University of North Carolina Chapel Hill Chapel Hill, NC, United States
Sonia Abichandani, MD, Akshay Roy-Chaudhury, MD, Seth Crockett, MD, MPH University of North Carolina Chapel Hill, Chapel Hill, NC
Introduction: Bowel injuries are a known complication of peritoneal dialysis catheter insertion and gastroenterologist should be aware of this rare complication.
Case Description/Methods: A 62 year old male on peritoneal dialysis (PD) presented with abdominal pain, shortness of breath, and discoloration of his dialysate fluid drainage for 3 days. The patient’s PD catheter had been placed three months prior by interventional radiology with ultrasound and fluoroscopy guidance. The operative note indicated difficulty manipulating the guidewire and a peritoneogram was performed to aid catheter insertion. Since placement, the patient successfully completed nightly home PD sessions prior to presentation.
On arrival, the patient was hemodynamically stable and without peritoneal exam findings. A diagnostic paracentesis revealed amber, cloudy fluid with 2,050 nucleated cells and 25% neutrophils. He was empirically started on cefepime and vancomycin. Peritoneal fluid culture grew 4+ Enterococcus faecalis. A CT scan demonstrated the PD catheter within the transverse colon without evidence of free air (A). Colonoscopy revealed the PD catheter traversing through the mid transverse colon with peritoneal cuff visible within the lumen (B). The scope was not advanced past this region to avoid dislodging the catheter or further damaging the colon wall.
He was taken to the operating room for laparotomy, where his PD catheter was visualized entering the anterior aspect of the transverse colon and exiting posteriorly. The catheter was removed and the anterior and posterior colostomies were sutured and covered with omental patches. An internal jugular tunneled line was placed for hemodialysis and he was discharged home.
Discussion: Bowel injuries due to PD catheter insertions are commonly detected intraoperatively. Signs of an intraoperative bowel perforation include visualization of the bowel lumen, evidence of bowel contents in the dialysate effluent, a subtle hissing sound from release of gas, or foul-smelling gas during the procedure. Less commonly, bowel injuries can be diagnosed post-operatively. Possible signs include severe watery diarrhea, abdominal pain with associated hypotension, acute abdomen and peritonitis. These manifestations can be temporarily masked in the event of a through-and-through bowel wall perforation and therefore gastroenterologist should be aware of this rate complication of PD catheter insertion.
Crabtree, J, and Chow, K. “Peritoneal Dialysis Catheter Insertion.” Sem in Neph. 2017; 37(1):17-29.
Figure: Peritoneal dialysis catheter coursing through the transverse colon demonstrated on CT abdomen and pelvis (A) and colonoscopy (B).
Sonia Abichandani indicated no relevant financial relationships.
Akshay Roy-Chaudhury indicated no relevant financial relationships.
Seth Crockett indicated no relevant financial relationships.
Sonia Abichandani, MD, Akshay Roy-Chaudhury, MD, Seth Crockett, MD, MPH. P1503 - Transcolonic Placement of Peritoneal Dialysis Catheter: A Delayed Cause of Bacterial Peritonitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.