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Hsin-Liang Liu, Jeng-Jong Huang, Roug-Ru Lan, Ming-Cheng Wang, Junne-Ming Sung, Ryh-Yaw Hsieh, Ischaemic bowel disease in patients on continuous ambulatory peritoneal dialysis, Nephrology Dialysis Transplantation, Volume 14, Issue 8, August 1999, Pages 2032–2034, https://doi.org/10.1093/ndt/14.8.2032
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Extract
Introduction
Peritoneal signs in patient on continuous ambulatory peritoneal dialysis (CAPD) are usually due to CAPD-associated peritonitis without or with bowel perforation. Ischaemic bowel disease (IBD), however, is a condition that must be considered in the differential diagnosis. It is an acute mesenteric catastrophe, which can be mistaken for CAPD-associated peritonitis because of their similar clinical features [1]. IBD can be classified as occlusive or non-occlusive [2]. Non-occlusive mesenteric infarction was first described by Ende in 1958 in non-renal patients with cardiac failure [3]. In recent years, however, a haemodialysis-induced hypotensive episode has been a common finding associated with non-occlusive mesenteric infarction [4]. Possibly because of the lower risk of hypotensive episodes, it has rarely been reported in CAPD patients. We observed two uraemic patients on CAPD, who developed IBD.
Cases
Case 1
A 71-year-old female with end-stage renal disease (ESRD) secondary to diabetic nephropathy had been on maintenance CAPD therapy for 14 months. There was a history of coronary artery disease (3-vessels-disease) with myocardial infarction and hypertension. She suffered from congestive heart failure and unstable angina. Her medication included recombinant human erythropoietin (rHuEpo) 4000 U s.c. weekly, aspirin 100 mg q.d., isosorbide dinitrate 10 mg t.i.d., nifedipine (Coracten®) 20 mg b.i.d., and potassium chloride (Slow-K®) 8 mmol b.i.d. When excessive fluid accumulation with facial and leg oedema developed, she had more frequent exchange of high-glucose concentration dialysate (4.25% Dianeal®). She was admitted because of epigastric pain with bloody stool, poor appetite, and general weakness. Her vital signs revealed a blood pressure (BP) of 63/48 mmHg (the baseline BP was around 150/80 mmHg); pulse rate, 70 beats/min; body temperature, 38.7°C, and CVP, −1 cm H2O. The patient's abdomen was soft and non-tender with normal bowel sounds. Peritoneal effluent was clear without leukocytosis, and the culture of drainage fluid grew no pathogens. The exit site was clean without erythema or purulent discharge, there was no tenderness over the tunnel tract. The haemogram showed WBC: 14 000/mm3 with left-shifting, and haemoglobin, 7.5 g/dl. Biochemistry showed serum amylase, 30 U/l; Na, 127 mmol/l; K, 2.1 mmol/l; bicarbonate, 18.7 mmol/l; and arterial blood pH, 7.365. Hypovolaemic shock combined with sepsis was suspected and the patient was treated with saline and antibiotics. Unfortunately high fever and cloudy dialysate set in rapidly. The culture of the dialysate grew Pseudomonas aeruginosa and Klebsiella pneumoniae. The amylase level in peritoneal fluid was 157 U/l. Blood culture yielded P. aeruginosa and oxacillin-resistant Staphyolcoccus aureus. The antibiotics were changed and intravenous vancomycin, ciprofloxcin, and metronidazole were administered. Abdominal computed tomography (CT scan) showed pneumatosis intestinalis (Figure 1). Exploratory laparotomy revealed infarction extending from jejunum to transverse colon. No vascular occlusive lesion was found and no resection attempted. The patient's condition rapidly deteriorated and she died on the first postoperative day.
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