Key words: continuous ambulatory peritoneal dialysis; months when the patient presented with the sudden onset of severe, constant, central abdominal pain ...
Nephrol Dial Transplant ( 1997) 12: 599–600
Nephrology Dialysis Transplantation
Case Report
Acute small-bowel obstruction following mesenteric perforation by CAPD catheter N. S. Kanagasundaram, S. Fletcher, S. Gupta and A. M. Davison Department of Nephrology, St James’s and Seacroft University Hospitals NHS Trust, Leeds, UK
Key words: continuous ambulatory peritoneal dialysis; complications; intestinal obstruction; mesenteric perforation; catheter
Introduction Continuous ambulatory peritoneal dialysis (CAPD) is a widely utilized mode of renal replacement therapy for patients with end-stage renal failure. It has a number of well-recognized complications including peritonitis, catheter migration, haemoperitoneum and, rarely, intestinal obstruction. We report a case in which, by a hitherto unreported mechanism, a CAPD catheter, having perforated the ileal mesentery, wrapped itself around the small bowel causing acute intestinal obstruction.
months when the patient presented with the sudden onset of severe, constant, central abdominal pain starting soon after eating his midday meal. Examination revealed the patient to be apyrexial, with a blood pressure of 175/70 mmHg and a regular pulse rate of 80 b.p.m. Abdominal examination showed no evidence of distension or peritonism although localized tenderness was elicited in the left iliac fossa. Bowel sounds were audible and non-obstructive in nature. The peritoneal effluent was clear, Gram stain and culture negative ,with a white cell count of only 0.03 cells/dl (normal range ∏0.01). There was a peripheral blood leukocytosis ( 15.6×109/l ) and a normal serum amylase. A plain abdominal X-ray revealed dilated loops of small bowel and catheter migration from the pelvis (see Figure 1 ).
Case report The patient, a 70-year-old caucasian male with endstage renal failure secondary to hypertensive nephrosclerosis, commenced CAPD in April 1994 via an Oreopoulos catheter inserted through a transverse incision under direct vision into the pelvis.Concomitant left inguinal herniorrhaphy was performed. CAPD was complicated by one bout of staphylococcal peritonitis, fully treated with intraperitoneal vancomycin (January 1995 ), and two episodes (July/December 1994) of constipation requiring hospital admission. Each of the two episodes was marked by abdominal pain and vomiting but associated with normal peritoneal white cell counts and cultures, and plain abdominal radiographs confirming faecal loading with no evidence of intestinal obstruction.The second episode prompted an abdominal computerized tomographic scan and barium enema from which the only abnormality detected were sigmoid diverticula. CAPD had progressed uneventfully for the next 12 Correspondence and offprint requests to: N. S. Kanagasundaram, Department of Nephrology, St James’s and Seacroft University Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK.
Fig. 1. Abdominal X-ray. Note dilated loops of small bowel and catheter migration from the pelvis.
© 1997 European Renal Association–European Dialysis and Transplant Association
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unreported. Perforation of a viscus by a peritoneal catheter usually occurs in the context of dormant peritoneal dialysis, e.g. in transplanted patients (in whom peritoneal friability due to immunosuppression contributes) [4] and in intermittent peritoneal dialysis [5] where the absence of dialysate fluid allows the peritoneum and bowel to rub directly against the catheter. It can, however, also occur in ongoing CAPD [5,6]. Late mesenteric perforation in itself has not, we believe, been previously reported although perforation/ laceration of the posterior peritoneum [7 ] and perforation of the urinary bladder [8 ] are described. Despite the rarity of the complication described in our case, it does illustrate that prompt surgical intervention—after initial conservative measures have failed—may prevent potentially disastrous sequelae. Fig. 2. Situs during surgery. See text for explanation.
The patient failed to settle with nasogastric aspiration and intravenous fluids, and laparotomy was undertaken. At operation the distal flange of the Oreopoulos catheter was seen to have passed through a tear in the ileal mesentery and wrapped itself around the small bowel (see Figure 2). The catheter was unwrapped from the bowel, passed back through the mesentery, and replaced in the pelvis. The mesenteric tear was repaired. Postoperative recovery was unremarkable and the patient has continued uneventfully with CAPD after initial convalescence on haemodialysis.
Discussion Intestinal obstruction is a rare complication of continuous ambulatory peritoneal dialysis but can occur in the settings of severe peritoneal adhesions [1 ] and herniation of bowel loops through the CAPD catheter insertion site [2,3]. The mechanism described in this case— entwining of the catheter around small bowel having perforated through mesentery—is hitherto
References 1. Cooles P, Power DA, Krukowski ZH. Small bowel obstruction secondary to recurrent peritonitis. J R Coll Surg Edinb 1985; 30 ( 3): 206–207, 2. Madden MA, Beirne GJ, Zimmerman SW, Sollinger H. Acute bowel obstruction: an unusual complication of chronic peritoneal dialysis. Am J Kidney Dis 1982; 1 (4 ): 219–221 3. Jorkasky D, Goldfarb S. Abdominal wall hernia complicating chronic ambulatory peritoneal dialysis. Am J Nephrol 1982; 2: 323–324 4. Brady HR, Abraham G, Oreopoulos DG, Cardella CJ. Bowel erosion due to a dormant peritoneal catheter in immunosuppressed renal transplant recipient. Perit Dial Int 1988; 8: 163 5. Korzets Z, Golan E, Ben-Dahan J, Neufeld D, Bernheim J. Decubitus small bowel perforation in ongoing continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 1992; 7: 79–81 6. Rotellar C, Sivarajan S, Mazzoni J, Aminrazavi M, Mosher WF, Rakowski TA, Argy WP, Winchester JF. Bowel perforation in CAPD patients. Perit Dial Int 1992 12: 396–398 7. Rodriguez-Perez JC, Palop L, Plaza C, Arrieta J. Perforation and/or laceration of posterior peritoneum in CAPD. Perit Dial Bull 1985; 3: 141 8. Vargemezis V, Pasadakis P, Thodis E, Ethimiadou A, Maltezos E, Kotsiou S. Late perforation of bladder as a complication of an unused straight Tenckhoff catheter Perit Dial Bull 1988; 8: 55–62 Received for publication: 22.8.96 Accepted: 5.9.96
