WIEDERSEHN L1, CHOU A1, MURALI K1
1Department of Renal Medicine The Wollongong Hospital, Wollongong, Australia
Background: Bowel perforation in peritoneal dialysis (PD) is mainly caused during the perioperative period. Despite being exceedingly rare, delayed bowel perforation by PD catheters can also occur. The optimal time frame to initiate PD after catheter insertion has not yet been established.
Case Report: A 73-year-old male with chronic obstructive uropathy presented for his initial PD session following (non-laparoscopic) surgical insertion of his PD catheter 4 weeks prior. He developed escalating watery diarrhoea throughout his first 3 x 1 Litre fills, having been completely well before commencement with no gastrointestinal symptoms. PD effluent, whilst initially clear, developed a brown sediment on subsequent drains. Bowel perforation was suspected, however the patient displayed no signs of peritonism or sepsis. Initial non-contrast CT Abdomen was unable to demonstrate evidence of a bowel perforation. The clinical picture was further confused by stool cultures returning positive for C. difficile. However, the decision was made to proceed with CT peritoneography. This did reveal an outflow of contrast media through the PD catheter into the luminal side of the mid and distal small bowel (although the tip of the catheter was seen in the peritoneal space). Laparoscopic examination revealed the PD catheter going through and through a loop of small bowel with no intra-abdominal contamination. After removal of his PD catheter with bowel repair and antibiotic coverage, the patient was converted over to haemodialysis.
Conclusions: This case demonstrates a delayed presentation of bowel perforation likely caused at the time of PD catheter insertion but remarkably only becoming clinically apparent at the initiation of PD 4 weeks later. This case highlights the diagnostic utility of CT peritoneography.
Lachlan Wiedersehn is a final year nephrology advanced trainee. Lachlan has a background in product design and biomedical engineering. He is interested in general nephrology with special interest in peritoneal dialysis and metabolic bone disease in chronic kidney disease. He hopes to use his medical training and design skills to enhance patient care.