Peritoneal adhesion: it can be life-threatening, and life-saving

Abstract

Background: The inevitable post-inflammatory fibrosis and adhesion often compromises future treatment in peritoneal dialysis patients. Here, we describe a patient who experienced an unusual form of peritoneal adhesion that made her give up peritoneal dialysis. However, its unique pattern also saved her from infection caused by bowel perforation.

Case presentation: The female patient discontinued peritoneal dialysis due to gradual dialysis inadequacy. Two months after shifting to hemodialysis with generally improved sense of well-being and no sign of abdominal illness, she was admitted to remove the Tenckhoff catheter. The procedure was smooth, but fever and abdominal pain not at the site of operation developed the next day. Abdominal ultrasound showed the presence of ascites and aspiration revealed slimy, green-yellowish pus that gave a negative result on bacterial culture. Abdominal computed tomography (CT) with oral contrast medium was performed, but failed to demonstrate the suspected bowel perforation. The examination, however, did show accumulation of pus inside the abdomen but outside the peritoneal cavity. We drained the pus with two 14-F Pig-tail catheters and the total amount of drainage approached 4000 ml. The second CT was performed with double dose of the contrast medium and found a leak of the contrast from the jejunum. She then received laparotomy and had the perforation site closed.

Conclusions: In summary, this uremic patient suffered from pus accumulation inside her abdomen without obvious systemic toxic effect. The bowel perforation and pus formation might be caused by repeated peritonitis, but the peritoneal adhesion itself might also isolate her peritoneal cavity from the anticipated toxic injuries of bowel perforation.

Figure 1

A and B. Large amount of pus (*). The pus was located inside the abdomen but did not involve the peritoneal cavity. Several peritoneal calcifications were seen (arrow), most likely due to the sequel of previous peritonitis.

Figure 2

A and B. Repeated CT scan with patient ingesting 200 ml of Ultravist® medium. Both transverse (A) and sagittal (B) sections showed suspicious medium leak (arrow) but the amount was small and inconclusive to reveal the site of leakage. The pus (*) had been partially drained.

Figure 3

A, B and C. Peated CT scan when pus was completely drained and patient ingested 400 ml of Ultravist® medium. The transverse image suggested a cocoon-like conformation which kept the leaking medium from entering the peritoneal cavity (arrow in Figure 3A and 3C). Figure 3B shows the favored site of perforation (solid arrow) near the original exit site of PD catheter (dotted arrow). It was later proved by the laparotomy finding.