Delayed Bowel Perforation in a Peritoneal Dialysis Patient: A Case Report and Literature Review

Erosion of the peritoneal dialysis (PD) catheter into the bowel is very rare. Some patients experience serious consequences such as peritonitis, difficulties in draining, and feculent dialysate effluent with watery diarrhea, but some patients develop no symptoms. Most cases have occurred upon insertion of a stylet-catheter. Perforation by a PD catheter is distinctly unusual. Here, we report a 72-year-old man who presented with a plastic tube protruding from the anus after defecating. We diagnosed the patient with delayed rectal perforation by a PD catheter. We compare our patient with similar patients identified by a search of the English-language literature indexed at PubMed (keywords: “perforation,” “erosion,” “peritoneal dialysis,” “catheter”) and a search for references within articles identified in the primary search.

Case Report

The patient was a 72-year-old man who initially presented in February 2001 with proteinuria (1250 mg daily) and elevated serum creatinine (350 μmol/L). He initially took a Chinese herb to treat his symptoms, but started PD in October 2002 when his serum creatinine was 680 μmol/L. A double-cuffed, curled Tenckhoff PD catheter was inserted by open surgery.

The patient remained on PD without complications for 27 months and was then converted to hemodialysis because of peritoneal membrane failure in January 2006. The peritoneal catheter was not removed at that time. In August 2010, the patient was admitted to the local hospital complaining that he felt a plastic tube protruding from his anus after defecation. Examination indicated that he was afebrile and had a stable cardiovascular system and a soft, tender abdomen. Rectal examination revealed the tip of the PD catheter protruding through the anus. The local doctor pulled and cut part of the protruding catheter before discharging the patient.

The patient was admitted to our hospital because of a tunnel infection related to the peritoneal catheter. Abdominal computed tomography (CT) showed that the catheter tip had entered the sigmoid colon (Figure 1), and a subsequent colonoscopy revealed that the catheter tip had invaded the rectal lumen (Figure 2).

Figure 1 —

Abdominal computed tomography images showing the peritoneal dialysis catheter tip inside the lumen of the rectum.

Figure 2 —

Colonoscopy showing the peritoneal dialysis catheter tip inside the rectal lumen.

The patient was given a cleansing enema, and the catheter was then removed by open surgery without bowel resection and without closure of the hole in the rectum within the peritoneal cavity. Some discolored substances were observed in the catheter when it was removed. The patient recovered fully and was well at a 3-month follow-up.

Discussion

Delayed perforation is an uncommon complication of PD and usually involves a dormant catheter. Our review of the literature indicated 28 cases, including the present case (Table 1). In 15 patients, PD had been suspended; the other 13 patients were on intermittent PD. Of the 28 patients affected, 10 had a straight PD catheter and 9 had a coiled catheter. The clinical course of the perforations was heterogeneous and included peritonitis, watery diarrhea, and catheter protrusion from the anus, among other manifestations. The diagnoses were confirmed by CT, contrast fluoroscopy, colonoscopy, or exploratory laparotomy. The risk factors in the 28 patients included use of immunosuppressants and the presence of diverticulitis or colonic amyloidosis.

TABLE 1.

Literature Reports of Delayed Bowel Perforation Caused by a Peritoneal Dialysis Catheter

In our patient, bowel perforation occurred more than 4 years after cessation of PD. Review of the other cases in the literature indicated that half were attributable to an unused PD catheter, typically 1.6 - 48 months after use had ceased. Lack of fluid in the peritoneal cavity after cessation of continuous ambulatory PD increases the risk for pressure-induced necrosis by the immobile catheter. Apparently, the peritoneal fluid that bathes the bowel loops acts as a barrier that prevents adhesion of the catheter to the bowel wall. However, in the Moncrief-Popovich technique, catheters are routinely implanted for several months without use, and regular flushing is not performed (21,22). For patients who suspend PD for more than 1 month, catheter removal might be the better choice to avoid severe complications such as bowel perforation. If the patient or doctor decides not to remove the catheter, then the catheter could be flushed regularly.

The continuous presence of fluid in the peritoneum of patients actively engaged in a continuous ambulatory PD program does not totally preclude the possibility of catheter adhesion. In fact, PD patients with diverticulitis might have an increased risk of catheter perforation (8,9). A patient with a history of diverticulitis should therefore be more carefully observed upon cessation of PD. Gastrointestinal pathology, including amyloidosis, might also increase the risk of catheter perforation (15). Although no general guidelines have been formulated concerning the timing of PD catheter removal after renal transplantation, the presence of a normally functioning allograft is the main indication for catheter removal. It might therefore be necessary to remove the catheter much sooner after transplantation or to flush the catheter regularly after cessation of PD.

The diagnosis of bowel perforation is definite when the catheter protrudes through the anus. Based on our literature review, we suggest that watery diarrhea during fluid instillation into the cavity, with or without peritonitis, could indicate bowel perforation. When clinical examination indicates peritonitis, it might be difficult to determine whether the cause is related to PD or is an acute problem arising from bowel perforation. Our review also indicates that bowel perforation might not be diagnosed even after death (5). Indeed, some patients remain asymptomatic (3,6). We therefore suggest routine abdominal CT imaging if a patient with peritonitis is treated with antibiotics for more than 3 days without resolution of symptoms.

The low incidence of bowel perforation makes establishing a standard management plan difficult, but surgery is the usual treatment. Successful endoscopic repair using clips (20) or endoscopic closure of the colonic perforation (23,24) after colonoscopy has also been reported. In addition, perforations could be self-curing, and so a conservative approach, with removal of the catheter, might be tried before consideration of surgical exploration. Favorable outcomes were reported in patients without signs of peritonitis or sepsis (6,14) or after conservative management with only catheter removal. In our view, if a patient presents with no signs of peritonitis or sepsis, but has formation of a sinus around the catheter, then simple catheter removal might be feasible if the patient can be carefully followed over time.

Conclusions

We want to emphasize several points with respect to the diagnosis and treatment of bowel perforation by a catheter in PD patients. First, the signs and symptoms of perforation are extremely variable. A high index of suspicion is required when the patient has watery diarrhea or peritonitis, and routine abdominal CT imaging should be performed if the patient has peritonitis and if antibiotic treatment for more than 3 days has not resulted in significant amelioration of symptoms. Second, patients discontinuing PD for more than 1 month could potentially benefit from catheter removal. Third, PD patients undergoing renal transplantation should have their catheters withdrawn or regularly flushed after the transplantation procedure. Finally, for a patient with no signs of peritonitis or sepsis, but with the formation of a sinus around the catheter, removal might be feasible if the patient can be followed over time.

Disclosures

The authors have no financial conflicts of interest to declare.