Intraperitoneal Extravasation Research Articles

Significant extravasation does not preclude conservative management of spontaneous perforation of the augmented bladder

BackgroundPerforation of the augmented bladder is a serious and well-known complication of bladder augmentation. The traditional treatment has been emergent surgical exploration and repair of the bladder perforation due to the risk of peritonitis, sepsis and mortality. Some studies have reported successful conservative management by maximizing bladder drainage in patients with stable hemodynamics and limited peritoneal extravasation. Herein, we report the successful conservative management of spontaneous perforation of augmented bladder in a 5-year-old boy with exstrophy-epispadias complex following epispadias repair with significant extravasation.Case presentationA 5-year-old boy had augmentation ileocystoplasty to facilitate repair of failed bladder exstrophy closure. Modified penile disassembly was used for epispadias repair with a transurethral catheter draining the bladder. The patient presented on postoperative day 2 with a non-draining catheter, fever, repeated vomiting and abdominal distension. Leukocytosis and elevated creatinine were evident on laboratory work-up. CT cystogram confirmed the diagnosis of spontaneous perforation of the augmented bladder with significant intraperitoneal extravasation. Conservative management was successful by inserting a suprapubic catheter and an intraperitoneal drain. The patient subsequently underwent creation of Mitrofanoff appendicovesicostomy and bladder neck closure to achieve dryness without recurrence of perforation on follow-up.ConclusionsPerforation of the augmented bladder can be managed conservatively even in the presence of significant peritoneal extravasation by maximizing bladder drainage and insertion of an image-guided intraperitoneal drain.

AB136. SOH23ABS_122. Management of intraperitoneal bladder rupture with ultrasound guided percutaneous drain insertion: a case report

Background: Intraperitoneal rupture of the bladder is a rare but significant complication of transurethral resection of bladder tumour (TURBT) with a high degree of associated morbidity and mortality. These patients are also exposed to a significant risk of developing TURBT syndrome secondary to intraperitoneal extravasation of irrigation fluid resulting frequently in electrolyte imbalances. Conventional management of intraperitoneal bladder rupture consists of formal laparotomy and open surgical repair. There is growing interest in less invasive management of bladder perforation in haemodynamically stable patients. We present one such case of intraperitoneal bladder rupture which was successfully managed with percutaneous drain insertion under ultrasound guidance. Percutaneous drain insertion is a novel, minimally invasive approach which has proven successful in the management of uncomplicated intraperitoneal bladder perforation. Three cases successfully utilising this treatment modality have been reported in the literature to date. Despite being performed in many institutions, there is a clear lack of reporting in the literature. This case study aims to add to the growing body of research supporting the use of percutaneous drainage in the management of uncomplicated intraperitoneal bladder rupture.

Acute Management of Intraperitoneal Extravasation of Total Parenteral Nutrition (TPN) in a Very Preterm Infant: Case Report and Literature Review

Acute Management of Intraperitoneal Extravasation of Total Parenteral Nutrition (TPN) in a Very Preterm Infant: Case Report and Literature Review

Beware of intraperitoneal rupture during computed tomography imaging of acute aortic syndrome

The prompt diagnosis of the impending rupture of abdominal aortic aneurysms (AAAs) is imperative for rapid treatment.1 Most ruptures will manifest as retroperitoneal hematomas; intraperitoneal extravasation is rarely seen.2 It usually requires several hours from the occurrence of intramural hemorrhage to extravasation into the periaortic soft tissues.

Intraperitoneal extravasation of total parenteral nutrition: A rare but life-threatening complication of umbilical vein catheter, two case reports

Umbilical vein catheter (UVC) is a commonly used intervention in neonatal intensive care units for total parenteral nutrition (TPN), antibiotic therapy, and investigations, especially in very low birth weight infants. In this report, a rare but life-threatening complication of UVC developed in two preterm infants was presented. Of two infants admitted to our neonatal intensive care unit due to prematurity, the first infant developed abdominal distension and a decreased urinary output on the 2nd day and the second infant on the 5th day. Enteral intake of the patients was discontinued with the presumed diagnosis of necrotizing enterocolitis, and broad-spectrum antibiotic therapy was initiated. There were free ascites on the abdominal ultrasonography. Macroscopic and microscopic examination of the fluid sample taken by paracentesis was compatible with TPN. Intraperitoneal extravasation of UVC, which is a rare but life-threatening complication of UVC and can be confused with necrotizing enterocolitis, should be kept in mind, especially in infants receiving TPN infusion from the UVC.

Umbilical Venous Catheter Complication Presenting as Chylous Ascites in a Newborn: Intraperitoneal Extravasation of Total Parenteral Nutrition Infusate

Umbilical Venous Catheter Complication Presenting as Chylous Ascites in a Newborn: Intraperitoneal Extravasation of Total Parenteral Nutrition Infusate

Rhodotorula Fungaemia in a Preterm Infant with umbilical Venous Catheter and Parenteral Nutrition Intraperitoneal Extravasation

Rhodotorula Fungaemia in a Preterm Infant with umbilical Venous Catheter and Parenteral Nutrition Intraperitoneal Extravasation

Abdominal compartment syndrome during hip arthroscopy for an acetabular fracture: a case report

BackgroundWe encountered a case of abdominal compartment syndrome during hip arthroscopic surgery, caused by the irrigation fluid flowing into the peritoneal cavity.Case presentationA 47-year-old male patient with the acetabulum fracture underwent open reduction and internal fixation with hip arthroscopy. Hypothermia, increased airway pressure (under volume-controlled ventilation) and oliguria were observed during the operation, and arterial blood gas analysis showed decreased oxygenation and metabolic acidosis. Abdominal distention was observed, and a postoperative CT revealed accumulation of a large volume of irrigation fluid in the peritoneal cavity and retroperitoneum. The patient was diagnosed as having abdominal compartment syndrome and treated by percutaneous peritoneal drainage. His subsequent course was uneventful, and he was discharged 8 weeks after the operation. Intraperitoneal extravasation of irrigation fluid may occur during hip arthroscopic surgery, and is more likely to occur in the presence of an injury.ConclusionAnesthesiologists should be aware of the possible occurrence of the abdominal compartment syndrome during hip arthroscopic surgery and ensure that it is detected early.

The Case Files

A 59-year-old woman presented to the emergency department complaining of worsening abdominal pain and distension as well as four episodes of syncope and lightheadedness. The patient reported a past medical history of hypertension and hypothyroidism, but denied other comorbidities. The patient reported that she was walking her dog the previous night when the dog bolted forward, causing her to lose her balance and fall forward. The patient reported that she was able to tuck into a ball and roll, sustaining minor trauma only to her right side. She denied any head trauma or loss of control after falling. She was able to walk home, and she felt fine apart from some bruising on her right lower ribs. Over the course of the evening, however, the patient's pain began to worsen. She had several episodes of nausea and non-bloody, non-bilious emesis. The next morning she began to feel short of breath, and her abdominal pain continued to worsen. She reported two episodes of syncope, which she attributed to the severity of her pain or because she was breathing too quickly.FigureFigureThe patient's systolic blood pressure was in the 80s when she arrived in the ED, and her heart rate was 130 bpm. Her respiratory rate was 26 bpm, and her SPO2 was 85% on room air. The patient was in distress and started on oxygen, intravenous access was obtained, and she was resuscitated with normal saline. She had significant abdominal pain that seemed to localize to the right upper quadrant, and a bedside FAST exam was positive for intra-abdominal fluid. The patient was expeditiously transferred to a trauma center where she underwent a CT with IV contrast for the abdomen and pelvis. A large smoothly marginated cystic lesion was noted on the dome of the right hepatic lobe measuring 13.1 x 8.6 cm. A grade 3 liver laceration was noted at the base of the hepatic cysts with a surrounding large hematoma. Moderate amounts of fluid were noted in Morrison's pouch, the surrounding paracolic gutter, and the pelvis. A fracture was also noted in the right eighth rib that was not displaced. The patient's hemoglobin levels continued to drop, and she was taken to interventional radiology, where she was noted to have a small pseudoanuerysm of a segmental branch of the right hepatic artery within the hepatic cyst, with evidence of active intraperitoneal extravasation. The patient then underwent an embolization of the segmental branch of the right hepatic artery, and hemostasis was successfully obtained. The patient's hemoglobin levels stabilized after the embolization, and she was able to resume a regular diet. She was discharged on hospital day six with the plan to follow up with trauma surgery.FigureFigureFigureUnintended falls are the most common cause of injury in the United States. They lead to 7.9 million emergency department visits per year and 860,000 hospitalizations. (Acad Emerg Med 1998;5[11]:1064.) In our particular case, what appeared to be a benign mechanism resulted in a serious injury because of the presence of a benign hepatic cyst that the patient didn't know about. Simple hepatic cysts are believed to be present in five to 10 percent of the population, with increasing incidence with age. (J Clin Ultrasound 1996;21[2]:115.) Common complications of hepatic cysts include rupture, contained hemorrhage, and obstructive jaundice. (J Nippon Med Sch 2010;77[3]:181; West J Med 1982;136[3]:246; Am J Gastroenterol 1988;83[1]:93.) Multiple cases of traumatic rupture of hepatic cysts are reported, but these are typically contained within the cyst. Few reports exist suggesting hemoperitoneum after cyst rupture. In our case, the rupture of the hepatic cyst was accompanied by a liver laceration, which led to extravasation of blood leading to hemoperitoneum. (HPB Surg 1988;1[1]:81; South Med J 1989;82[5]:667.) Focused bedside ultrasonography and strong clinical suspicion assisted in expediting a transfer to a trauma center where intervention corrected the problem.

Serum Cystatin C as a Novel Marker to Differentiate Pseudoazotemia in the Setting of Intraperitoneal Urine Extravasation

Urinary ascites results in pseudoazotemia due to urinary creatinine reabsorption across the peritoneum. We report a case of a pyeloplasty complicated by urine extravasation, in which the diagnosis was aided by discrepant findings of an elevated serum creatinine level but a stable cystatin C level. Cystatin C is a marker of renal function but is not typically excreted into the urine and therefore can be used to differentiate pseudoazotemia from true azotemia and is a better marker of renal function in the setting of known urinary ascites. These findings are relevant for patients with potential traumatic or nontraumatic sources of urine extravasation.

Percutaneous Suprapubic Stone Extraction for Posterior Urethral Stones in Children: Efficacy and Safety

To evaluate the safety and efficacy of percutaneous suprapubic stone extraction (PSPSE) for pediatric posterior urethral stones. Between July 2007 and June 2010, 54 boys presenting with acute urinary retention due to posterior urethral stones underwent PSPSE. Patients were a mean age of 66.4 months (range, 8-180 months). The stone size was 0.7-1.9 cm. Patients were placed under general anesthesia, and a 7F urethroscope was used to pushback the stone to the bladder. A 3-mm suprapubic puncture with a scalpel was performed, followed by insertion of a straight narrow hemostat through the puncture aided with cystoscopic guidance. The stone was grasped with the hemostat in its narrowest diameter and was extracted percutaneously or crushed if friable. The suprapubic puncture was closed with a single 4-0 Vicryl (Ethicon) suture. Intact stone retrieval was achieved in 45 patients, and the stone was crushed into minute fragments in 9 patients. Intraperitoneal extravasation developed in 1 patient that required open surgical intervention. Mean operative time was 22 minutes. Patients were monitored for up to 17 months, with complete resolution of symptoms and stone clearance. PSPSE provides a minimally invasive approach for the extraction of urethral and bladder stones in the pediatric population. The use of a straight hemostat for suprapubic stone extraction or crushing is a good alternative to suprapubic tract dilation, with minimal morbidity.

Meconium pseudocyst with particular pathologic findings: a case report and review of the literature

Meconium peritonitis is a sterile chemical peritonitis caused by bowel perforation with intraperitoneal extravasation of the meconium in utero. When the inflamed intestinal loops become fixed, meconium peritonitis leads to a cystic cavity with a fibrous wall, and the result is termed cystic-type meconium peritonitis. On the contrary, a meconium pseudocyst has a muscle layer continuous with the normal intestine and is distinguished from cystic-type meconium peritonitis based on the histopathologic findings.This report describes the rare case of a neonate complicated by a meconium pseudocyst, which was successfully treated with 1-stage resection and primary anastomosis. There have been few cases of meconium pseudocysts reported in the literature. Meconium peritonitis should be considered in the differential diagnosis in patients who develop large abdominal cysts with air and fluid content.Cystic-type meconium peritonitis is usually treated using drainage with subsequent elective surgery. However, for a meconium pseudocyst, 1-stage intestinal resection with primary anastomosis may be recommended. A meconium pseudocyst may be treatable using 1-stage resection based on histopathologic features.

Postprostatectomy seizures: A case report

A 75-year-old Caucasian male presented with generalized seizures half-hour post-transurethral resection of the prostate surgery. The intra-operative course was complicated by perforation of the posterior wall of the bladder neck during a difficult Foley catheter placement. This resulted in intraperitoneal extravasation of the glycine containing bladder irrigation fluid. An emergent laparotomy was performed, and 3.5-4 L of fluid was drained from the peritoneal cavity. Postoperative course was complicated by two seizures within a short interval. Patient developed profound hyponatremia (Na of 109 mEq/L). However, measured serum osmolality was normal (283 mOsm/kg). The serum osmolality remained relatively stable, indicating that the absorbed glycine and its metabolites remained osmotically active in the intravascular space (until they were dialyzed as mentioned later), making the hyponatremia less pernicious and an unlikely cause of patient's symptoms. The encephalopathy and seizures were ascribed to accumulation of toxic metabolites of glycine, especially ammonia (serum level -1261 mcmol/L). During a complicated postoperative period, patient developed oligo-anuric renal failure, and was started on slow low-efficiency dialysis for 8 hours resulting in rapid lowering of serum ammonia levels and glycine with reversal of encephalopathy including seizures. There was no recurrence of encephalopathy, seizures, or metabolic acidosis. Although rare, glycine toxicity may be life threatening. The pathophysiology, need for early detection and the role of early use of renal replacement therapy in acute glycine toxicity is discussed below.

Intraperitoneal extravasation from umbilical venous catheter in differential diagnosis of neonatal chylous ascites

Dear Editor, We read with great interest the recent paper by Karagol et al. about management of neonatal chylous ascites. Authors reviewed neonatal chylous ascites in the newborn period and emphasized paracenthesis as a diagnostic and therapeutic method in the management but did not comment on its usage in differential diagnosis (1). We have recently experienced an unusual complication of intraperitoneal extravasation of total parenteral nutrition (TPN) because of umbilical venous catheter (UVC). A 3-day-old male preterm infant with 26 gestational weeks and 1140 g birthweight developed abdominal distension which was initially diagnosed as necrotising enterocolitis. However, a diagnostic abdominal paracentesis yielded chylous-looking ascites which is known to be extremely rare. The X-rays of the removed UVC confirmed the correct position of the catheter tip at the junction of inferior vena cava and right atrium, and the liver function tests were in normal ranges on follow-up. A total of 100 mL of yellowish and milky-looking fluid was removed by paracenthesis (Fig. 1). The biochemical analysis of the obtained fluid showed it to be consistent with the composition of the hyperosmolar TPN solution. The patient improved in few days after the paracentesis and antibiotic treatment. Total parenteral nutrition is often infused through a UVC in the first few days of life for the nutritional support. Although various complications have been associated with this path of delivery, only few cases were reported to have intraperitoneal extravasation of TPN infusate from an UVC (2,3). Correct position never guarentees uneventful catheterization in the newborn, and intraperitoneal extravasation should be kept in mind in the differential diagnosis of chylous ascites. We suggest that paracenthesis and biochemical analysis can be helpful in correct evaluation in differential diagnosis.

Intrathoracic Fluid Extravasation After Hip Arthroscopy

The case of intrathoracic extravasation of irrigation fluid after hip arthroscopy in a 21-year-old woman is presented. In this patient intraperitoneal and retroperitoneal fluid collection developed, as seen in other case reports documenting irrigation fluid extravasation during hip arthroscopy. The patient presented to the emergency department on the first postoperative day complaining of shortness of breath. Computed tomography of the chest, abdomen, and pelvis showed retroperitoneal fluid, extensive abdominal ascites, and bilateral pleural effusions within the chest. The fluid diminished pulmonary volume by elevating the diaphragm and causing compression atelectasis of both lungs. The patient's hemodynamic status was stable and unaffected. She developed hypothermia during the procedure, which is consistent with other reports on extravasated irrigation fluid during arthroscopy. She was able to rapidly compensate for fluid overload and eliminated it uneventfully, with resolution of her symptoms. A similar procedure was performed on the contralateral hip 6 months later. During that procedure, there was a suspected (not confirmed) recurrence of intraperitoneal extravasation of the pump fluid as well as transient hypothermia, which resolved by the first postoperative visit. The physiologic effects of intrathoracic fluid accumulation and the literature regarding extravasation of irrigation fluid during hip arthroscopy are also reviewed.

Western Trauma Association Critical Decisions in Trauma: Nonoperative Management of Adult Blunt Hepatic Trauma

Western Trauma Association Critical Decisions in Trauma: Nonoperative Management of Adult Blunt Hepatic Trauma

Intraperitoneal bladder rupture presenting as acute bloody ascites and oliguric acute renal failure in an alcoholic liver cirrhosis patient

Intraperitoneal bladder rupture is a rare cause of acute abdomen with bloody ascites. We report herein the case of a patient who had alcoholic liver cirrhosis and multiple liver nodules, and experienced acute bloody ascites and oliguric acute renal failure in association with intraperitoneal bladder rupture. A 33-year-old male suffered from acute abdominal pain and oliguria following consumption of a large amount of alcohol and after blunt abdominal trauma. He was also found to have acute renal failure and newly onset bloody ascites that rapidly subsided following transurethral catheter drainage. Computed tomography cystography revealed intraperitoneal extravasation of contrast from the dome of the bladder, suggestive of intraperitoneal bladder rupture. The patient received surgical repair and was discharged with full recovery. This case shows that it is important for physicians to be aware of the possibility of intraperitoneal bladder rupture after alcohol consumption accompanied with abdominal blunt trauma. In particular, it has diagnostic complications for underlying liver tumors.

Enterolithiasis: a case report and review

Background Enterolithiasis is an uncommon finding of intraluminal calcified meconium. Whereas extraluminal calcifications are commonly reported and usually indicate intrauterine intestinal perforation with intraperitoneal extravasation of meconium (meconium peritonitis), true intraluminal calcifications of meconium in newborns are rare. Case Report We report a case of a newborn boy with pneumothorax and pneumoperitoneum because of a transmediastinal air leakage who unfortunately died on the fifth postnatal day after a pneumopericard. The baby had lung hypoplasia and a hypoplastic thorax. Oligohydramnion was present because of urethral agenesis and anal atresia with rectourinary fistula. Enterolithiasis was found, distributed from the transverse to the rectosigmoid colon. Enterolithiasis was not diagnosed prenatally in this boy, and any of those preexisting pathologies were therefore not assumed before birth except the suspicion for urethral valves because of oligohydramnion. Discussion Approximately 48 cases of human neonatal enterolithiasis have been described in the medical literature. The etiology of enterolithiasis appears to be intraluminal mixture of meconium und alkaline urine—as it appears in anal atresia with enterourinary fistula. Most cases of enterolithiasis are associated with major urogenital and intestinal malformations—especially VACTERL association. With support of modern high-resolution imaging devices, enterolithiasis can be detected antenatally. We suppose that prenatal diagnosis of enterolithiasis is a warning sign of underlying pathologies.

Spectrum of CT Findings in Rupture and Impending Rupture of Abdominal Aortic Aneurysms

Prompt diagnosis of rupture and impending rupture of abdominal aortic aneurysms is imperative. The computed tomographic (CT) findings of ruptured abdominal aortic aneurysms are often straightforward. Most ruptures are manifested as a retroperitoneal hematoma accompanied by an abdominal aortic aneurysm. Periaortic blood may extend into the perirenal space, the pararenal space, or both. Intraperitoneal extravasation may be an immediate or a delayed finding. Discontinuity of the aortic wall or a focal gap in otherwise continuous circumferential wall calcifications may point to the location of a rupture. There usually is a delay of several hours between the initial intramural hemorrhage and frank extravasation into the periaortic soft tissues. Contained or impending ruptures are more difficult to identify. A small amount of periaortic blood may be confused with the duodenum, perianeurysmal fibrosis, or adenopathy. Imaging features suggestive of instability or impending rupture include increased aneurysm size, a low thrombus-to-lumen ratio, and hemorrhage into a mural thrombus. A peripheral crescent-shaped area of hyperattenuation within an abdominal aortic aneurysm represents an acute intramural hemorrhage and is another CT sign of impending rupture. Draping of the posterior aspect of an aneurysmal aorta over the vertebrae is associated with a contained rupture.

Transurethral Resection Syndrome Occurred by Bladder Perforation during Transurethral Resection - A case report -

A transurethral resection of the prostate (TURP) is often performed to treat benign prostatic hypertrophy or prostatic carcinoma. Transurethral resection syndrome (TURS) is a rare but serious complication of TURP that has two different causes: (1) intravascular absorption of the irrigation fluid through the open prostatic venous sinus (TURP syndrome); and (2) intraperitoneal extravasation of the irrigation fluid through perforation of the bladder. In general, a laparotomy, repair of injury, or conservative approach such as bladder drainage, percutaneous drainage of the abdomen combined with medical treatment are performed to manage TURS attributed to the latter mechanism. We report a patient with TURS, who showed a gradual onset of hyponatremia after bladder perforation and intraperitoneal extravasation of the irrigation fluid, and was treated successfully using a conservative approach.