Continuous Peritoneal Lavage Research Articles

SOME ASPECTS OF SURGICAL TREATMENT OF DIFFUSE PERITONITIS

The purpose of the study was to analyze the characteristics of the course and outcome in patients with diffuse peritonitis, depending on the methods of repeated sanitation and drainage of the abdominal cavity and ultrasound monitoring. The authors carried out a retro-spective analysis of the results of treatment of 102 patients. All patients were divided into 2 groups depending on the method of treatment, with randomization by extent and phase of peritonitis. In the group 1, a semi-open method of treatment was used: sanitation and drainage of the abdominal cavity with continuous peritoneal lavage, and staged relaparotomy according to indications. In the group 2, video laparoscopic sanitation and drainage of the abdominal cavity on demand were applied. In this group, with the Mannheim Peritonitis Index below 15 points, drainage was not performed. With the Mannheim index below 20 points, 1–2 drains were installed, when above 25 points — 3–4 drains. Postoperative complications in patients of the group 1 were found in 40.9%. In the group 2, there were fewer complications compared the group 1. This was due not only to fewer local complications, but also intra-abdominal complications, which were almost 2 times fewer. Thus, video laparoscopic sanitation is the method of choice for planned repeated sanitation of the abdominal cavity. Relaparotomy should be performed only with strict indications in the event of intra-abdominal complications and if video laparoscopic sanitation cannot be performed. Ultrasound monitoring in the post-operative period makes it possible to timely identify postoperative complications, differentiate their nature and exact localization.

Continue peritoneal lavage in acute pancreatitis: How do peritoneal cells response?

Continuous peritoneal lavage is part of a set of minimally invasive techniques, called the Step up approach. These techniques have been used in the management of acute necrotizing (severe) pancreatitis (SAP), as they remove toxins and reduce serious metabolic disorders, although their effects on mild acute pancreatitis and on the content of peritoneal cells during mild and SAP are still unknown, since inflammation is an important factor in the progression of the disease. The peritoneum is a tissue with important immunological functions, and the characterization of peritoneal cells during acute pancreatitis can be a relevant strategy to understand the mechanism by which peritoneal lavage has worked during clinical practice, as well as to uncover possible pharmacological targets. This review presents an approach to minimally invasive techniques in the management of AP, emphasizing peritoneal lavage and its nuances.

History of Medicine: The Emergence of Intestinal Dialysis.

Abstract In 1923, Georg Ganter at the University of Würzburg performed the first peritoneal dialysis for patients with chronic kidney disease. During the period from 1924 to 1938, intermittent peritoneal dialysis was used in the USA and Germany as a short-term replacement for the renal functions. In 1946, Fine and colleagues described the use of peritoneal irrigation in a patient with severe anuria, who survived after four days of continuous peritoneal lavage. In 1943, a Dutch physician named Willem Kolff developed the first dialyzer which was called “Artificial kidney” with aim of cleaning the blood of patients with acute renal failure. Kolff moved to the USA and improved the early design of the dialyzer and was manufactured in the early 1950s. During the 1980s and 1990s, experimental studies on animals suggested that dietary fibers including acacia gum have a urea lowering effect (Yatzidis et al., 1980; Rampton et al., 1984; Tetens et al., 1996). In 1996, in 1996, Bliss et al. reported that the use of acacia gum supplementation in adult patients with asymptomatic early chronic renal failure on low protein diet was associated with urea lowering effect. The use of Intestinal dialysis in symptomatic chronic renal failure patients was first described by Aamir Jalal Al-Mosawi in 2002. The achievement of six-year dialysis freedom with the use of intestinal dialysis in patients with end-stage renal failure was described by Aamir Jalal Al-Mosawi in 2009. Late during the 2000s, “Only medical talks” web site included Aamir Jalal Al-Mosawi in the list of famous physicians of all time for describing intestinal dialysis [9]. During the previous two decades there have been a plethora of publications describing the concepts, principles and use of intestinal dialysis including journal articles, conference papers and books. Some of these publications have been translated to eight languages confirming that intestinal dialysis has become an established medical therapeutic technology. The aim of this paper is to review the milestones associated with intestinal dialysis which was considered by many experts as a Nobel Prize winning technology.

A prolonged multispecies outbreak of IMP-6 carbapenemase-producing Enterobacterales due to horizontal transmission of the IncN plasmid

A multispecies outbreak of IMP-6 carbapenemase-producing Enterobacterales (IMP-6-CPE) occurred at an acute care hospital in Japan. This study was conducted to understand the mechanisms of IMP-6-CPE transmission by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing and whole-genome sequencing (WGS), and identify risk factors for IMP-6-CPE acquisition in patients who underwent abdominal surgery. Between July 2013 and March 2014, 22 hospitalized patients infected or colonized with IMP-6-CPE (Escherichia coli [n = 8], Klebsiella oxytoca [n = 5], Enterobacter cloacae [n = 5], Klebsiella pneumoniae [n = 3] and Klebsiella aerogenes [n = 1]) were identified. There were diverse PFGE profiles and sequence types (STs) in most of the species except for K. oxytoca. All isolates of K. oxytoca belonged to ST29 with similar PFGE profiles, suggesting their clonal transmission. Plasmid analysis by WGS revealed that all 22 isolates but one shared a ca. 50-kb IncN plasmid backbone with blaIMP-6 suggesting interspecies gene transmission, and typing of plasmids explained epidemiological links among cases. A case-control study showed pancreatoduodenectomy, changing drains in fluoroscopy room, continuous peritoneal lavage and enteric fistula were associated with IMP-6-CPE acquisition among the patients. Plasmid analysis of isolates in an outbreak of IMP-6-CPE suggested interspecies gene transmission and helped to clarify hidden epidemiological links between cases.

Continuous peritoneal lavage with vacuum peritoneostomy: an experimental study

OBJECTIVE:Despite advances in diffuse peritonitis treatment protocols, some cases develop unfavorably. With the advent of vacuum therapy, the use of laparostomy to treat peritonitis has gained traction. Another treatment modality is continuous peritoneal lavage. However, maintaining this technique is difficult and has been associated with controversial results. We propose a new model of continuous peritoneal lavage that takes advantage of the features and benefits of vacuum laparostomy.METHOD:Pigs (Landrace and Large White) under general anesthesia were submitted to laparostomy through which a multiperforated tube was placed along each flank and exteriorized in the left and lower right quadrants. A vacuum dressing was applied, and intermittent negative pressure was maintained. Peritoneal dialysis solution (PDS) was then infused through the tubes for 36 hours. The stability of peritoneostomy with intermittent infusion of fluids, the system resistance to obstruction and leakage, water balance, hemodynamic and biochemical parameters were evaluated. Fluid disposition in the abdominal cavity was analyzed through CT.RESULTS:Even when negative pressure was not applied, the dressing maintained the integrity of the system, and there were no leaks or blockage of the catheters during the procedure. The aspirated volume by vacuum laparostomy was similar to the infused volume (9073.5±1496.35 mL versus 10165±235.73 mL, p=0.25), and there were no major changes in hemodynamic or biochemical analysis. According to CT images, 60 ml/kg PDS was sufficient to occupy all intra-abdominal spaces.CONCLUSION:Continuous peritoneal lavage with negative pressure proved to be technically possible and may be an option in the treatment of diffuse peritonitis.

Clinical effectiveness of continuous peritoneal lavage in moderately severe to severe acute pancreatitis

Purpose: This study aims to evaluate the clinical effectiveness of continuous peritoneal lavage in moderately severe to severe acute pancreatitis (AP). Materials and Methods: We studied 58 patients with moderately severe to severe AP who were admitted from January 2015 to April 2017. Among these patients, 31 patients were treated only conventional therapy (control group). Twenty-seven patients were received continuous peritoneal lavage with conventional therapy (study group). Laboratory parameters and severity scores were compared before and 7 days after therapy between two groups. Mortality rate, the incidence of local complications and length of hospital stay were also compared between two groups. Results: There were no adverse events (bowel perforation and bleeding) associated with abdominal paracentesis for peritoneal lavage. The level of all parameters (white blood cell [WBC], C reactive protein [CRP], serum amylase, lactate dehydrogenase [LDH], blood glucose, serum creatinine, base excess, and serum calcium) and all the severity scores (systemic inflammatory response syndrome [SIRS], Marshall) were significantly improved 7 days after treatment compared before therapy in two groups (P < 0.05). We also compared the level of all laboratory parameters and severity scores between two groups 7 days after therapy. The level of serum amylase, blood glucose, and serum calcium was similar between two groups 7 days after treatment. In the study group, the level of WBC, CRP, LDH, serum creatinine, base excess, and severity scores (SIRS, Marshall) was significantly improved compared with control group 7 days after therapy (P < 0.05). Mortality rate was significantly decreased in the study group compared with control group (7.4% vs. 16.1%, P < 0.01). The incidence of local complication had also a significant difference between two groups (22.2% vs. 35.5%, P < 0.05). The length of hospital stay was significantly reduced in the study group compared with control group (33.1 ± 28.0 vs. 48.9 ± 36.2 days, P < 0.01). Conclusion: Continuous peritoneal lavage can significantly reduce mortality, complications, and length of hospital stay in moderately severe to severe AP.

A Clinical Study of Continuous Peritoneal Lavage in the Treatment of Endoscopic Iatrogenic Peritoneal Contamination and Infection

A Clinical Study of Continuous Peritoneal Lavage in the Treatment of Endoscopic Iatrogenic Peritoneal Contamination and Infection

Animal model of continuous peritoneal lavage with vacuum peritoneostomy.

To establish and evaluate the feasibility of continuous peritoneal lavage with vacuum peritoneostomy in an animal model. Eight pigs aged 3-4 months, females, were anesthetized and submitted to laparotomy and installation of a continuous peritoneal lavage with vacuum peritoneostomy. The sta-bility of the system, the physiological effects of washing with NaCl 0.9% and the sys-tem clearance were evaluated. Stability of vacuum peritoneostomy was observed, with no catheter leaks or obstructions and the clearance proved adequate, however, the mean volume of fluids aspirated by the peritoneostomy at the end of the experiment was higher than the volume infused by the catheters (p=0.02). Besides that, the animals presented a progressive increase in heart rate (p=0.04) and serum potassium (p=0.02). The continuous peritoneal lavage technique with vacuum peritoneostomy is feasible and presents adequate clearance.

Clinical Value of Continuous Peritoneal Lavage for the Treatment of Iatrogenic Peritonitis After Endoscopic Intervention

Clinical Value of Continuous Peritoneal Lavage for the Treatment of Iatrogenic Peritonitis After Endoscopic Intervention

English

The aim of this study was to study the effect of ozonized saline solutions administered intraperitoneally in rabbits suffering from severe acute pancreatitis with infected necrosis. The acute pancreatitis was induced by infusion of sodium taurocholate into the main pancreatic duct and in the next 24 h, a cecal fistula was created to obtain infection of the pancreatic necrosis with intestinal germs. The rabbits were divided into 3 groups of study and each of them underwent continuous peritoneal lavage 2 times a day for 5 days with simple saline (control group), ozonized saline solution 5 mg/L (group A) and respectively ozonized saline solution 9 mg/L processed under an intense electric field (group B). Serum level of C-reactive protein and total peroxides, bacterial content of the peritoneal liquid and tissue specimens from the pancreas and the peripancreatic area were evaluated. Six days after the induction of pancreatitis all surviving animals were sacrificed. Serum levels of C-reactive protein and total peroxides in rabbits treated with ozonized saline solution were significantly lower as compared to those of rabbits belonging to the control group. Regarding bacterial growth, a significant decrease was obtained in the peritoneal liquid or even no bacterial growth in groups A and B. Histological examination of the tissue showed specific pancreatic changes in all the groups, but less expressed in groups A and B. No significant differences were encountered between rabbits treated with different ozone concentrations. Intraperitoneal ozone therapy is effective in the amelioration of acute pancreatitis by means of laboratory analysis and decreased bacterial growths. Key words: Severe acute pancreatitis, ozone-therapy, infection of pancreatic necrotic tissues, intense electric fields.

Su1520 Clinical Value of Continuous Peritoneal Lavage for the Treatment of Latrogenic Peritonitis After Endoscopic Intervention

Su1520 Clinical Value of Continuous Peritoneal Lavage for the Treatment of Latrogenic Peritonitis After Endoscopic Intervention

Automated peritoneal lavage: an extremely rapid and safe way to induce hypothermia in post-resuscitation patients

IntroductionMild therapeutic hypothermia (MTH) is a worldwide used therapy to improve neurological outcome in patients successfully resuscitated after cardiac arrest (CA). Preclinical data suggest that timing and speed of induction are related to reduction of secondary brain damage and improved outcome.MethodsAiming at a rapid induction and stable maintenance phase, MTH induced via continuous peritoneal lavage (PL) using the Velomedix® Inc. automated PL system was evaluated and compared to historical controls in which hypothermia was achieved using cooled saline intravenous infusions and cooled blankets.ResultsIn 16 PL patients, time to reach the core target temperature of 32.5°C was 30 minutes (interquartile range (IQR): 19 to 60), which was significantly faster compare to 150 minutes (IQR: 112 to 240) in controls. The median rate of cooling during the induction phase in the PL group of 4.1°C/h (IQR: 2.2 to 8.2) was significantly faster compared to 0.9°C/h (IQR: 0.5 to 1.3) in controls. During the 24-hour maintenance phase mean core temperature in the PL patients was 32.38 ± 0.18°C (range: 32.03 to 32.69°C) and in control patients 32.46 ± 0.48°C (range: 31.20 to 33.63°C), indicating more steady temperature control in the PL group compared to controls. Furthermore, the coefficient of variation (VC) for temperature during the maintenance phase was lower in the PL group (VC: 0.5%) compared to the control group (VC: 1.5%). In contrast to 23% of the control patients, none of the PL patients showed an overshoot of hypothermia below 31°C during the maintenance phase. Survival and neurological outcome was not different between the two groups. Neither shivering nor complications related to insertion or use of the PL method were observed.ConclusionsUsing PL in post-CA patients results in a rapidly reached target temperature and a very precise maintenance, unprecedented in clinical studies evaluating MTH techniques. This opens the way to investigate the effects on neurological outcome and survival of ultra-rapid cooling compared to standard cooling in controlled trials in various patient groups.Trial RegistrationClinicalTrials.gov: NCT01016236See related letter by Esnault et al., http://ccforum.com/content/17/3/431

Is automated peritoneal lavage a better way than an endovascular device to induce mild therapeutic hypothermia after resuscitated cardiac arrest?

We read with great interest the study by de Waard and colleagues highlighting interest in continuous peritoneal lavage (PL) to induce mild therapeutic hypothermia (MTH) in unconscious patients after resuscitated cardiac arrest [1]. It is now quite well established that MTH improves outcome [2]. Compared with cooled intravenous infusion and cooled blankets, the authors showed that the target temperature was reached faster (30 minutes vs. 150 minutes) and had a lower coefficient of variation during the maintenance phase (0.5% vs. 1.5%) in the PL group [1]. However, using this PL method in daily practice seems difficult to us and this device must be used by experimented operators (usually surgeons) to limit the complications. In our unit, we have used an intravascular device consisting of a central venous catheter (Icy™ catheter; ALSIUS Corporation, Irvine, CA, USA) associated with an external heat exchange system (CoolGard 3000™; ALSIUS Corporation). This device acts as a thermostat for core body temperature control. This system replaces the triple-lumen central venous catheter, whose efficacy is proven [3,4]. The CoolGard 3000™ allows fast cooling, stability of the temperature and controlled progressive reheating. Few complications have been reported and have been essentially related to the central venous access (placement errors, catheter-related thrombosis, infection) [5]. The system's main limitation is its accessibility and its cost. To conclude, although PL is interesting to obtain MTH in post-resuscitation patients, we believe that the use of an endovascular device seems to have a better benefit/risk ratio.

The history of peritoneal dialysis: Early years at Toronto Western Hospital

The history of peritoneal dialysis: Early years at Toronto Western Hospital

Clinical effects of laparotomy with perioperative continuous peritoneal lavage and postoperative hemofiltration in patients with severe acute pancreatitis

BackgroundThe elevated serum and peritoneal cytokine concentrations responsible for the systemic response syndrome (SIRS) and multiorgan failure in patients with severe acute pancreatitis lead to high morbidity and mortality rates. Prompted by reports underlining the importance of reducing circulating inflammatory mediators in severe acute pancreatitis, we designed this study to evaluate the efficiency of laparotomy followed by continuous perioperative peritoneal lavage combined with postoperative continuous venovenous diahemofiltration (CVVDH) in managing critically ill patients refractory to intensive care therapy. As the major clinical outcome variables we measured morbidity, mortality and changes in the Acute Physiology and Chronic Health Evaluation (APACHE II) score and cytokine concentrations in serum and peritoneal lavage fluid over time.MethodsFrom a consecutive group of 23 patients hospitalized for acute pancreatitis, we studied 6 patients all with Apache II scores ≥19, who underwent emergency surgery for acute complications (5 for an abdominal compartment syndrome and 1 for septic shock) followed by continuous perioperative peritoneal lavage and postoperative CVVDH. CVVDH was started within 12 hours after surgery and maintained for at least 72 hours, until the multiorgan dysfunction syndrome improved. Samples were collected from serum, peritoneal lavage fluid and CVVDH dialysate for cytokine assay. Apache II scores were measured daily and their association with cytokine levels was assessed.ResultsAll six patients tolerated CVVDH well, and the procedure lasted a mean 6 days (range, 3-12). Five patients survived and one died of Acinetobacter infection after surgery (mortality rate 16.6%). The mean APACHE II score was ≥ 19 (range 19-22) before laparotomy and decreased significantly during peritoneal lavage and postoperative CVVDH (P = 0.013 by matched-pairs Students t-test). The decrease in cytokine concentrations in serum and lavage fluid was associated with the decrease in APACHE II scores and high interleukin 6 (IL-6) and tumor necrosis factor (TNF) concentrations in the hemofiltrate.ConclusionIn critically ill patients with abdominal compartment syndrome, septic shock or high APACHE II scores related to severe acute pancreatitis, combining emergency laparotomy with continuous perioperative peritoneal lavage followed by postoperative CVVHD effectively reduces the local and systemic cytokines responsible for multiorgan dysfunction syndrome thus improving patients' outcome.

Surgical intervention in patients with necrotizing pancreatitis

This study evaluated the various surgical strategies for treatment of (suspected) infected necrotizing pancreatitis (INP) and patient referrals for this condition in the Netherlands. This retrospective study included all 106 consecutive patients who had surgical treatment for INP in the period 2000-2003 in one of eight Dutch university medical centres including three teaching hospitals. Surgical approaches included an open abdomen strategy, laparotomy with continuous postoperative lavage, minimally invasive procedures or laparotomy with primary abdominal closure. The National Hospital Registration System was searched to identify patients with acute pancreatitis who were admitted to the 90 Dutch hospitals that did not participate in the present study. The overall mortality rate was 34.0 per cent, 70 per cent (16 of 23) for the open abdomen strategy, 25 per cent (13 of 53) for continuous peritoneal lavage, 11 per cent (two of 18) for minimally invasive procedures and 42 per cent (five of 12) for primary abdominal closure (P < 0.001). During the study interval, 44 (12.2 per cent) of 362 patients with acute pancreatitis who were likely to require surgical intervention had been referred to university medical centres. Laparotomy with continuous postoperative lavage is the surgical strategy most often used in the Netherlands. The results of the open abdomen strategy are poor whereas a minimally invasive approach seems promising.

A meta-analysis of peritoneal lavage for acute pancreatitis.

It has been postulated that continuous irrigation of the peritoneal cavity with crystalloid solutions in patients with acute pancreatitis can improve mortality and morbidity. The aim of the study is to perform a meta-analysis of available randomized prospective clinical trials, to evaluate whether lavage influences mortality and morbidity in patients with acute pancreatitis. We performed a computer search of Medline for all available literature on the use of lavage in patients with acute pancreatitis. A meta-analysis was conducted on eight randomized, prospective, clinical trials (a total of 333 patients) evaluating continuous peritoneal lavage in patients with acute pancreatitis. The end-points were mortality and morbidity (i.e. pancreatic necrosis, peripancreatic fluid collections, intra-abdominal abscess formation, septicemia, organ system failure). Continuous lavage did not improve either mortality (weighted mean difference 1.6%, 95% CI -6.7% to 9.9%, not significant (n.s.)) or morbidity (weighted mean difference 6.2%, 95% CI -3.2% to 15.6%, n.s.) when compared with control patients. The use of continuous peritoneal lavage in patients with acute pancreatitis has not been found to be associated with any significant improvement in mortality or morbidity.

Peritonitis in childhood: aspects of pathogenesis and therapy.

The pathogenesis of peritonitis due to hollow-viscus perforation is currently accepted as being mainly based on the local and systemic release of pro- and anti-inflammatory mediators triggered by the presence of bacteria and bacterial products in the abdominal cavity. Therefore, treatment consists in focal restoration, intraoperative debridement and lavage, and postoperative measures such as drainage, continuous peritoneal lavage, or scheduled reoperation aiming at the removal of infectious agents from the peritoneal cavity to prevent persisting peritonitis and sepsis. In order to evaluate the pathophysiologic relevance of the bacterial and endotoxin load of the peritoneal exudate, we examined the peritoneal fluid of 20 children with perforated appendicitis for qualitative and quantitative analysis of bacteria, antibiotic concentrations, and endotoxin content. The time period ranged in 12-h intervals from intraoperatively to day 5. Eighteen of 20 fluid specimens (90%) showed endotoxin levels above 1.5 endotoxin units EU/ml (standard <0.1 EU/ml). The most common bacterial species isolated was Escherichia coli, mostly in high concentrations. Despite persisting high endotoxin concentrations and bacterial loads in the peritoneal cavity during the 5 postoperative days, the children recovered uneventfully and the systemic signs of infection disappeared rapidly. In conclusion, neither the bacterial nor the endotoxin load of the peritoneal cavity proved to be associated with the clinical course. Therefore, we hypothesize that during peritonitis compartmentalization of the focus of infection prevents further systemic reactions and ultimately leads to removal of the infectious agents by endogenous mechanisms. At least in peritonitis due to perforated appendicitis in children, adjuvant surgical measures in addition to appendectomy and intraoperative debridement are not necessary.

Factors Increasing Severity of Peritonitis in Long-Term Peritoneal Dialysis Patients

Peritonitis is the most frequent complication and a leading cause of discontinuation of peritoneal dialysis (PD). Intact epithelial lining, sufficient blood flow, and adequate immunologic responses are vital to eradicate infection. In long-term PD, various pathological changes such as denudation of peritoneal mesothelial cells, duplication of submesothelial and/or capillary basement membranes, submesothelial fibrin deposit, and peritoneal fibrosis have been reported. Causes of these changes of the peritoneum are multifactorial. Commonly used dialysis solutions that are acidic, hypertonic, containing high concentrations of glucose and lactate, contaminated by glucose and/or plastic degradation products are not biocompatible and may induce chronic immune reactions in the peritoneal cavity. Long-term exposure of the peritoneum to dialysis solutions, the peritoneal catheter, and recurrent episodes of peritonitis all contribute to peritoneal injury. In addition, long-term exposure of peritoneal cells such as macrophages, mesothelial cells, and fibroblasts to dialysis solutions may also alter the normal immunologic reactions against bacteria. Peritoneal concentrations of opsonins such as Ig, complement, and protease are approximately 1% of the serum levels and far below the level sufficient to eradicate bacteria due to continuous peritoneal lavage and dilution with dialysis solutions. Furthermore, glycation of IgG induces chronic activation of macrophages and decreases normal opsonic activities against bacteria. Fibrin deposits, collagen accumulation, and cellular desert of the peritoneum observed in long-term peritoneal dialysis patients may serve as a safe shelter for bacteria from contact with inflammatory cells and opsonin and delay eradication of bacteria. In conclusion, peritonitis is often more severe in patients on long-term PD. In this setting, peritonitis needs special attention to prevent life-threatening infection and further damage of the peritoneum.

Hemoperitoneum in Peritoneal Dialysis Secondary to Retroperitoneal Hematoma

Editor: Hemoperitoneum is an unusual complication in patients undergoing CAPD (1). In most cases it has a benign course. Two milliliters of blood can dye the peritoneal effluent an intense red. The most frequent cause is endometriosis. However, other gynecological, hematological, tumoral, and abdominal sources can cause hemoperitoneum. Polycystic kidney disease, peritonitis, pancreatitis, cholecystitis, and extracorporeal lithotripsy are other possibilities. Rarely, hemoperitoneum is associated with rupture of the spleen (2) or iliopsoas spontaneous hematoma (3). We present a case of hemoperitoneum consequent to retroperitoneal hematoma after manipulating a double-lumen femoral catheter for hemodialysis. This 44-year-old woman with systemic lupus erythematosus and end-stage renal disease has been on hemodialysis for the last three years. Because of thrombosis of every possible vascular access site, it was decided to change her to peritoneal dialysis. A left Swan neck Missouri peritoneal catheter was placed by surgical technique without complication. A peritoneal lavage at the seventh and fourteenth day was clear. The patient continued on hemodialysis through a doublelumen femoral catheter on the right side. We waited four weeks before standard CAPD was begun. Seventeen days after placement of the peritoneal catheter, during a hemodialysis session, her femoral catheter was changed through a guide wire because of poor flow. Suddenly, she developed severe pain in the right lumbar fossa, right hemiabdomen, and acute anemia and hypovolemic shock occurred. The femoral catheter was removed, and she received intravenous fluids and transfusion of six packed red blood cells, achieving hematologic and hemodynamic stabilization. No surgery was required. A computed tomography scan of the abdomen showed retroperitoneal hematoma involving the right anterior and posterior pararenal space and right iliopsoas muscle. Twenty-four hours later, nightly intermittent peritoneal dialysis was begun. The first peritoneal effluent was very bloody. After continuous peritoneal lavage with 1-L exchanges at room temperature over two hours, the dialysate became clear. One year later, the patient continues on continuous cycling peritoneal dialysis without any problems. To our knowledge, this cause of hemoperitoneum has not been reported before. Therefore, we believe that retroperitoneal hematoma secondary to hemodialysis with a femoral catheter may be listed in the causes of hemoperitoneum in peritoneal dialysis. F. Fernandez Giron F. Hermosilla Sanchez M. Paralle Alcalde J. Gonzalez Martinez