Ultrasound (US) evaluation of peritoneal thickness in children and young patients on peritoneal dialysis (PD): A single centre experience

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1 Ultrasound (US) evaluation of peritoneal thickness in children and young patients on peritoneal dialysis (PD): A single centre experience Poster No.: C-2812 Congress: ECR 2010 Type: Scientific Exhibit Topic: Pediatric Authors: I. M. Borzani, S. Testa, A. Castelli, U. Matta, M. A. Pavesi, F. Paglialonga, G. Ardissino, A. Edefonti, P. Biondetti; Milan/IT Keywords: Ultrasonography, Peritoneum, Peritoneal Dialysis DOI: /ecr2010/C-2812 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 23

2 Purpose Prolonged peritoneal dialysis (PD) and frequent episodes of peritonitis lead to structural changes and thickening of the peritoneum and can progress to sclerosing peritonitis, a rare but life-threatening complication of PD. It is the result of peritoneal membrane proliferation, thickening and calcification, leading to small bowel occlusion and sometimes to death. The disease can remain clinically silent for many years before the occurrence of intermittent partial small bowel obstruction, bowel perforation, or impaired ultrafiltration. The interest in morphology and function of the peritoneum has increased since chronic ambulatory peritoneal dialysis (CAPD) has become a routine procedure for the treatment of patients with terminal renal failure. Sonography is an important non-invasive method to examine morphological structures of many organs. Ultrasonography investigations may provide the opportunity to detect morphological changes early, but the role of US peritoneal evaluation is not well established in the literature so we propose US screening for assessing peritoneal membrane thickening in patients on PD. Methods and Materials Study population Between April and September 2009 we prospectively performed US abdominal evaluation in the 21 patients (16M) on PD followed in our Dialysis Unit, median age 6.4 yrs (0.6-27); the median PD duration was 27.6 mo. ( ). Patients' characteristics are summarized in table 1. Characteristic Datum Sex (male/female) 16/5 Age (median, range) 6.4 yrs (0.6-27) Height (median, range) 105 cm (53-163) Page 2 of 23

3 Weight (median, range) 17.2 Kg (5.3-46) Number of peritonitis episodes (mean, 1.5 (0-9) range) Table 1. Baseline characteristics in 21 patients US evaluation Sonography was performed with a small amount of peritoneal fluid to better separate peritoneal layers. After a normal abdominal US evaluation performed using Prosound Alpha 10 ALOKA, the parietal portion of the peritoneum of every patients was examined via a high frequency linear probe (UST-5411, 5-13 MHz) in the supine position at three different ventral windows (sterno-umbilical line, right and left lower abdomen). The values are expressed as an average of three measurements. Each measure was obtained at a distance of at least 10 cm from the peritoneal catheter insertion. We analyzed the correlation between PD duration and number of peritonitis and peritoneal membrane (PM) thickness. Results The peritoneum can be imaged sonographically as a hyperechogenic band between the abdominal muscles and the intra-abdominal viscera. The presence of peritoneal fluid allows to better separate and measure visceral and parietal layers. Twelve patients out of 21 (57%) showed a peritoneal thickness < 1mm (reference normal upper limit) (Figure 1 on page 12) and 5 patients (24%) between 1 and 1.5mm (Figure 2 on page 13). Nobody in these two groups had abdominal symptoms or abnormal small bowel loops distribution. Page 3 of 23

4 Fig.: 1-Normal US appearance and thickness of PM References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY Page 4 of 23

5 Fig.: 2-US appearance of peritoneal thickness of 1.2mm (arrowhead) References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY The last 4 patients (19%), with longer dialysis duration, had a peritoneal thickness > 1.5 mm (Figure 3 on page 14). Page 5 of 23

6 Fig.: 3-US appearance of peritoneal thickness of 1.8mm (arrowhead) References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY Two out of these last 4 patients also showed small bowel loops fixed and tethered posteriorly (Figure 4 on page 15) and echogenic strands arising anterior to the matted bowel Figures ( 5 on page 16 and 6 on page 18) and widespread throughout the peritoneal liquid (Figure 7 on page 19). They had also intermitting clinical symptoms of subocclusion. Page 6 of 23

7 Fig.: 4-Ultrasound can demonstrate tethering of the bowel to the posterior abdominal wall, thickened peritoneal membranes, and intraperitoneal echogenic strands. Peritoneal membrane are thickened and encoloses small intestine in a "cocoon" References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY Page 7 of 23

8 Page 8 of 23

9 Fig.: 5-US high-frequency image shows perivisceral membrane with echogenic strands arising anterior to the matted bowel and widespread throughout the peritoneal cavity (arrows). References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY Page 9 of 23

10 Fig.: 6-US high-frequency image shows perivisceral membrane with echogenic strands arising anterior to the matted bowel and widespread throughout the peritoneal cavity (arrows). Peritoneum thickened, 2.7mm (arrowhead) References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY Fig.: 7-Ultrasound image demonstrates a peritoneal fluid collection with the appearance of internal septa (arrow). References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY Figure 8 on page 19 shows the linear regression between PD duration and PM thickness that is statistically significant (r: 0.85, p< ); Page 10 of 23

11 Fig.: 8-Simple regression between PM thickness and PD duration (r: 0,85, p< 0,0001) References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY Figure 9 on page 20 shows the linear regression between number of peritonitis episodes and PM thickness (r: 0.56, p< 0.001). Page 11 of 23

12 Fig.: 9-Simple regression between PM thickness and number of peritonitis episodes (r: 0,56, p< 0,001) References: I. M. Borzani; Pediatric Radiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY Images for this section: Page 12 of 23

13 Fig. 1: 1-Normal US appearance and thickness of PM Page 13 of 23

14 Fig. 2: 2-US appearance of peritoneal thickness of 1.2mm (arrowhead) Page 14 of 23

15 Fig. 3: 3-US appearance of peritoneal thickness of 1.8mm (arrowhead) Page 15 of 23

16 Fig. 4: 4-Ultrasound can demonstrate tethering of the bowel to the posterior abdominal wall, thickened peritoneal membranes, and intraperitoneal echogenic strands. Peritoneal membrane are thickened and encoloses small intestine in a "cocoon" Page 16 of 23

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18 Fig. 5: 5-US high-frequency image shows perivisceral membrane with echogenic strands arising anterior to the matted bowel and widespread throughout the peritoneal cavity (arrows). Page 18 of 23

19 Fig. 6: 6-US high-frequency image shows perivisceral membrane with echogenic strands arising anterior to the matted bowel and widespread throughout the peritoneal cavity (arrows). Peritoneum thickened, 2.7mm (arrowhead) Fig. 7: 7-Ultrasound image demonstrates a peritoneal fluid collection with the appearance of internal septa (arrow). Page 19 of 23

20 Fig. 8: 8-Simple regression between PM thickness and PD duration (r: 0,85, p< 0,0001) Page 20 of 23

21 Fig. 9: 9-Simple regression between PM thickness and number of peritonitis episodes (r: 0,56, p< 0,001) Page 21 of 23

22 Conclusion CT is considered the gold standard examination in the diagnosis of sclerosing peritonitis in adult population, however it encompasses high radiation dose and is not suitable for repeated examinations. Our data suggest that US examination represents a safe tool to monitor peritoneal changes during PD, allowing good peritoneal visualisation and dynamic evidence of small bowel distribution that can correlate with clinical symptoms even when they are still mild. We suggest to address all PD patients to US peritoneal screening once every 6 months. References Faller U, Stegen P, Klaus G, et al. Sonographic determination of the thickness of the peritoneum in healthy children and paediatric patients on CAPD. Nephrol Dial Transplant 1998;13(12): George C, Al-Zwae K, Nair S, et al. Computed tomography appearances of sclerosing encapsulating peritonitis. Clin Radiol 2007;62(8):732-7 Hoshii S, Honda M, Itami N, et al. Sclerosing encapsulating peritonitis in pediatric peritoneal dialysis patients. Pediatr Nephrol 2000;14(4):275-9 Lee TC, Yang JY, Wang HP, et al. Peritoneal thickening is not inevitable in long-term peritoneal dialysis and is associated with peritoneal transport characteristics: a two-centre sonographic study. Nephrol Dial Transplant 2008;23(3): Stuart S, Booth TC, Cash CJ, et al. Complications of continuous ambulatory peritoneal dialysis. Radiographics 2009;29(2): Verbanck JJ, Schoonjans RS, Vandewiele IA, et al. Sclerosing peritonitis with gross peritoneal calcification and abdominal wall abscess secondary to bowel perforation: ultrasonographic appearance. J Clin Ultrasound 1997;25(3): Personal Information Dr. I.M. Borzani, MD, Pediatric Radiologist Page 22 of 23

23 Fondazione Ca' Granda - Ospedale Maggiore Policlinico Institute of Pediatrics-Pediatric Radiology Unit Via Commenda 9, 20122, Milan, Italy phone: irene.borzani@policlinico.mi.it Page 23 of 23