Detroit Medical Center/Wayne State University Detroit, MI
Aabid Mohiuddin, DO, Leslie Lin, MD, Abdallah Almawazreh, MD, Ahmed Alhaj, MD, Yahya Osman, MD Detroit Medical Center/Wayne State University, Detroit, MI
Introduction: Encapsulating peritoneal sclerosis (EPS) is a rare complication of chronic peritoneal dialysis (PD) in which inflammatory fibro-collagenous layers encase the small intestine and other intra-abdominal organs. It develops due to chronic peritoneal exposure to high-glucose concentrations in the dialysate and often presents after conversion to hemodialysis. Clinical findings include severe, refractory abdominal pain and progressive malnutrition as a result of a non-functioning gut.
Case Description/Methods: A 32-year old woman with lupus nephritis on PD for the past five years was admitted to the medicine service with nausea, poor appetite, and diffuse cramping abdominal pain. Three days prior, she was discharged from an outside facility on empiric oral and intraperitoneal antibiotics after a diagnosis of culture-negative peritonitis, however she did not take them due to prescription misinterpretation.
On admission, she was afebrile and hemodynamically stable; labs showed marked leukocytosis with white blood cell count of 31 cells per microliter. Her PD was resumed as was a broad-spectrum antibiotic regimen. Over the next week, there was no improvement of her nausea and abdominal pain despite unremarkable computed tomography (CT) imaging and unrevealing endoscopy.
Peritoneal fluid culture from day 4 of admission grew E. faecalis; the PD catheter was therefore removed and she was converted to hemodialysis via a patent arteriovenous fistula. Her condition soon worsened and she was admitted to the intensive care unit (ICU) in septic shock.
Abdominal x-rays showed severe stool burden not responding to bowel regimen escalation. Repeat CT imaging revealed a critical finding of pneumoperitoneum and profound gastroduodenal, jejunal, and cecal mucosal edema. During emergent exploratory laparotomy, surgeons repaired a 4-cm hole in the transverse colon which was complicated by one hour spent lysing adhesions caused by a ‘very thickened peritoneum, with encapsulation of the liver, transverse colon, and stomach.’ An ultimate diagnosis of EPS was made based on these surgical findings.
Discussion: For gastroenterologists, this case highlights the need to consider EPS as a cause of refractory abdominal pain in PD patients. Imaging and clinical correlation aid early suspicion while definitive diagnosis is via laparotomy/laparoscopy. Acute management is similar to small bowel obstruction while chronic cases benefit from enterolysis. Recognition of EPS avoids unnecessary workup and prolonged patient suffering.
