Peritonitis is a major complication of continuous ambulatory peritoneal dialysis (CAPD). Visceral perforation accounts for 110% of such complications and can be a difficult diagnosis to make [1,2]. The delay in diagnosis has a significant impact on mortality and morbidity [1]. We would like to highlight a case of CAPD peritonitis that was associated with visceral perforation.
A 47-year-old patient presented to a district general hospital with abdominal pain and was originally treated for CAPD peritonitis. He had been on CAPD for 2 years having reached end-stage renal failure due to immunoglobulin-A nephropathy. There was no history of peptic ulcer disease nor was there steroid, proton pump inhibitor or H2 antagonist use. Initial clinical examination revealed diffuse tenderness across the abdomen without rebound or guarding and he was started on antibiotics for CAPD peritonitis. He was transferred to the regional renal unit and his clinical condition had deteriorated. On examination at this stage his abdomen was tender with guarding. His CAPD fluid was tested using dipstix testing and was found to be positive for bilirubin. The patient also had a chest X-ray, which showed air under the diaphragm. This can be normal in the CAPD population, but the chest X-ray was repeated after a temporary dialysis line was inserted and the air was no longer present. Due to the clinical picture and patient's condition he was taken to theatre where a perforated duodenal ulcer was found. He had a protracted post-operative course with an ITU stay and multiple intra-abdominal abscesses, but has now recovered.
Normal methods for diagnosis including erect chest X-rays have been shown to be of limited use in these patients and are not a reliable indicator of visceral perforation [3]. One of the more common indicators of visceral perforation is multiple enteric organisms on culture of CAPD fluid. This in itself can take a few days, which is also delaying the patient's treatment. We feel that the bedside testing of CAPD fluid for bilirubin may help with the diagnosis of visceral perforation. If we can shorten the time to surgery for these patients we may be able to make an impact on the mortality and morbidity.
Conflict of interest statement. None declared.
Manchester Institute of Nephrology and Transplantation Manchester Royal Infirmary Manchester, UK Email: hscarborough{at}ntlworld.com
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