Slideshow
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Slide
An x-ray of the abdomen and pelvis was performed and a representative image is shown.
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A second x-ray image obtained 24 hours later showing a decrease in stool burden and catheter tip pointing toward the pelvis.
An adult male recently had peritoneal dialysis (PD) catheter placement after a new diagnosis of end-stage renal disease (ESRD). He had residual urine output totaling more than 1 liter per day and has been doing continuous ambulatory PD (CAPD) with manual exchanges for the past 2 months. His initial PD course was remarkable for end of drain pain, which abated with time. He uses a stimulant laxative and a surfactant to maintain regular bowel movements. He denied any change in quality or color of his effluent and denied abdominal pain. He endorsed abdominal fullness over the past week. For the past day, he noted a decrease in outflow volume.
During his evaluation, his blood pressure was 160/90 mm Hg. His lungs were fairly clear. His abdomen was mildly distended and non-tender to palpation. His PD exit site was clear and non- erythematous. There was no tunnel tract tenderness. Under observation, 1 liter of fluid was infused without issue, but minimal volume could be drained and he was sent for further work up. Heparin instillation in the catheter did not lead to improvement, and there was no recent evidence of fibrin blockage.
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This case was prepared by Kevin T. Harley, MD, Assistant Clinical Professor of Medicine, Division of Nephrology & Hypertension, at the University of California in Irvine.
References
1. McCormick BB, Bargman JM. Noninfectious complications of peritoneal dialysis: implications for patient and technique survival. J Am Soc Nephrol. 2007;18:3023-3025.
2. Yasuda G, Shibata K, Takizawa T, et al. Prevalence of constipation in continuous ambulatory peritoneal dialysis patients and comparison with hemodialysis patients. Am J Kidney Dis. 2002;39:1292-1299.
Answer: A
Explanation:
The plain film x-ray of the abdomen and pelvis show a patient with obvious constipation, with substantial stool burden throughout the colon. The PD catheter is misplaced with its spiraled end pointing toward the left upper quadrant and the splenic flexure. The second x-ray image from 24 hours later shows a decrease in stool burden, with the catheter tip now migrated toward the midline lower pelvis.
Constipation is a major problem in all ESRD patients. Inciting factors include decreased physical activity, a large pill burden that includes multiple agents known to lead to stool immobility, and decreased water and fluid intake. Some past data suggest constipation may be less prevalent in CAPD compared with hemodialysis.
However, PD patients are particularly prone to adverse effects from constipation. An increase in intestinal distention from a large stool burden can lead to PD catheter displacement from an ideal location in the pelvis. PD patients are instructed to avoid bowel irregularity and are usually prescribed a standing regiment of agents to affect mobility and lessen stool hardness. High fiber diet and supplements may also be beneficial.
The differential diagnosis of PD catheter migration/misplacement includes improper surgical placement, entrapment in the omentum or other viscus, interference from intraperitoneal adhesions, and, rarely, intestinal perforation.
Our patient had much improved dialysate outflow with continued catharsis. He did not require any surgical intervention for this episode.
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