Quiz page November 2007:

Article Outline

• Clinical Presentation
• Discussion
  • What does the abdominal tomography show?
  • What is your diagnosis?
• Final Diagnosis
• References
• Copyright

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Clinical Presentation 

A 49-year-old man with human immunodeficiency virus (HIV) and end-stage renal disease was managed with peritoneal dialysis for 5 years. During this time, he experienced 4 mild episodes of peritonitis treated with antibiotics. He now presents with abdominal pain, anorexia, nausea, and vomiting for 15 days. Physical examination shows signs of marked malnutrition, a palpable abdominal mass, and decreased bowel sounds. Abdominal tomography was performed (Fig 1).

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• Figure 1. 

  Noncontrasted abdominal tomography.

■What does the abdominal tomography show?

■What is your diagnosis?

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Discussion 

What does the abdominal tomography show? 

Abdominal tomography in Fig 1 shows extensive calcification of the peritoneum, with the bowel loops incorporated in a cocoon-like mass and loculated ascites.

What is your diagnosis? 

These findings are consistent with the diagnosis of sclerosing encapsulating peritonitis. The patient was transferred to hemodialysis therapy and prescribed tamoxifen, 40 mg, and prednisone, 60 mg/d. Enteral nutrition was started. The patient’s condition initially improved, but he died 2 months later of likely abdominal sepsis. Autopsy was not performed.

Sclerosing encapsulating peritonitis is a rare, but fatal, complication of long-term peritoneal dialysis. It should be suspected in peritoneal dialysis patients who develop a clinical syndrome compatible with bowel obstruction.¹ Although the cause is unknown, risk factors include previous episodes of peritonitis, high glucose or lactate dialysate, and such medications as β-blockers and chlorhexidine.², ³ Steroids and anti-inflammatory and immunosuppressive drugs have been used for treatment, but mortality remains high (60% to 90%).

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Final Diagnosis 

Massive sclerosing encapsulating peritonitis.

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References 

1. Summers AM, Clancy MJ, Syed F, et al. Single-center experience of encapsulating peritoneal sclerosis in patients on peritoneal dialysis for end-stage renal failure. Kidney Int. 2005;685:2381–2388
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2. Yamamoto R, Otsuka Y, Nakayama M, et al. Risk factors for encapsulating peritoneal sclerosis in patients who have experienced peritoneal dialysis treatment. Clin Exp Nephrol. 2005;9:148–152
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3. Slim R, Tohme C, Yaghi C, Honein K, Sayegh R. Sclerosing encapsulating peritonitis: A diagnostic dilemma. J Am Coll Surg. 2005;200:974–975
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