EPS is a life-threatening complication of long- term PD. Many factors have been incriminated in its pathogenesis but they don’t explain all risk conditions. Probably unidentified factors make some patients more susceptible to developing EPS.
A 71-year-old female for 7 years on CCPD1 presented with recurrent small-bowel obstruction. Her medical history reported 1 episode of peritonitis. No ultrafiltration failure or hypertonic dialysis solutions use; the adequacy was always according guidelines. For 2 months she experienced abdominal discomfort and recurrent abdominal pain. Since starting gastrointestinal symptoms, the dialysate leukocytes and cultures were negative for peritoneal infection. PCR, procalcitonin levels and leucocytes were in normal range. Abdominal CT scan demonstrated peritoneal sclerosis and absence of gas-fluid levels and calcifications. The patient refused the hospital admission but 2 weeks later she experienced again bowel immobility. Laboratory investigations for peritonitis were negative. The patient was diagnosed with EPS and antibiotics and total parenteral nutrition were initiated. PD was stopped and HD was started. Two days later the patient developed a severe bowel obstruction. The new abdominal CT scan showed the same picture and air gas-fluid levels. The patient underwent surgical intervention.
Under a sclerotic membrane we found thickening of intestinal wall and entrapment of small bowel in fibrous tissue; a cocoon-like encapsulation was surrounding last 80 cm of small-bowel loops. We detected a single intestinal perforation in small-intestine last loop. It was performed ileocaecal resection and ileocolic anastomosis; after 12 hours the patient died for septic shock. Histopathology examination showed massive alterations in peritoneal membrane with a PD-induced chronic tissue damage, consisting of mesothelial denudation and interstitial fibrosis.
Among suggested predisposing factors of EPS, the present case showed the duration of PD and one episode of peritonitis (no peritoneal deterioration features neither chronic inflammatory state).Up to now, not all predisposing factors have been identified.
