穿孔性腹膜炎合併腹腔內膿腫在腹膜透析綠膿桿菌腹膜炎的病人：個案報告

Perforative Peritonitis with Intra-abdomen Abscess in peritoneal Dialysis-related Pseudomonas peritonitis: A Case Report

在腹膜透析病人中，腹膜炎是常見的感染併發症。穿孔性腹膜炎是少見但是會造成病人死亡的嚴重問題。臨床上有效的抗生素治療和及時的手術處理可以有效改善病人預後。我們報告一位腹膜透析綠膿桿菌腹膜炎的個案，雖然積極的抗生素治療和手術移除腹膜透析導管，在手術移除腹膜透析導管後第3天發生迴腸穿孔合併腹部手術傷口大量混濁液體滲漏。在住院第17天，緊急的腹腔鏡手術來修補迴腸穿孔腹膜炎。然而在腹腔鏡手術2星期後（住院第30天），持續的腹痛且每天大量混濁液體600–700 c.c.從引流管流出。腹部電腦斷層發現一個小網膜膿腫和另一個骨盆腔內的膿腫。臨床上診斷為迴腸穿孔手術傷口滲漏合併腹膜內膿腫。保守治療包含負壓引流、抗生素治療和全靜脈營養注射持續了3個星期。最後病人成功治癒出院轉到血液透析治療。我們的個案報告指出在腹膜透析綠膿桿菌腹膜炎病人中，需要非常注意穿孔性腹膜炎的併發症。

Perforative peritonitis is a rare but fatal complication associated with significant mortality in peritoneal dialysis (PD). Clinical practice with antibiotics combined with surgical intervention improves perforative peritonitis outcomes. We report a case of PD-related Pseudomonas peritonitis under aggressive antibiotics, ileum perforation with turbid fluid leakage occurring three days after catheter removal. Exploratory laparotomy was arranged for small intestinal repair on day 17. However, progressive abdomen pain with massive turbid discharge 600–700 c.c./ day from combination waste vent (CWV) drain was noted on day 30 (2 weeks after the small intestinal repair operation). Abdomen computed tomography reported residual lesser sac abscess with air-fluid collection and another encapsulated abscess over the midline lower pelvis. Leakage of the anastomosis of the small intestine with intra-abdominal abscess was diagnosed. Conservative treatment with negative pressure CWV drainage, antibiotic therapy, and total parenteral nutrition was performed for three weeks. Finally, the patient was successfully discharged under regular hemodialysis. Our case suggests that it is necessary to keep in mind the possibility of perforative peritonitis in PD patients with Pseudomonas peritonitis.