Abstract
BackgroundThe inevitable post-inflammatory fibrosis and adhesion often compromises future treatment in peritoneal dialysis patients. Here, we describe a patient who experienced an unusual form of peritoneal adhesion that made her give up peritoneal dialysis. However, its unique pattern also saved her from infection caused by bowel perforation.Case presentationThe female patient discontinued peritoneal dialysis due to gradual dialysis inadequacy. Two months after shifting to hemodialysis with generally improved sense of well-being and no sign of abdominal illness, she was admitted to remove the Tenckhoff catheter. The procedure was smooth, but fever and abdominal pain not at the site of operation developed the next day. Abdominal ultrasound showed the presence of ascites and aspiration revealed slimy, green-yellowish pus that gave a negative result on bacterial culture. Abdominal computed tomography (CT) with oral contrast medium was performed, but failed to demonstrate the suspected bowel perforation. The examination, however, did show accumulation of pus inside the abdomen but outside the peritoneal cavity. We drained the pus with two 14-F Pig-tail catheters and the total amount of drainage approached 4000 ml. The second CT was performed with double dose of the contrast medium and found a leak of the contrast from the jejunum. She then received laparotomy and had the perforation site closed.ConclusionsIn summary, this uremic patient suffered from pus accumulation inside her abdomen without obvious systemic toxic effect. The bowel perforation and pus formation might be caused by repeated peritonitis, but the peritoneal adhesion itself might also isolate her peritoneal cavity from the anticipated toxic injuries of bowel perforation.
Highlights
The inevitable post-inflammatory fibrosis and adhesion often compromises future treatment in peritoneal dialysis patients
The bowel perforation and pus formation might be caused by repeated peritonitis, but the peritoneal adhesion itself might isolate her peritoneal cavity from the anticipated toxic injuries of bowel perforation
Peritoneal dialysis (PD) is a modality chosen by approximately 11% of end-stage renal disease (ESRD) patients in 2004 and 15.8% in 2009 globally [1]
Summary
We described an unusual clinical course of a CAPD patient who suffered from peritoneal adhesion due to CAPD-related peritonitis. We had cautiously considered the possible diagnosis of encapsulated peritoneal sclerosis (EPS), the most serious complication of long-term PD therapy, because the treatment of EPS was usually unsatisfactory and outcome could be poor with high mortality rate [10] This patient presented several risk factors associated with EPS development, including long duration of PD, young age, exclusive use of dextrose solution, peritonitis, and late ultrafiltration failure. The CT images supported the diagnosis of EPS and cocoon formation, but they showed that the adhesion and fibrosis were relatively mild in the peritoneum between intestines This might partly explain the absence of excruciating abdominal symptoms of bowel obstruction. Pus was later drained smoothly with pigtail catheters and the bowel perforation was successfully closed This patient had suffered from peritonitisrelated peritoneal adhesion severe enough to cause ultrafiltration failure that made her change dialysis modality.
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