Imaging Teaching CaseDevelopment of Encapsulating Peritoneal Sclerosis Following Bacterial Peritonitis in a Peritoneal Dialysis Patient
Introduction
Encapsulating peritoneal sclerosis (EPS) is an uncommon and often fatal complication in patients on peritoneal dialysis (PD) therapy. EPS is a clinical syndrome characterized by symptoms of impaired intestinal motility, such as anorexia, nausea, vomiting, abdominal fullness, abdominal pain, absent bowel sounds, and constipation.1 These presentations result from diffuse peritoneal thickening, sclerosis, calcifications, and encapsulation of the bowel loops.1 Progression of EPS usually is considered to be insidious; however, we describe a patient who developed EPS immediately after an episode of bacterial peritonitis. The diagnosis of EPS requires a high index of clinical suspicion, especially in long-term PD patients with symptoms of ileus. Imaging studies can be very important in confirming the diagnosis.
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Clinical History and Initial Laboratory Data
A 40-year-old woman with end-stage renal disease caused by chronic glomerulonephritis, who had received PD for 12 years, presented to the emergency department with fever, nausea, diarrhea, and diffuse abdominal pain after ingesting seafood in October 2008. She had controlled hypertension and had undergone parathyroidectomy for secondary hyperparathyroidism in January 2007.
The patient's PD regimen included 5 exchanges of 2 L of PD solution daily. Before July 2007, all exchanges were performed
Discussion
EPS is an uncommon, but catastrophic, complication of long-term PD therapy in which the peritoneum becomes progressively thickened, causing encasement of the small intestine. Its high mortality rate is related to complications from bowel obstruction (such as malnutrition, sepsis, and bowel perforation) and complications after surgical enterolysis. The incidence of EPS reported in the literature ranges from 0.7%-7.3%.1 Recent studies described the incidence to be 2.5% in Japan2 and 3.3% in a
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References (19)
- et al.
Encapsulating peritoneal sclerosis in Japan: a prospective, controlled, multicenter study
Am J Kidney Dis
(2004) - et al.
Single-center experience of encapsulating peritoneal sclerosis in patients on peritoneal dialysis for end-stage renal failure
Kidney Int
(2005) - et al.
Sclerosing peritonitis: identification of diagnostic, clinical, and radiological features
Am J Kidney Dis
(1994) Sclerosing encapsulating peritonitis in chronic ambulatory peritoneal dialysis
Clin Radiol
(1990)- et al.
Computed tomography appearances of sclerosing encapsulating peritonitis
Clin Radiol
(2007) - et al.
Ultrasound changes in sclerosing peritonitis following continuous ambulatory peritoneal dialysis
Clin Radiol
(1991) - et al.
The calcified abdominal cocoon
Lancet
(2008) - et al.
Encapsulating peritoneal sclerosis: definition, etiology, diagnosis, and treatmentInternational Society for Peritoneal Dialysis Ad Hoc Committee on Ultrafltration Management in Peritoneal Dialysis
Perit Dial Int
(2000) - et al.
Increasing incidence of severe encapsulating peritoneal sclerosis after kidney transplantation
Nephrol Dial Transplant
(2007)
Cited by (11)
Imaging pearls and differential diagnosis of encapsulating peritoneal sclerosis: Emphasis on computed tomography
2023, Clinical ImagingCitation Excerpt :Ultrasonography may show a thickened peritoneum, loculated ascites, and small bowel abnormalities (kinking, rigidity, dilatation, and decreased peristalsis; Fig. 3). A trilaminar membrane appearance has been described as a hallmark of EPS.15,16 It comprises a superficial hyperechoic membrane (representing peritoneal thickening), a middle hypoechoic layer (the bowel wall), and a deep hyperechoic layer (bowel gas).
Encapsulating Peritoneal Sclerosis: What Have We Learned?
2011, Seminars in NephrologyCitation Excerpt :In addition, recurrent peritonitis is associated with higher levels of inflammatory cytokines with each subsequent infection, indicating a sustained alteration in peritoneal cytokine regulation.49 In agreement with the two-hit hypothesis, an episode of severe peritonitis may precede the cessation of PD and development of EPS14,50 when occurring on a background of long-term peritoneal dialysis and chronic membrane change. A large number of chemokines and other mediators promoting inflammation, fibrosis, and angiogenesis have been shown to have a potential role in peritoneal membrane damage.
Encapsulating Peritoneal Sclerosis
2010, Clinical Gastroenterology and HepatologyPeritoneal Dialysis Guidelines 2019 Part 1 (Position paper of Japanese Society of Dialysis Therapy)
2021, Renal Replacement TherapyLong-term outcome of chronic dialysis in children
2021, Pediatric Dialysis: Third Edition
Originally published online as doi:10.1053/j.ajkd.2009.06.043 on September 27, 2009.