different clinical approach.
Acute Abdominal Pain in the Fertile Woman
Assessment
We do not have to remind you to take a history concerning menstruation,
sexual activity, and contraception. Pregnancy, whether uterine or ectopic, should
always be ruled out; this is done in most hospitals with a rapid pregnancy test. Any
history of pain that occurs during the first days of the menstrual period hints at
underlying endometriosis or endometrioma (“chocolate cyst”). Acute pain developing midcycle (mittelschmerz) may be due to rupture of the Graafian follicle at
ovulation. Pain referred to the shoulder raises the possibility of free intraperitoneal
blood irritating the diaphragm, with a likely source of bleeding being a ruptured
ovarian cyst or an ectopic pregnancy.
33 Gynecological Emergencies 349
We do not need to talk to you about physical examination. You surely know
that the conditions to be discussed can produce signs of peritoneal irritation,
often indistinguishable from those of acute appendicitis. However, the site of
pain and local findings on examination are helpful in narrowing the differential
diagnosis. When bilateral, consider pelvic inflammatory disease (PID); when on
the right, think about acute appendicitis; when on the left, in an older lady, consider acute diverticulitis (> Chap. 3). Bimanual vaginal examination performed
by your gynecological friend (or by you) is an essential part of the assessment of
these patients. You are palpating for masses or fullness in the cul-de-sac (pouch
of Douglas) and looking for excitation tenderness—when moving the cervix pro-
duces a lot of pain (PID, ectopic pregnancy).
Ultrasound (it is hoped your gynecologist friend is armed with a transvaginal US) is the key investigation, allowing visualization of any free fluid, the
uterus, and adnexae. When fluid is present in the cul-de-sac, it can be aspirated
with a needle through the vagina (culdocentesis). When pus is present, think
about PID or perforated appendicitis, while blood hints at a ruptured cyst or
ectopic pregnancy.
Generally, most acutely painful gynecological conditions are treated nonoperatively. With all the information just given at hand, your job, together with
the gynecologist, is to classify the patient into one of the following groups:
“Benign” abdominal examination—most probably a gynecological condi-
tion. Treat conservatively.
“Impressive” abdominal examination with no apparent gynecological pathol-
ogy. This is perhaps the best indication for diagnostic/therapeutic laparoscopy.
“Not sure.” Admit and observe with or without a computed tomographic
(CT) scan (> Chaps. 3 and 28).
Ectopic Pregnancy
The great French surgeon Henri Mondor (1885–1962) said:
“When faced with an acute abdomen, consider ectopic pregnancy, think always
about it always. Just thinking about it again is not enough, keep thinking about it.”
Ectopic means that the fertilized ovum has implanted somewhere outside
the usual location (i.e., the body of the uterus). The most common site for an ectopic is the tubes, but implantation may occur in the ovary, cervix, and abdominal
350 Bernard Cristalli · Moshe Schein
cavity. Heterotopic pregnancy (intrauterine and ectopic pregnancy at the same
time) is so rare that if a normal pregnancy is seen, an ectopic can be ruled out.
Abdominal pregnancy is a late ectopic pregnancy with development of a fetus.
Although the presentation of these patients varies tremendously, typically
they have abdominal pain and vaginal bleeding. Many women do not even know
about the pregnancy, ignoring associated symptoms of pregnancy such as a missed
menstrual period. Some elements of history may be considered risk factors: previous history of ectopic pregnancy, PID, tubal surgery (including tubal ligation!), endometriosis. Contraception with an intrauterine device (IUD) is not a risk factor in
itself, but an early pregnancy with an IUD in situ has to be considered ectopic until
proven otherwise. An IUD prevents intrauterine pregnancies but not ectopics!
The diagnosis rests on a tripod of pregnancy, pain, and bleeding. Typically,
the patient arrives with a sharp and sudden unilateral pelvic pain, mild brownish
bleeding, and pregnancy (positive pregnancy test) with an empty uterus at US.
The diagnosis comes easily when the woman knows she is pregnant and has vaginal bleeding. It can be a lot more difficult when pain is the only sign, and the
pregnancy is yet to be discovered. Cataclysmic hemorrhage is very rare now, but
any internal hemorrhage syndrome in a woman is a ruptured ectopic pregnancy
until proven otherwise.
Physical findings: signs of hypovolemic shock and peritoneal irritation are
proportional to the amount of blood loss. On pelvic examination, you may find a
parauterine painful mass or at least a “little something” next to the uterus. The
pouch of Douglas is tender and may contain a boggy mass (hematocele).
Ultrasound is the imaging of choice to show the ectopic gestational sac and
free intraperitoneal bleeding.
Management: although some ectopic pregnancies may resolve and absorb
spontaneously over time, the standard of care is an operative approach in all cases.
As a general surgeon, you are more likely to be involved with the more dramatic
scenario of a ruptured tubal ectopic (usually affecting the distal segment of the
tube), which may occur as early as the fourth week of gestation. The sudden develop-
ment of acute peritonitis and hypovolemic shock will force you to rush to the oper-
ating room without the gynecologist and perform a laparotomy. Whether to enter
the abdomen through a midline incision or a Pfannenstiel incision depends on the
urgency of the situation and the build of the patient. Evacuate the gestational sac,
control the bleeding sites with suture-ligatures, and preserve the ovary. Less-dramatic
presentations are usually managed by or in partnership with the gynecologist, preferably through the laparoscope. In early cases, the uterus is normal or mildly en-
larged, and the ectopic pregnancy can be seen as a tube swollen by a blue “tumor”;
there is a small-to-moderate amount of black blood in the pouch of Douglas. Note
that in most ectopics at operation the bleeding has already stopped; when it is active,
it may necessitate a simple salpingectomy. When the ovaries are left intact, the patient can still undergo in vitro fertilization even after bilateral salpingectomies.
33 Gynecological Emergencies 351
Ovarian Cysts
Ovarian cysts are common in young women; they are usually “functional”
cysts (follicular or corpus luteum) and mostly asymptomatic. However, when cysts
develop in postmenopausal women, ovarian cancer has to be suspected and excluded. Only complicated ovarian cysts, regardless of etiology, present as surgical
emergencies.
Acute pain develops when a cyst bleeds or undergoes torsion. The intensity
of pain and abdominal signs of peritoneal irritation are proportional to the
amount of bleeding. Pain is severe in the case of torsion. In women of childbear-
ing age, complications of ovarian cyst may mimic acute appendicitis. To prevent
unnecessary operation, you have to image the abdomen (> Chap. 28).
Imaging: typically, functional cysts are solitary, simple, and small (<8 cm).
Free fluid in the pouch of Douglas suggests rupture and bleeding. Larger and
more complex cysts suggest pathology, such as dermoid cyst. Absence of blood
flow on US strongly indicates torsion. Commonly today, such patients initially
undergo a CT examination “to exclude acute appendicitis,” which in addition to
showing a normal appendix may document the free pelvic fluid and the ovarian
pathology. If this is the case, we would follow up with a transvaginal US, which
is more accurate in delineating the pelvic pathology.
Management: small (<8 cm) simple ruptured cysts with minimal local and
systemic findings should be treated conservatively. If, however, the rupture re-
sults in significant intraperitoneal hemorrhage and when another pathology cannot be ruled out (e.g., larger or complex cysts), surgical intervention is indicated.
Laparoscopy is preferable for smaller cysts and when malignancy is not suspected, but for very large cysts (>10 cm) laparotomy allows removal of the intact
ovarian mass without disrupting it. Whether you can do it through a Pfannenstiel
incision depends on the build of the patient. Torsion is usually associated with
more severe and persistent pain and more dramatic abdominal findings together
with systemic manifestations; it is an indication for operation. At operation, if
there is active bleeding from the cyst, obtain local hemostasis by whichever
means. There is no need to aspirate or resect the cyst and, please, do not even
think of removing the ovary. If viable, the tube and ovary can be detorted and
conserved; only if clearly nonviable is the ovary resected. Dermoid cysts are resected. Discussion of ovarian malignancies is beyond the scope of this book.
Pelvic Inflammatory Disease
Pelvic inflammatory disease is seldom a surgical emergency now, but it remains a frequent reason to visit the emergency room. Its is an infective syndrome that involves, to a greater or lesser extent, the endometrium, tubes, and
352 Bernard Cristalli · Moshe Schein
ovaries. The patient is commonly young and sexually active. The clinical spectrum
of infection is wide, ranging from minimal pain, dyspareunia, fever, and vaginal
discharge, associated with mild endometritis/salpingitis, to severe peritonitis and
septic shock due to ruptured tubo-ovarian abscess. Likewise, physical findings depend on the disease process and vary from localized abdominal tenderness to generalized tenderness and rebound. Note that the pain and tenderness are commonly
bilateral. Pelvic examination reveals purulent discharge with cervical motion tenderness. Ovarian or pelvic abscesses may be palpated or seen on US or CT.
Treatment: without treatment, the infection may develop into a tubal abscess and then spread intrapelvically and result in a true peritonitis. The late risk
is tubal obstruction and pelvic adhesions, leading to infertility and chronic pelvic pain. The majority of mild cases should be treated with antibiotics. Outpatient
treatment is appropriate for patients who can tolerate oral diet. Patients with
severe abdominal and systemic manifestation should be admitted for intravenous antibiotic therapy. Antibiotic treatment is empiric, targeting the common
causative organisms, which are, in isolation or combination, Chlamydia tracho-
matis, Neisseria gonorrhea, Escherichia coli, and Haemophilus influenzae. Many
oral and intravenous agents are available.
Patients who do not respond to this regimen or in whom the diagnosis is
uncertain are subjected to laparoscopy. This should be left to the gynecologist.
The typical case you will be involved with is the ruptured tubo-ovarian abscess,
causing severe pelvic or diffuse peritonitis. During laparotomy or laparoscopy,
you will find pus; you read how to deal with peritonitis in > Chap. 12. The abscess
should be drained; whether to remove the uterus and ovaries depends on the age
of the patient, the operative findings, and the patient’s gynecologist. When talking about PID, “formal” textbooks usually mention the Curtis-Fitz-Hugh syn-
drome or “perihepatitis” as a late sequela—ascending from the pelvis. Although
originally associated with gonococcal infection, nearly all present-day cases are
associated with C. trachomatis infection. It may produce nonspecific abdominal
complaints and has been reported to mimic acute cholecystitis, but in our experience it has never represented a specific entity warranting operative measures.
We have seen it, however, as an incidental finding of perihepatic “piano-string”
adhesions at laparoscopy or laparotomy for other conditions.
Vaginal Tears
Vaginal tears are rare but may cause severe hemorrhage representing a true
gynecological emergency. A vaginal tear can occur in young females at their first
intercourse—the “bloody defloration” (what a way to spend her wedding night!).
It can affect women of any age who experience violent or peculiar sexual relations
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