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Wednesday, December 11, 2013
My 39 year old brother passed away last week. (Diabetes and end stage renal faliure) He was on peritoneal dialysis for the past year. The medical examiner said he aspirated his peritoneal fluid. there was a lot of black sticky fluid coming from his mouth. I don`t seem to get a satisfactory answer as to what the fluid was. And, how this happened (he was sleeping,and on p.d.) I would appreciate your answer.
First, let me offer my condolences for your loss. I am afraid I can`t offer a firm diagnosis but I can offer some questions you may choose whether to ask of the medical examiner. The first question we would teach a medical student to ask when a person vomits up black fluid is whether there is evidence of acid-digested blood. When there is bleeding in the stomach or at another point fairly high up in the gastrointestinal system, the acid in the stomach damages the blood cell proteins and, because of the iron in those proteins, turns the damaged blood black. The same black can be seen in a bowel movement when either acid-exposed blood passes through or when a person is taking iron supplements. Black colored material can also result from certain foods or medications. I would imagine it might also happen with some nutritional supplements although I am not aware of specific examples. It would be total guesswork on my part how to tie together the black fluid and the report of aspirating the peritoneal fluid into a single explanation for what happened. However, aspiration refers to a fluid going into the bronchial (airway) tree from either the mouth or the intestinal system. From there, it can cause inflammation in the lung, a so-called aspiration pneumonia. Therefore, in order to have aspiration of peritoneal fluid, it would be necessary to come up with a reason for the peritoneal fluid to enter the mouth or intestinal system. Ordinarily, peritoneal dialysis is conducted by having fluid run through a tube (catheter) placed across the abdominal wall into the peritoneal space, a space in the abdomen and pelvis in which the intestines are located but which ordinarily has no direct communication with the food and fluid absorbing surface of the intestines. Hence, ordinarily, peritoneal dialysis fluid should not be in a location from which it could be aspirated. The key questions are what is the nature of the black material and how did the peritoneal fluid get into the lungs, if there is in fact evidence for that? One possible scenario is that there could have been a bowel perforation, i.e. the development of an injury with a hole in the wall of the bowel. The injury itself would cause loss of blood into the intestine and the presence of the perforation would permit fluid to be transferred from the peritoneal space to the space inside the intestine from which it could be vomited back up and then go down the wrong tube into the airways. It is easy to let your imagination get out of hand in these situations. Hopefully, the medical examiner can help to pin down the facts and keep the explanation as grounded as possible.
Robert M Cohen, MD
Professor of Clinical Medicine
College of Medicine
University of Cincinnati