Peritoneal adhesion: it can be life-threatening, and life-saving
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The 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.
The 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.
In 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.
KeywordsPeritoneal dialysis Peritonitis Ultrafiltration failure Peritoneal adhesion Encapsulating peritoneal sclerosis
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 . The primary advantage of PD is patients’ ability to undertake treatment without having to visit a medical facility frequently. It has comparable risks attributed to the permanent catheter that may introduce bacteria into the abdomen and cause peritonitis, the most common acute complication of PD . PD-related peritonitis is largely caused by cutaneous Gram’s (+) bacteria, although Gram’s (−) bacteria peritonitis has become more and more common, and can usually be treated effectively by appropriate antibiotics . However, the inevitable post-inflammatory fibrosis and adhesion often compromise patients’ future treatment. Manifestations of impaired peritoneal function include ultrafiltration failure, PD inadequacy, abdominal symptoms of bowel obstruction, and malnutrition, thus threatening patients’ lives . The most severe form estimated to occur in roughly 2.5% of patients is encapsulating peritoneal sclerosis (EPS), in which the bowels become obstructed due to the growth of a thick layer of collagen within the peritoneum . Mortality rate of EPS can be as high as 50%. The management of peritoneal fibrosis and adhesion itself is usually not effective enough to restore the peritoneal function to its original level. Therefore, peritonitis rate is often employed to audit the quality assurance in PD practice and it also reflects faithfully whether the education offered to the patients and prevention measures are successful .
Here, we describe a patient who experienced an unusual form of EPS that made her give up PD. However, its unique pattern also saved her from infection caused by bowel perforation.
Six months after surgery, her body weight increased gradually to 37–38 Kg. There was no edema, and abdominal symptoms were absent.
In this article, we described an unusual clinical course of a CAPD patient who suffered from peritoneal adhesion due to CAPD-related peritonitis. The complication was serious enough to compromise her CAPD, but was so specific that it prevents the invasion of a potentially lethal infection.
Peritonitis remains a leading complication of PD and contributes greatly to morbidity and mortality of PD patients . Severe peritonitis can cause peritoneal membrane failure and stays as the major cause of discontinuing PD and shifting to HD. Peritonitis infected by Gram’s (−) bacteria has become more common, although Gram’s (+) organisms remain the major causes . Previous study has shown that Pseudomonas aeruginosa peritonitis is generally severe and associated with longer duration of admission, more severe peritoneal membrane damage, and higher rate of catheter removal and transfer to HD . Therefore, some even suggested prompt catheter removal upon diagnosis of Pseudomonas peritonitis for better outcomes . Our patient, in her second peritonitis event, was successfully treated with antibiotics for one month and continued her PD treatment. However, PD inadequacy soon became evident and this was also proved by follow-up peritoneum equilibration test. Her Kt/V decreased from 1.99 to 1.44, and weekly creatinine clearance dropped from 56 liters per week to 41 liters per week. These findings and severe edema persuaded her to switch to HD.
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 . 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. She also suffered from gradual reduction of appetite, progressive weight loss (obvious peripheral edema but unvarying body weight), malnutrition (serum albumin < 3.5 g/dl for almost a year before shifting to HD), and favorable structural finding noted during laparotomy. However, she did not experience symptoms and signs of bowel obstruction that are common in patients with severe EPS, such as progressive abdominal pain, abdominal distention, or difficulties in defecation. The poor appetite and peripheral edema were effectively corrected by changing treatment modality without specific treatment for EPS, such as enterolysis , tamoxifen , or immunosuppressive agents . In the most severe form of EPS, a sclerotic layer may completely cover the intestines, which gives them the appearance of a cocoon. The CT images supported the diagnosis of EPS and cocoon formation, but they also 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.
This patient did not experience any traumatic event that might lead to her bowel perforation. The most reasonable explanation would still be the adhesion between the intestines and abdominal wall at the insertion site. She had kept her Tenckhoff catheter for about two months before removal. With hindsight, the catheter might have been pulled unintentionally, thus tearing and bowel wall. Nevertheless, the tear was too small to cause significant abdominal symptoms, as shown by the clinical wellness and improvement in the period before Tenckhoff catheter removal. The leakage still was manifested by large amount of intra-abdominal pus accumulating gradually between the parietal and visceral peritoneal membranes, within the same period of time. It’s very likely that the peritoneal cavity was completely covered by a fibrotic layer and the pus did not gain access into the intestinal loops. Therefore, this patient could live a life of wellness devoid of any significant gastrointestinal symptoms in those two months of HD. Pus was later drained smoothly with pigtail catheters and the bowel perforation was then successfully closed.
In summary, this patient had suffered from peritonitis-related peritoneal adhesion severe enough to cause ultrafiltration failure that made her change dialysis modality. Diagnosis of EPS was supported by image findings. Nevertheless, the pattern of adhesion was so specific that kept the pus out of her intestinal loops and salvaged her from the anticipated abdominal catastrophe.
Written consent was obtained from the patient’s family for the publication of the case report and its accompanying images.
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