| Abstract|| |
Continuous ambulatory peritoneal dialysis (CAPD) has gained in popularity in recent years as a mode of renal replacement therapy. We report a 23 year old patient who was initiated on CAPD using curley Tenckhoff catheter in January 1992. In May 1993, the patient presented with features suggestive of intestinal obstruction. Plain x-ray of the abdomen showed that the CAPD catheter had migrated to the left hypochondrium. During surgery for catheter removal, it was found that the intraperitoneal cuff was adherent to the greater omentum forming a band over which the jejunal loop was kinked causing obstruction. Within 24 hours of removal of the catheter, the intestinal obstruction was relieved. The problem encountered in our patient is unique in illustrating the reversible mechanical intestinal obstruction relieved by catheter removal.
Keywords: CAPD, Intestinal obstruction, Tenckhoff catheter.
|How to cite this article:|
Huraib SO. Intestinal Obstruction as a Complication of Continuous Ambulatory Peritoneal Dialysis: A Case Report. Saudi J Kidney Dis Transpl 1995;6:304-7
|How to cite this URL:|
Huraib SO. Intestinal Obstruction as a Complication of Continuous Ambulatory Peritoneal Dialysis: A Case Report. Saudi J Kidney Dis Transpl [serial online] 1995 [cited 2013 May 22];6:304-7. Available from: http://www.sjkdt.org/text.asp?1995/6/3/304/40667
| Introduction|| |
Peritoneal dialysis has been used in the treatment of end-stage renal disease (ESRD) for a long time, but it was not until the introduction of continuous ambulatory peritoneal dialysis (CAPD) by Popovich, et al in 1976 , , and its modification by Oreopoulos subsequently  , that it became an acceptable form of renal replacement therapy. Since then, CAPD has gained in popularity over the years. Various complications related either to peritoneal access, infusion of dialysate or dialysis dwell periods have been reported in patients on CAPD. Peritonitis is one of the major complications of CAPD, but with the improvements achieved in the technique, the rate of peritonitis is on continuous decline  . Complications other than peritonitis are also being increasingly reported such as exit-site and tunnel infections , , hernias and intestinal perforation  as well as adhesions and sclerosing peritonitis  . We report here, a case of intestinal obstruction which occurred in a patient on CAPD.
| Case Description|| |
A 23 year old female patient of Pakistani nationality was admitted in March 1992 to our unit with advanced degree of renal failure secondary to glomerulonephritis. She was put on conservative therapy till she reached ESRD and was started on CAPD in December 1992. Curley Tenckhoff peritoneal dialysis (PD) catheter was surgically implanted in January 1992. There was no history of previous abdominal surgery and there were no hernias. After the necessary training, she was discharged from the hospital. Two months later, she developed an episode of Staphylococcus epidermidis peritonitis which was successfully treated with antibiotics. She also had one episode of spontaneous hemoperitoneum which resolved spontaneously. In May 1993, the patient was admitted with upper abdominal pain, vomiting and constipation of five days duration. The pain was moderately severe in intensity and colicky in nature. On physical examination, she looked dehydrated and her blood pressure was 90/60 mm Hg. Abdominal examination showed tenderness in the upper abdomen, bowel sounds were heard and rectal examination showed empty rectum. Peritoneal dialysis fluid examination did not show any evidence of peritonitis and the serum amylase levels were within normal limits. Plain x-ray of the abdomen, in supine and erect postures, showed no fluid levels. However, distension of loops of small intestine was noted and intestinal obstruction was thought to be present [Figure - 1]. The PD catheter was noted to have migrated to the left hypochondrium. Despite this migration, there was no problem with the inflow and outflow of the PD fluid. Surgical consultation confirmed the possibility of upper intestinal obstruction and she was put on nasogastric aspiration and intravenous fluid replacement. Small bowel barium follow-through x-ray [Figure - 2] clearly showed obstruction at the distal jejunum with a possible adhesion band. Conservative treatment for a further two days did not help and it was decided to remove the CAPD catheter and prepare the patient for laparotomy if catheter removal alone did not help.
The PD catheter was removed under local anesthesia. During surgery, it was found that the intraperitoneal cuff of the catheter was adherent to the greater omentum forming a sort of band over which the jejunal loop was overhanging causing mechanical obstruction. The adhesions around the cuff were released and the catheter was pulled out easily. There was no evidence of peritonitis or strangulation. Within 24 hours of the removal of the PD catheter, the intestinal obstruction was relieved and repeat x-ray of abdomen showed that the barium had moved down the intestine [Figure - 3]. On the next day, she developed loose motions and got completely relieved of her pain. She was shifted to hemodialysis and discharged from the hospital in good condition.
| Discussion|| |
Various modifications of the CAPD technique, and growing knowledge of various aspects of CAPD have made this modality a widely accepted form of renal replacement therapy in patients with ESRD. Consequently, various complications are being increasingly recognized and reported.
To the best of our knowledge mechanical intestinal obstruction as a complication of CAPD has not been reported yet. The suggested mechanism is as follows [Figure - 4]: the PD catheter tip was initially placed in the pelvis between the loops of the jejunum. One of the jejunal loops lifted the PD catheter gradually to the left hypochondrium. The inner cuff of the PD catheter was adherent all around to the greater omentum. This resulted in the creation of a shelf-like window between the anterior abdominal wall and the omental adhesions. The jejunal loop overhanged itself through this window resulting in mechanical obstruction. When the catheter was removed and the omental adhesions freed, the jejunal loop was released and returned back to its normal position thereby relieving the obstruction. This complication could be avoided by placing the inner cuff of the PD catheter outside the peritoneum in the rectus sheath.
Peritoneal dialysis catheter related complications such as catheter tip migration, dialysis solution leak and exit-site infection are not uncommonly encountered with the straight Tenckhoff silicone catheter which is still widely used  . To prevent catheter tip migration, numerous modifications of the straight catheters have been made including: the curled-tail Tenckhoff catheter, wherein, the coil is supposed to prevent migration of the catheter tip as also to reduce the force of the inflow stream; the Toronto Western Hospital catheter by Oreopoulos and Zelluman  , the main distinguishing feature being the presence of two flat silicone rubber discs in the intraabdominal segment of the catheter which prevent the free movement of the catheter tip within the peritoneal cavity; the Toronto Western Hospital Catheter, Type 2 with a short intra-abdominal segment and the Swan-Neck catheter, the distinguishing feature of which is the presence of a molded band between the two cuffs preventing catheter migration.
The problem we encountered in this patient is unique in clearly illustrating the reversible mechanical intestinal obstruction relieved by catheter removal. The simple procedure, performed under local anesthesia, saved the patient from laparotomy and its attendant risks.
| References|| |
|1.||Popovioh RP, Moncrief JW et al. The definition of a novel portable-wearable equilibrium technique. Abst Am Soc Artif Intern Organs 1976;64. |
|2.||Popovich RP, Moncrief JW, Nolph KD, Ghods AJ, Twardowski ZJ, Pyle WK. Continuous ambulatory peritoneal dialysis. Ann Intern Med 1978;88:449-56. [PUBMED] |
|3.||Oreopoulos DG, Robson M, Izatt S, Clayton S, Deveber GA. A simple and safe technique for continuous ambulatory peritoneal dialysis (CAPD). Trans Am Soc Artif Intern Organs 1978;24:484-9. [PUBMED] |
|4.||National CAPD Registry of the NIH. January 1, 1981 through August 31, 1986. 1987. Wu G, Khanna R, Vas S, Oreopoulos DG. Is extensive diverticulosis of the colon a contraindication to CAPD. Perit Dial Bull 1983;3:180-3. |
|5.||Ryan GB, Grobety G, Majno G. Postoperative peritoneal adhesions. A study of the mechanisms. Am J Pathol 1971;65:117-48. |
|6.||Tenckhoff H, Schecter H. A bacteriologically safe peritoneal access device. Trans Am Soc Artif Intern Organs 1968;14:181-7. |
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|8.||Morgenstein BZ, Balurate H. Peritoneal dialysis kinetics in children. In: Fine RA (Ed). Chronic ambulatory peritoneal dialysis (CAPD) and chronic cycling peritoneal dialysis (CCPD) in children. Martinus Nijhoff, Boston 1987;47-62. |
Sameer O Huraib
Department of Medicine, King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]