Features helpful in diagnosis and associated with death were evaluated In 26 episodes of peritonitis associated with intra-abdominal pathology (IAP) In continuous ambulatory peritoneal dialysis (CAPD) patients. Culture of multiple enteric pathogens, or of a single unusual enteric pathogen, from the dialysate was useful for diagnosis in 22/26 instances. Other diagnostic features (fecal material in dialysate, diarrhea containing dialysate, Increasing free air in the abdominal cavity) were infrequently found. A comparison of patients who died (n=11, 42%) and those who survived revealed that death was associated with bowel gangrene (5/6 died), recovery of bacteroides from the dialysate, more frequent and severe comorbid conditions (bacteremia, pneumonia, intra-abdominaland intracerebral bleeding, septic shock, hepatic failure), the development of severe malnutrition and thrombocytopenia during infection, and multiple surgical procedures until the diagnosis was established. Peritonitis associated with intra-abdominal pathology In CAPD patients is a severe infection with considerable diagnostic difficulty and high mortality. Early exploratory laparotomy upon suspicion of the nature of the peritonitis, usually raised by the recovery of enteric pathogens from the dialysate, may improve mortality.
Patients with recurrent kidney stone disease or stone formers at increased risk of recurrence deserve a thorough metabolic workup. This should be based on a careful history and include urinalysis, serum chemistry studies, and analysis of 24-hour urine collections. Measures to prevent recurrent stone formation are aimed at correcting the metabolic imbalances detected in the workup. A variety of drugs are available that target one or more of the metabolic abnormalities that may be involved. For "surgically active" renal and ureteral stone disease, newer techniques make surgery unnecessary in most cases. Extracorporeal shock wave lithotripsy is becoming the preferred technique for disintegration of upper urinary tract stones. Percutaneous ultrasonic lithotripsy and electrohydraulic disintegration also are widely used. For lower urinary tract stones, the ureteroscope permits either extraction under visualization or ultrasonic disintegration.
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