Encapsulating peritoneal sclerosis is a rare but serious complication of peritoneal dialysis. It has a mortality of more than 30%.
Our Case
Elderly male with longstanding history of renal failure, status post failed renal transplant, and history of long standing peritoneal dialysis.
Findings are consistent with encapsulating peritoneal sclerosis characterized by thickening of the peritoneum, ascites under pressure with deformity of the posterior aspect of the liver, compression of bowel loops so they do not consistently rise to the anterior abdominal wall, and suggestion of cocoon formation of some of the bowel loops and peritoneal fat. There is no evidence of obstruction and no findings of omental metastases
Kawanishi et al Successful surgical management of encapsulating peritoneal sclerosis Journal of the International Society for peritoneal Dialysis
Courtesy PDI connect.com
Frontiers in Physiol. 2014; 5: 470.
Published online 2015 Jan 5.
aka
abdominal cocoon
sclerosing peritonitis, encapsulating peritonitis, and peritonitis chronica fibrosa incapsulata.
Cause
Dialysis fluid is hyperosmotic, hyperglycemic, and acidic
• Autoimmune diseases
• Sarcoidosis TB
• Peritoneal and intra-abdominal malignancies
• Chronic peritoneal ascites
• Intra-peritoneal chemotherapy
• Intraperitoneal exposure to particulate matter or disinfectant
• Abdominal surgery
• Endometriosis
• Intra-peritoneal infections (tuberculosis)
• Beta-blocker administration
Presentation
low-grade fever,
ascites with negative culture,
elevated C-reactive protein level
poor response to antibacterial therapy.
Stages
Stage 1- Asymptomatic with mild ascites and no inflammation.
Stage 2- Inflammatory stage: Patients are symptomatic with nausea and diarrhea consistent with partial encapsulation of the bowel and intestinal swelling. Mild inflammation with fibrin exudation is present.
Stage 3- Encapsulation: Symptoms of bowel obstruction due to the formation of the fibrous cocoon causing encapsulation. It can be associated with mild to severe inflammation.
Stage 4- Chronic stage of ileus: Patients have absolute bowel obstruction caused by thickening of the encapsulating fibrous cocoon. There is little, if any, inflammation at this stage.