A 46-year-old male patient was a known case of alcohol-related chronic pancreatitis
with underlying chronic liver disease. He presented with fever and abdominal distension.
With suspicion of spontaneous bacterial peritonitis, an ascitic fluid examination
was done, which showed leukocytosis (49,491 cells/ μm3), high protein (2.9 g/dl) and low glucose (5 mg/dl) levels. It was lymphocyte predominant
with elevated adenosine deaminase levels (46 U/l), and culture had growth of Staphylococcus aureus, for which patient was started on sensitivity-based antibiotics. In view of persisting
sepsis, ascites was drained using two 14 Fr percutaneous drain catheter placed in
bilateral flanks (
[Fig. 1]
). Despite intravenous antibiotics and drainage, the fever persisted. 18-FDG positron
emission tomography (PET) revealed nonuniform peritoneal uptake. A PET-guided fine
needle aspiration from peritoneal lesions was inconclusive. No peritoneal deposits
were visualized on endoscopic ultrasound (EUS). With no definite etiology of ascites,
we decided to do a flexible peritoneoscopy under conscious sedation. The previously
placed drain was removed over a guidewire, and a 5.8-mm ultrathin endoscope was inserted
into the peritoneum over the guidewire along the catheter tract (
[Video 1]
). Carbon dioxide was used for insufflation. The visceral peritoneum was observed
to be inflamed and friable with fibrinous exudate (
[Fig. 2]
). No peritoneal deposits were observed, and the peritoneal cavity was flushed and
cleaned with saline. Antibiotics were continued and the patient gradually improved.
The drains were subsequently removed, and patient is doing well on follow-up without
recurrence of ascites or fever.
Video 1Peritoneum being visualized using a 5.8-mm ultrathin endoscope after insertion into
the peritoneal cavity along the percutaneous catheter tract.
Fig. 1 CT abdomen: infected ascites drained with bilateral flank percutaneous drains.
Fig. 2 Flexible peritoneoscopy shows inflamed peritoneum with fibrinous exudates.
Patients with inconclusive ascitic fluid analysis are a diagnostic dilemma that usually
requires laparoscopy to solve the diagnostic conundrum. EUS is an excellent modality
for diagnosing and sampling small peritoneal deposits in patients with undiagnosed
ascites.[1] Percutaneous ultrathin flexible peritoneoscopy also seems to be technically feasible
method for evaluation of peritoneum in patients with undiagnosed ascites.[2] The advantage of this approach is that the peritoneal cavity can be examined under
conscious sedation, and no suturing is required to close the abdominal wall defect.
Also, the abnormal peritoneal lesions can be biopsied under endoscopic vision for
establishing a diagnosis. However, carbon dioxide should be used for insufflation
to reduce the risk of embolism. Moreover, use of carbon dioxide is associated with
minimal postprocedure discomfort because of rapid absorption across the membranes
and excretion via the lungs. A detailed anatomical knowledge of the peritoneal cavity
is required to perform this procedure successfully. Also, this procedure can be performed
only in the presence of ascites. Despite the advantages of carbon dioxide for insufflation,
it should be used sparingly because large volumes of carbon dioxide can get absorbed
into the circulation, causing a high pCO2 and a low pH with its clinical consequences, including lowering of the arrhythmia
threshold, increased blood pressure, pulse and cardiac output.[3]
