Case Presentation:
A 44-year-old female with end-stage renal disease on hemodialysis presented to the hospital with progressive nausea, vomiting and abdominal pain. The etiology of her renal disease was unknown. She had received a renal transplant 17 years ago, which then failed. She was maintained on peritoneal dialysis (PD) for 12 years until she was converted to hemodialysis two months prior to her presentation. Physical examination revealed tachycardia, abdominal distension without a fluid wave or shifting dullness, and diffuse tenderness to palpation. Laboratory studies were significant for creatinine of 4.9 mg/dL and albumin 2.0 g/dL. Abdominal xray showed a non-obstructive bowel gas pattern. A CT abdomen and pelvis demonstrated a large encapsulated fluid collection, measuring approximately 20 cm by 26 cm in its largest dimension, along the peritoneum with coarse calcifications and compression on the bowel. Consultation with nephrology and surgery confirmed the diagnosis of sclerosing encapsulating peritonitis (SEP). She was started on prednisone and tamoxifen for treatment of the condition. Multiple changes to her pain and anti-emetic medications were made without improvement in symptoms. She underwent a therapeutic paracentesis on hospital day 11 with removal of 3 liters of fluid. She had significant improvement in her nausea, vomiting, anorexia and abdominal pain, and she was discharged home.
Discussion:
Sclerosing encapsulating peritonitis is a rare condition characterized by inflammation causing fibrous thickening of the peritoneum. It has a prevalence rate of only 0.5-0.9%, and it is most commonly seen in patients who have been treated with PD for over 5 years. Its incidence increases with duration on PD and number of prior episodes of peritonitis. It is diagnosed clinically based on symptoms and CT scan findings. Although changing to hemodialysis and using anti-inflammatory and anti-fibrosing agents have been used to treat SEP, mortality rates still approach 60%. Death typically occurs as a result of surgical complications or small bowel obstruction.
Conclusions:
Sclerosing encapsulating peritonitis is one of the most serious complications of ambulatory peritoneal dialysis. Clinicians should consider the diagnosis of SEP in patients on chronic PD with small bowel obstruction symptoms, in order to rapidly recognize and start treatment for the condition. Palliation of symptoms with paracentesis in this case proved to be a successful intervention.