Extraperitoneal Fluid Research Articles

An Incidental Discovery of a Serious Complication

An Incidental Discovery of a Serious Complication

Enterocutaneous Fistula and Abscess Diagnosed with Point-of-care Ultrasound.

Case PresentationA 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented with 10 days of abdominal and flank pain. The patient was tachycardic, normotensive, afebrile, and had an erythematous, tender, protuberant abdominal wall mass. Point-of-care ultrasound (POCUS) revealed an irregular, heterogeneous extraperitoneal fluid collection with intraperitoneal communication; these findings were consistent with an abscess and infected mesh with evidence for intraperitoneal extension. The diagnosis of enterocutaneous fistula (ECF) with infected mesh and abdominal wall abscess was confirmed with computed tomography and the patient was admitted for antibiotics and source control.DiscussionA rare complication of hernia repair with mesh, ECF typically occurs later than more common complications including cellulitis, hernia recurrence, and bowel obstruction. In the emergency department, POCUS is commonly used to evaluate for abscess; in other settings, comprehensive ultrasound is used to evaluate for complications after hernia repair with mesh. However, to date there is no literature reporting POCUS diagnosis of ECF or mesh infection. This case suggests that distant surgery should not preclude consideration of mesh infection and ECF, and that POCUS may be useful in evaluating for these complications.

RADIATION DIAGNOSIS OF ABDOMINAL TRAUMA IN CHILDREN

Blunt abdominal trauma is one of the leading causes of the morbidity and mortality in all age groups. Among all the causes of deaths due to injury, abdominal damage accounted of about 10%, and in children - 8.5%. Timely imaging takes a key place in assessing abdominal injury in traumatized children. Computer tomography (CT) is a method of visualization that allows recognize and evaluate characteristic signs of the traumatic damage in hemodynamically stable children. Modern multislice spiral computer tomographs (MSCT) provide high quality of the image due to the improvement of both scanning methods and post-processing facilities. Currently, CT allows most accurately detect lesions of parenchymal and hollow organs, as well as reveal and quantify intraperitoneal and extraperitoneal fluid and blood. In addition, CT has an exceptional sensitivity in the diagnosis of the combined trauma of various organs and systems. The use of CT as the main screening method for the examination of traumatized children along with the improvement of maintenance therapy plays a crucial role in the success of the not operative treatment of trauma to parenchymatous organs. The rapid assessment of the state of traumatized children according to CT findings also contributed to the decline of the incidence of complications and mortality rate. The decision about surgical intervention in a small number of children in need of surgical treatment is primarily made on the basis of clinical criteria, not CT results. Thus, CT mainly determines non-operative decisions regarding, for example, duration of hospitalization, intensity of care and limitation of the activity. In this paper, we propose a standardized CT technique and the main symptomatology that determines the severity of the damage of abdominal organs in children, based on own experience, taking into account the world literature data on CT.

Chronic pancreatitis with extra peritoneal fluid collection misleadingly presenting as ascites

A 30 year old male was admitted to our medical ward with recurrent abdominal distension. He had multiple admissions for therapeutic and diagnostic peritoneal tapping, but culture & cytology came back negative. He was initially treated as alcoholic chronic liver disease (CLD) Child-Pugh B. Despite having recurrent admissions and treated as decompensated alcoholic CLD with spontaneous bacterial peritonitis, his peritoneal fluid cultures were negative and medical therapy for CLD failed to improve symptoms. We proceeded with Computed Tomography Abdomen and showed a large collection of fluid in the extraperitoneum with mild ascites. Subsequently, pigtail catheter was inserted under ultrasound guidance to drain extraperitoneal fluid and biochemistry came back with high amylase level of 9043 U/L and total protein of 1.2 g/dL. As fluid amylase level >1000 U/L, it fulfills the criteria for chronic pancreatitis and he was managed conservatively with continuous fluid drainage. Patient improved gradually.

Cross-sectional imaging of thoracic and abdominal complications of cerebrospinal fluid shunt catheters.

This study aims to review the imaging findings of distal (thoracic and abdominal) complications related to ventriculo-peritoneal (VP), ventriculo-pleural (VPL), and ventriculo-atrial (VA) cerebrospinal fluid (CSF) shunt catheter placement. Institution review board-approved single-center study of patients with thoracic and abdominal CSF catheter-related complications on cross-sectional imaging examinations over a 14-year period was performed. Clinical presentation, patient demographics, prior medical history, and subsequent surgical treatment were recorded. The presence or absence of CSF catheter-related infection and/or acute hydrocephalus on cross-sectional imaging was also recorded. There were 81 distal CSF catheter-related complications identified on 47 thoracic or abdominal imaging examinations in 30 patients (age 5-80 years, mean 39.3 years), most often on CT (CT = 42, MRI = 1, US = 4). Complications included 38 intraperitoneal and 11 extraperitoneal fluid collections. Extraperitoneal collections included nine abdominal wall subcutaneous (SC) pseudocysts associated with shunt migration and obesity, an intrapleural pseudocyst, and a breast pseudocyst. There were also two large VPL-related pleural effusions, a fractured catheter in the SC tissues, and a large VA shunt thrombus within the right atrium. Ten patients (33.3 %) had culture-positive infection from CSF or shunt catheter samples. Ten patients (33.3 %) had features of temporally related acute or worsening hydrocephalus on neuroimaging. In four of these patients, the detection of thoracic and abdominal complications on CT preceded and predicted the findings of acute hydrocephalus on cranial imaging. Thoracic and abdominal complications of CSF shunts, as can be identified on CT, include shunt infection and/or obstruction, may be both multiple and recurrent, and may be predictive of concurrent acute intracranial problems.

Pancreatic trauma: The role of computed tomography for guiding therapeutic approach.

To evaluate the role of computed tomography (CT) for diagnosing traumatic injuries of the pancreas and guiding the therapeutic approach. CT exams of 6740 patients admitted to our Emergency Department between May 2005 and January 2013 for abdominal trauma were retrospectively evaluated. Patients were identified through a search of our electronic archive system by using such terms as "pancreatic injury", "pancreatic contusion", "pancreatic laceration", "peri-pancreatic fluid", "pancreatic active bleeding". All CT examinations were performed before and after the intravenous injection of contrast material using a 16-slice multidetector row computed tomography scanner. The data sets were retrospectively analyzed by two radiologists in consensus searching for specific signs of pancreatic injury (parenchymal fracture and laceration, focal or diffuse pancreatic enlargement/edema, pancreatic hematoma, active bleeding, fluid between splenic vein and pancreas) and non-specific signs (inflammatory changes in peri-pancreatic fat and mesentery, fluid surrounding the superior mesenteric artery, thickening of the left anterior renal fascia, pancreatic ductal dilatation, acute pseudocyst formation/peri-pancreatic fluid collection, fluid in the anterior and posterior pararenal spaces, fluid in transverse mesocolon and lesser sac, hemorrhage into peri-pancreatic fat, mesocolon and mesentery, extraperitoneal fluid, intra-peritoneal fluid). One hundred and thirty-six/Six thousand seven hundred and forty (2%) patients showed CT signs of pancreatic trauma. Eight/one hundred and thirty-six (6%) patients underwent surgical treatment and the pancreatic injures were confirmed in all cases. Only in 6/8 patients treated with surgical approach, pancreatic duct damage was suggested in the radiological reports and surgically confirmed in all cases. In 128/136 (94%) patients who underwent non-operative treatment CT images showed pancreatic edema in 97 patients, hematoma in 31 patients, fluid between splenic vein and pancreas in 113 patients. Non-specific CT signs of pancreatic injuries were represented by peri-pancreatic fat stranding and mesentery fluid in 89% of cases, thickening of the left anterior renal fascia in 65%, pancreatic ductal dilatation in 18%, acute pseudocyst/peri-pancreatic fluid collection in 57%, fluid in the pararenal spaces in 45%, fluid in transverse mesocolon and lesser sac in 29%, hemorrhage into peri-pancreatic fat, mesocolon and mesentery in 66%, extraperitoneal fluid in 66%, intra-peritoneal fluid in 41% cases. CT represents an accurate tool for diagnosing pancreatic trauma, provides useful information to plan therapeutic approach with a detection rate of 75% for recognizing ductal lesions.

Encysted Fluid Collections after Catheter Removal for Peritonitis in Peritoneal Dialysis Patients

Introduction: Peritonitis is a frequent complication of continuous ambulatory peritoneal dialysis (CAPD). This case series describes episodes of peritoneal dialysis (PD) related fungal or Pseudomonas peritonitis that were complicated by the formation of encysted intra abdominal fluid collections despite prompt catheter removal and appropriate therapy. Case series: The first patient presented with fever and abdominal pain two weeks after removing his PD catheter because of fungal peritonitis. Examination revealed fluid collection in the former catheter tunnel. This turned out to be pus on surgical drainage. Abdominal computed tomography (CT) scan revealed another extensive encysted extra-peritoneal fluid collection that was aspirated and found to be clear transudate fluid. The second patient presented with abdominal pain and distention seven weeks after removing her PD catheter because of fungal peritonitis. She had a large intra abdominal encysted fluid collection that was drained under ultra sound guidance. The third patient presented with painless abdominal distention one month after removing the PD catheter because of Pseudomonas peritonitis. He had two encysted extra peritoneal fluid collections that were aspirated under ultra sound guidance. This occurred despite three weeks of treatment with oral fluconazole in the case of the first two patients and appropriate antibiotic therapy in the case of the third patient. Key Words: CAPD, Fungal peritonitis, Pseudomonas peritonitis, Encysted abdominal fluid collection, Sudan

Potential extraperitoneal space continuous with the peri-intestinal space: CT evidence and anatomical evaluation in patients with pneumatosis intestinalis without intestinal ischemia

Extraperitoneal spaces, such as the mesenteric space and the retroperitoneal space, can serve as areas that enable a reduction in the pressure exerted by extraperitoneal fluid collection and infiltrating diseases. In clinical practice, understanding the existence of these decompression spaces (or pathways) is very important for making accurate diagnoses. Here, we evaluated potential anatomical extraperitoneal spaces based on the extraluminal gas distribution in patients with pneumatosis intestinalis without intestinal ischemia. The computed tomography scans of ten patients with pneumatosis intestinalis without intestinal ischemia were reviewed, and the anatomic location of the extraluminal gas distribution was investigated. Four patients were diagnosed as having pneumatosis intestinalis of the small intestine and six were diagnosed as having pneumatosis intestinalis of the large intestine. Mesenteric pneumatosis was observed in nine (90%) of the ten patients. The potential anatomical extraperitoneal spaces (or decompression pathways) were classified as follows: mesenteric (n = 3), retroperitoneal (n = 4), and direct (n = 5). The distributions of the extraluminal gas were classified into three categories, and each location may characterize a different decompression pathway. The existence of a potential extraperitoneal space continuous with the peri-intestinal space was confirmed in living subjects.

Spontaneous atraumatic rupture of urinary bladder

Spontaneous atraumatic rupture of urinary bladder is a very rare condition, difficult to distinguish from other causes of acute abdomen. Causes, which have been reported, are:Perforation of an infected urachal cyst,Perforation following augmentation enterocystoplasty,Emphysematous cystitis, Following intra-pelvic gynecological operations,Associated with alcohol abuse,Due to eosinophilic cystitis,Complication of neurogenic bladder dysfunction,In association with carcinoma (TCC),After pelvic radiotherapy,Bladder outlet obstruction THE CASE A 51years old male with a history of multiple sclerosis presented to emergency department at Russells hall hospital with symptoms of acute abdominal pain and rigors.PMH included MS,PVD-left BKA and depression. SH: Previous professional boxer drinks 3-4 units of alcohol daily, smokes 20 cigarettes a day and has long-term urinary catheter. Signs: Lower abdominal rigidity and mass, Sepsis: BP 83/52, HR: 110/min, T: 38 C, Sweaty, rigors, Urinalysis revealed: Nitrite ++, Blood ++++, Protein ++, and Leucocytes ++. However, urine culture showed no growth Laboratory findings: WBC: 19.9, CRP: 221 Initial diagnosis made as sepsis secondary to UTI Because of the persistent hypotension and tachycardia and the presence of lower abdominal mass, abdominal CT scan was arranged, which showed distended bladder, urinary catheter blocked, and extraperitoneal urinary bladder rupture Treatment: Systemic broad-spectrum antibiotics, Drainage of urine via transurethral Foley catheter, admission to SHDU and CVP monitoring, IV fluids and nutritional support. The further course of the disease was: Patient responded to above treatment, CT scan repeated 5 days later showed no pelvic fluid collection and discharged home on 10/7/2007 DISCUSSION Acute bladder rupture is a surgical emergency, which may be rapidly fatal if diagnosis and treatment are delayed. The combination of non-specific symptoms, the absence of trauma history and its very rare occurrence mean that initially a spontaneous bladder rupture may not be suspected. Multiple sclerosis is characterized by disseminated patches of demyelination in the brain and spinal cord. Urinary dysfunction and difficulty in bladder control (urgency, hesitancy, retention or incontinence) are some of the symptoms Decreased sensation of bladder filling may play roles in the mechanism of rupture, triggered by urinary retention A CT scan or retrograde cystography would provide the diagnosis. Extraperitoneal vesical perforations can be resolved with a vesical catheter or cystostomy. Spontaneous atraumatic rupture of urinary bladder 2 of 3 Figure 1 Extravasation of the infected urine may result in a perivesical abscess, septic shock, and abdominal and thoracic wall phlegmone. Early surgical management should be considered in these cases.The attached CT images of the same patient: First one showing the extraperitoneal fluid .Second showing gas in the bladder CORRESPONDENCE TO Firas Arnaout Russells Hall Hospital Dudley West Midlands DY1 2HQ Email: firasarnaout@doctors.org.uk References r-0. Emergencies in Urology Hohenfellner M Santucci R r-1. http://www.emedicine.com r-2. Campbell-Walsh Urology Wein A J Kavoussi L R r-3. Bladder rupture caused by spontaneous perforation of an infected urachal cyst,Maruschke M, Kreutzer HJ, Seiter H. Urologe A. 2003 Jun;42(6):834-9. Epub 2003 Feb 7 r-4. Four cases of spontaneous rupture of the urinary bladder,Amano T, Miwa S, Takashima H, Takemae K. Hinyokika Kiyo. 2002 Apr;48(4):243-5. Links r-5. and Medical Association, 25-October-2002, No 1164 Spontaneous atraumatic rupture of urinary bladder 3 of 3 Author Information Firas Arnaout Russells hall Hospital

Abdominal distention and shock in an infant

Acute abdominal distention in the pediatric patient may be attributable to extraperitoneal fluid, masses, organomegaly, air, an ileus, a functional or mechanical bowel obstruction, or injury and blood secondary to trauma. An infant who presents to the emergency department with acute abdominal distention and shock is a true emergency for which the differential diagnosis is extensive. An unusual case of abdominal distention, ascites, hematochezia, and shock in an infant, subsequently found to have spontaneous perforation of the common bile duct is reported. This uncommon cause of abdominal distention and shock in an infant is many times left out of the differential diagnosis of an acute abdomen. The presentation may be as an uncommon acute form or a classis subacute type. This patient had hematochezia, which had not been previously reported in association with this entity. Failure to recognize and treat an acute abdomen can result in high mortality.

CT diagnosis of pancreatic injury in children: significance of fluid separating the splenic vein and the pancreas.

The purpose of our study was to evaluate the relationship of fluid between the splenic vein and the pancreas to fluid in the anterior pararenal space in children following blunt trauma and to assess the usefulness of detecting fluid separating the splenic vein and the pancreas in the CT diagnosis of pancreatic injury in children. Twenty-five of 1725 consecutive children who underwent abdominal CT following blunt trauma had surgically or autopsy-proven pancreatic injury or clinical pancreatitis. An additional 29 children who underwent CT for evaluation of blunt trauma did not have pancreatic injury and were prospectively noted to have fluid in the anterior pararenal space. CT findings (visceral injury or intraperitoneal or extraperitoneal fluid) were recorded at the time of initial interpretation in all children. The CT scans of these 54 children were reviewed for the presence of fluid separating the splenic vein and the pancreas. Fluid separating the splenic vein and the pancreas was noted in 15 (60%) of 25 children with pancreatic injury and in 14 (48%) of 29 children who had fluid in the anterior pararenal space without pancreatic injury. In 14 of 15 children with pancreatic injury and fluid between the splenic vein and the pancreas, additional collections of peripancreatic fluid (anterior pararenal space or lesser sac) were also noted. In another four children with pancreatic injury, additional collections of peripancreatic fluid were noted in the absence of fluid between the splenic vein and the pancreas. Fluid separating the splenic vein and the pancreas on CT scans is a nonspecific finding usually associated with fluid in the anterior pararenal space. Although it may be seen in conjunction with pancreatic injury, it is rarely the only abnormal CT finding in such an injury.

Extraperitoneal paravesical spaces: CT delineation with US correlation.

The extraperitoneal space around the urinary bladder is lamellate, just like the retroperitoneal space around the kidneys. The bladder, urachus, and obliterated umbilical arteries lie within the perivesical space, surrounded by umbilicovesical fascia, analogous to the perinephric space within the renal fascia. A much larger prevesical space, analogous to the anterior pararenal space, lies anterior and lateral to the umbilicovesical fascia. Posterior to the urinary bladder, the lower uterine segment or seminal vesicles lie within the perivesical space, rather than in a separate compartment, corresponding to the posterior pararenal space. The cul-de-sac, and the inferolateral extension of its peritoneal layers as the rectovaginal or rectovesical septum, separate the posterior perivesical space from the rectum. The sectional anatomy of these spaces, and particularly their computed tomographic and ultrasound appearances, were noted in normal anatomic sections, patients with extraperitoneal fluid collections, and a cadaver into which fluid was injected.

Displaced lateral surface of the liver (Hellmer's sign) secondary to an extraperitoneal fluid collection

In 1942, Bellmer (1) first described visualization of a medially displaced lateral liver edge on abdominal radiographs in patients with ascites. In Hellmer's original article and all cases subsequently reported, this appearance was described as being pathognomonic of intraperitoneal fluid. This paper reports the occurrence of Hellmer's sign in a patient with a large extraperitoneal fluid collection extending into the flank. Thus the differential diagnosis associated with a medially displaced lateral liver edge includes pathologic processes in both the intra- and extraperitoneal spaces.

Radiologic features of extraperitoneal effusions. An anatomic approach.

Criteria for radiological diagnosis of specific compartmentalization of extraperitoneal fluid and its possible sources were developed by (a) determining pathways of extraperitoneal fluid flow and establishing preferential routes of spread from various sites; (b) establishing fascial boundaries which direct and compartmentalize extraperitoneal fluid collections; and (c) defining the role of peritoneal reflections in the passage of exudates. The correlation of the distribution of fluid with the extraperitoneal fascial planes is based on cross-sectional planes derived from frozen cadavers, postmortem injection studies, and selected clinical cases in various disease states.

The extraperitoneal perivisceral fat pad. II. Roentgen interpretation of pathological alterations.

THE PURPOSE of this paper is to describe the roentgen manifestations of alterations of the normal anatomy of the extraperitoneal perivisceral fat pad and to emphasize that both intra- and extraperitoneal pathologic processes can affect the e. p. f. p. Intraperitoneal Disease A. Fluid: Intraperitoneal fluid in the upper abdomen frequently manifests itself radiologically by collecting adjacent to the properitoneal fat line as a linear density, displacing the colon medially and thinning the properitoneal fat. This shadow has been called the “flank stripe” (5). In addition, the medial margin of the “hepatic angle” may be lost (Fig. 1). What is the explanation for the loss of the hepatic angle by intraperitoneal fluid if the shadow of the hepatic angle is cast by the liver's contrasting with extraperitoneal Iat?3 The great pliability of the e. p. f. p. explains this finding. The intraperitoneal fluid fills the peritoneal recess about the posterior inferior portions of the liver, widening and blunting it. The fluid also displaces the liver medially and anteriorly. The pliable e. p. f. p. which encases this medial portion of the hepatic angle is thinned and flattened (similarly to the properitoneal fat line) by the combined fluid and liver in the peritoneal recess. The resultant anterior-posterior soft-tissue-fat interface disappears, rendering the hepatic angle invisible to the roentgen ray (Figure 2). A similar explanation applies to the loss of the splenic angle with intraperitoneal fluid. B. Mass: Intraperitoneal masses which significantly indent the e. p. f. p. may be visualized on plain supine films. These masses are located posteriorly in the peritoneum (Fig. 3). Anteriorly situated intraperitoneal masses are notoriously difficult to visualize except as they displace gas-containing portions of the gastrointestinal tract. The difficulty in demonstrating hydrops of the gallbladder on plain films is an example of this. Extraperitoneal Disease A. Fluid: Extraperitoneal fluid infiltrates the e. p. f. p. and by increasing the fat's density negates its contrast, causing loss of the normal shadows. The obliteration of the psoas and renal shadows by extraperitoneal fluid are well known radiological signs. Less well known manifestations of extraperitoneal fluid should, however, be emphasized. Extraperitoneal fluid in the posterior right upper quadrant may dissect superiorly and laterally. It can obliterate the hepatic angle by infiltrating the properitoneal fat laterally and, medially, the e. p. f. p. which juxtaposes the medial inferior border of the liver angle (Fig. 4). In addition, when the fluid is loculated in the perirenal space medial to the lateroconal fascia and without extension into the pararenal space, the hepatic angle can be lost, even though the properitoneal fat line is intact.