A 54-year-old man with diabetes mellitus and end-stage renal disease underwent percutaneous implantation of a double-cuffed continuous ambulatory peritoneal dialysis (PD) catheter using a dilator with pull-apart sheath and was started on 3 daily exchanges of 2 L of PD fluid. He experienced 1 episode of culture-negative peritonitis 43 days later, which improved after treatment with intraperitoneal cefazolin and gentamicin. Five months later, he presented with profuse watery diarrhea. There was no history of fever, abdominal pain, or vomiting. Physical examination showed blood pressure of 170/110 mm Hg, nontender abdomen with intact bowel sounds, and pedal edema. Investigations showed the following values: white blood cell count, 76.1 × 103/µL with a differential of 58% polynuclear cells, 41% lymphocytes, and 1% eosinophils; hemoglobin, 86 g/L; sodium, 138 mEq/L; potassium, 4 mEq/L; blood urea, 104 mg/dL (37 mmol/L); and serum creatinine, 9.5 mg/dL (842 μmol/L). A stool specimen was positive for reducing substance. Peritoneal fluid total count was 30,000 cells/mL, with culture growing Escherichia coli sensitive to cefaperazone and amikacin. A plain X-ray of the abdomen showed the catheter tip located in the right lumbar region with no air-fluid levels. Computed tomography was performed after instillation of contrast through the catheter lumen.
■ What does the computed tomographic scan show?
■ What is your diagnosis?
■ Who is at risk of this complication?
Discussion
What Does the Computed Tomographic Scan Show?
Computed tomography performed after instilling contrast through the catheter showed contrast within the bowel lumen and visualization of colonic haustra (Fig 1).
Figure 1. Computed tomographic scan of the abdomen.
What is Your Diagnosis?
This is suggestive of penetration of the bowel wall by the catheter. During laparotomy, the catheter was seen to have entered the colon by penetrating through the base of the appendix. There was no evidence of chronic adhesions or malignancy. Histopathologic examination of the appendix showed serosal inflammation only.
Who is at Risk of This Complication?
Tenckhoff catheters are biocompatible, and bowel perforation is extremely rare. It is believed that frequent instillation of PD fluid prevents friction between the catheter tip and the bowel. Failure to perform PD exchanges for a prolonged period can place the patient at increased risk of perforation.1 This was described in renal allograft recipients in whom the PD catheter was not removed despite cessation of PD therapy.2 Use of corticosteroids and other immunosuppressive drugs after renal transplantation can result in decreased local tissue reaction to catheter trauma and increased risk of perforation. It thus is recommended that PD catheters be removed after a successful renal transplantation or a single daily PD exchange be continued.3 There are few reports of bowel perforation by functioning PD catheters in patients with colonic diverticuli occurring spontaneously or from erosion of the catheter.4 Patients undergoing continuous ambulatory PD have a greater prevalence of constipation, probably because of fluid restriction and use of phosphate binders, which places them at greater risk of developing diverticulosis.2
The striking clinical features of bowel perforation by PD catheters are fever, abdominal pain, and, occasionally, fecal effluent.4 Other clues include polymicrobial cultures, especially gram-negative bacteria with anaerobes.5 Our patient had an unusual presentation of severe watery diarrhea after instillation of PD fluid. The positive test result for reducing substance in the stool also was suggestive of PD fluid leak. Although the effluent was cloudy, it is surprising that our patient did not have fever or abdominal pain. Frequent instillation of PD fluid may have washed the peritoneal cavity and contributed to the less severe presentation.
Final Diagnosis
Perforation of a functioning Tenckhoff catheter through the appendix.
References
1. 1Pomer S, Rau J, Ziegler T, Zierenberg G, Ritz E, Rambausek M. Traumatic small bowel perforation by Tenckhoff catheter in the renal transplant recipient. Perit Dial Bull. 1987;7:S60.
2. 2Brady HR, Abraham G, Oreopaulos DG. Bowel perforation due to a dormant peritoneal catheter in immunosuppressed renal transplant recipient. Perit Dial Int. 1988;8:163–165.
3. 3Rambausek M, Zeier M, Weinreich T, Ritz E, Rau J, Pomer S. Bowel perforation with unused Tenckhoff catheters. Perit Dial Int. 2005;25:296–297. MEDLINE
4. 4Valles M, Cantavell C, Vila J. Delayed perforation of the colon by Tenckhoff catheter. Perit Dial Bull. 1982;2:190.
5. 5Rotellar C, Sivarajan S, Mazzoni MJ, et al.Bowel perforation in CAPD patients. Perit Dial Int. 1992;12:396–398. MEDLINE
Case provided and authored byJacob George, MD, DM, FRCP (Glasg),1 Sandeep Varma, MD, DM,1 Sreepa Palliyil Gopi, MD,1 Sreekumar Ramachandran, MS,2 Manju Thampi, MD, DM,1 Mohandas Kunjukunju, MD, DM,1 and Ramdas Pisharody, MD, DM, FRCP (Glasg),1 Departments of Nephrology1 and Surgery2, Medical College, Trivandrum, India.
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