Peritonitis and Hemoperitoneum in Peritoneal Dialysis: A Rare Traumatic Complication

Introduction: The most common complications of peritoneal dialysis (PD) catheters include infections and mechanical catheter dysfunction. Perioperative complications of catheter insertion include intraabdominal organ perforation and bleeding, while delayed complications include impaired dialysate flow, pericatheter leakage, and superficial cuff extrusion. Here, we present an interesting case of an acutely ill PD patient with multiple PD complications. Case Description: A 44 year old man with End Stage Renal Disease (ESRD) on PD presented to the hospital with septic encephalopathy, inability to complete cycler PD for three days, and bloody PD effluent. Preceding the admission, he had a three month history of PD peritonitis treated by his outpatient nephrologist with intraperitoneal (IP) Vancomycin. After hospitalization, he was given broad spectrum intravenous (IV) and IP antibiotics for culture confirmed and recurrent Staphylococcus epidermidis peritonitis. Cycler PD was not reattempted, and the patient was given manual PD with 2.5 liters every six hours including IP cefazolin and heparin as well as hemodialysis (HD). He had continued grossly bloody PD effluent with red blood cell counts of 650,000/uL on admission decreasing only to 320,000/uL after one week, necessitating transfusions of ten units of packed red blood cells over this period. Discussion: Initial and repeat computed tomography of the abdomen and pelvis demonstrated displaced PD catheter tip terminating in the right abdomen, as well as an expanding intraabdominal fluid collection without active IV contrast extravasation. Surgery performed an exploratory laparoscopy with extensive lysis of adhesions, converted to open laparotomy, and the PD catheter course was tracked entering the lower abdomen directly into the urinary bladder. Cystotomy finally revealed that the source of bleeding was within the bladder itself, and the remaining hematoma was evacuated. The PD catheter was completely removed, and Urology was consulted intraoperatively for bladder repair/closure. The patient later remarked that 3 days prior to admission, he fell onto a truck dolly causing blunt force trauma to his abdomen, followed immediately by PD cycler low flow errors and blood in the PD effluent. He remained anuric throughout the hospitalization and eventually clinically recovered. He was discharged in good condition to continue on HD.