Bacterial Peritonitis Following Esophagogastroduodenoscopy in a Patient on Peritoneal Dialysis

___________________________________________________________________________________________ *Co esponding au ho : Email: a [email protected]; B i ish Jou nal o Medicine & Medical Resea ch 3(3): 784-789, 2013 SCIENCEDOMAIN in e na ional www.sciencedomain.o g Bac e ial Pe i oni is Following Esophagogas oduodenoscopy in a Pa ien on Pe i oneal Dialysis Ramachand am A usula1*, Michael Shoemake -Moyle1, Minesh B. Pa hak3, É a Csong ádi2,4 and Tibo Fülöp1 1Di ision o Neph ology, Depa men o Medicine, Uni e si y o Mississippi Medical Cen e , Jackson, MS, Uni ed S a es o Ame ica. 2Di ision o Endoc inology, Depa men o Medicine, Uni e si y o Mississippi Medical Cen e , Jackson, MS, Uni ed S a es o Ame ica. 3Kidney Ca e Consul an s, PC, Memphis, TN, Uni ed S a es o Ame ica. 41s Depa men o Medicine, Medical and Heal h Science Cen e , Uni e si y o Deb ecen, Hunga y. Au ho s’ con ibu ions This wo k was ca ied ou in collabo a ion be ween all au ho s. Au ho s RA and TF designed and w i en he case epo , including ini ial d a and inal e sion. Au ho s MBP and TF collec ed he pa ien ’s clinical da a. Au ho s RA, TF and ÉC managed he li e a u e sea ches. Au ho s MSM, ÉC, TF u he edi ed he manusc ip and p o ided c i ical commen a y. All au ho s ead and app o ed he inal manusc ip . Recei ed 30 h Sep embe 2012 Accep ed 23 d Janua y 2013 Published 6 h Ma ch 2013 ABSTRACT Aims: To ecognize he impo ance o conside ing pe o a ion o iscus in he di e en ial o pe i oni is a e uppe gas oin es inal endoscopy in pe i oneal dialysis pa ien s and o add ess he po en ial bene i o an ibio ic p ophylaxis in PD pa ien s unde going uppe GI p ocedu es. P esen a ion o Case: We epo he case o a 54-yea -old A ican Ame ican emale wi h end-s age enal disease on pe i oneal dialysis p esen ing wi h gene alized abdominal pain, along wi h nausea and omi ing. Pe i oneal luid e ealed a WBC coun o 1,499/mm3. Two days ea lie , she had unde gone an esophagogas oduodenoscopy wi h biopsy. B oad spec um an ibio ics we e s a ed o ea possible pe i oni is. Case S udy B i ish Jou nal o Medicine & Medical Resea ch, 3(3): 784-789, 2013 785 Su gical explo a ion e ealed no pe o a ion bu mu ky pe i oneal luid was no ed and g am s ain showed mixed lo a (bo h g am nega i e and g am posi i e ods); howe e , blood and pe i oneal luid cul u e g ew only S ep ococcus pneumoniae. Discussion and Conclusion: An occul pe o a ion, which may no be ob ious o he naked eye o signs o con as ex a asa ion can occu a e esophagogas oduodenoscopy wi h manipula ions and can lead o pe i oni is, especially in high- isk pa ien s such as hose wi h end-s age enal disease on pe i oneal dialysis. To ou knowledge, his is he i s epo ed case o mixed pe i oni is a ibu able o suspec ed mic o-pe o a ion a e esophagogas oduodenoscopy. Whe he p e- p ocedu e an ibio ics a e wa an ed o dec ease he occu ence o in ec ious complica ions in PD pa ien s unde going uppe gas oin es inal p ocedu es emains unce ain and no well s udied. The p omp ecogni ion o possible mixed bac e ial in ec ion emains essen ial a e hese p ocedu es. Keywo ds: Con inuous ambula o y pe i oneal dialysis; end-s age enal disease; gas oin es inal endoscopy; iscus pe o a ion; pe i oni is. 1. INTRODUCTION Pe i oni is is a common complica ion in pa ien s wi h end-s age enal disease (ESRD) unde going pe i oneal dialysis. Pe i oni is in his g oup o pa ien s can lead o conside able mo bidi y, echnique ailu e and may equi e con e sion o hemodialysis. Pe i oni is causes up o 18% o he in ec ion ela ed dea hs in pa ien s on pe i oneal dialysis (PD) and almos 4% o pe i oni is episodes in PD pa ien s lead o dea h [1]. This complica ion mos commonly occu s due o con amina ion o he ca he e wi h pa hogenic skin lo a o di ec con amina ion o he luid bag connec o [2]. O he impo an causes o pe i oni is in hese pa ien s include cholecys i is, appendici is, up u ed di e iculum, ansmu al mig a ion o in ec ion in se e e cons ipa ion, and pe o a ion o he iscus du ing a ious gas oin es inal (GI) p ocedu es. Two a e causes o pe i oni is a e hema ogenous sp ead o he in ec ion and aginal leak. The case desc ibed in his epo epo s possible iscus pe o a ion due o esophagogas oduodenoscopy (EGD) in a pa ien wi h end-s age enal disease on con inuous ambula o y pe i oneal dialysis (CAPD). 2. PRESENTATION OF CASE A 54-yea -old A ican Ame ican emale wi h ESRD on CAPD p esen ed wi h a wo-day his o y o gene alized abdominal pain wi h nausea and omi ing. Two days be o e p esen ing o he hospi al she unde wen EGD which showed mild gas i is and a small hia al he nia. Mul iple biopsies om esophagus, s omach and duodenum we e ob ained du ing he p ocedu e. No an ibio ic p ophylaxis was gi en du ing EGD. Sho ly a e he p ocedu e, she de eloped c escendo di use abdominal pain accompanied by a igue, nausea and gene alized weakness. He pas medical his o y included ESRD, sys emic lupus e y hema osus, diabe es melli us, hype ension, a his o y o me hicillin- esis an S aphylococcus au eus in ec ion, and deep enous h ombosis o he le lowe ex emi y. The pa ien ’s medica ions included se elame 800 mg h ee imes a day wi h meals, insulin, sus ained- elease dil iazem 360 mg wice a day, enal mul i i amin, and esomep azole 40 mg daily. She was alle gic o me ho exa e, B i ish Jou nal o Medicine & Medical Resea ch, 3(3): 784-789, 2013 786 enalap il, and codeine. Re iew o sys ems was nega i e o he han he p esen ing complain s. On admission, he pa ien had achyca dia wi h a hea a e o 145 bea s pe minu e, blood p essu e o 135/66 mmHg, achypnea wi h a espi a o y a e o 35, apid shallow b ea hing and looked acu ely ill wi h mode a e discom o seconda y o he abdominal pain. Ches exam was no mal. The e was mode a ely di use ende ness and in olun a y gua ding o he abdomen. A clean pe i oneal dialysis exi si e wi hou e y hema o exuda e was no ed on physical examina ion. A e ial blood gases e ealed a combina ion o espi a o y alkalosis and a me abolic acidosis wi h PH7.48, PaCO228 mmHg, PaO285, bica bona e 18 mmol/l and lac a e 7.2 mmol/l. The pa ien ’s whi e cell coun was ele a ed o 15,100/mm3, and he hemoglobin was 120 gm/l, pla ele s 297,000/mm3. Elec oly e le els included sodium 129 mmol/l, po assium 7.7 mmol/l, chlo ide 91 mmol/l, blood u ea ni ogen 26.06 mmol/l, c ea inine 686.34 µmol/l, and glucose 4 mmol/l. An e ec iew o abdominal X- ay showed an un ema kable bowel gas pa e n and a po able ches X- ay did no show any in il a e o pulmona y consolida ion. Elec oca diog am indica ed sinus achyca dia a a a e o 168 bpm wi hou any T wa e changes. Ini ial CT o he abdomen was aken wi hou o al con as as he pa ien was unable o inges o al con as . CT s udy e ealed an abno mally hickened appea ance o he duodenum and p oximal jejuna which we e assumed o be in lamma o y p ocesses due o he pa ien ’s sys emic lupus e y hema osus. I also showed a small amoun o pe i oneal ee luid and ai ha could be a ibu ed o he pe i oneal dialysis. Ini ially he pa ien was gi en I.V. ancomycin and gen amycin o ea possible pe i oni is in he Eme gency Depa men . In addi ion, she was gi en a combina ion o insulin, 50% dex ose and bica bona e i. o he ea men o hype kalemia and acidosis. Pe i oneal luid s udies e ealed WBC 1,499 /mm3(90% neu ophil g anulocy es), and RBC 3/mm3. G am s ain o PD luid showed bo h g am nega i e and g am posi i e ods wi hou any ungal elemen s bu cul u e g ew only S ep ococcus pneumoniae. In a enous pipe acillin/ azobac am was subsequen ly added o b oaden co e age o polymic obial in ec ion. Eme gency su gical consul a ion was ob ained and he pa ien unde wen eme gen explo a o y lapa o omy and PD ca he e emo al, which e ealed mu ky pe i oneal luid and hickened p oximal jejunum bu no ob ious pe o a ion o he iscus o obs uc ion o bowel lumen we e no ed. Blood cul u es g ew g am posi i e cocci, also inalized as S. pneumoniae. Repea ed blood cul u es we e nega i e o any o ganism and he pa ien was ini ia ed on hemodialysis une en ully. Ini ially, lupus was en e ained in he di e en ial o pe i oni is and abno mal hickening o he duodenum and me hylp ednisolone 20 mg wo imes a day was s a ed. Glucoco icoids we e apidly discon inued a e isual hallucina ions eme ged, and subsequen clinical e alua ion and se ologic wo k-up uled ou la e o signi ican lupus ac i i y. The ea e , he pa ien eco e ed smoo hly and discha ged home a e se en hospi al days wi h con inued in-cen e ou pa ien dialysis ia a unneled dialysis ca he e . 3. DISCUSSION Pe i oni is is he majo complica ion o pe i oneal dialysis and can lead o ca he e loss, ans e o o he o ms o enal eplacemen he apy, inc eased mo bidi y and mo ali y. These complica ions mos commonly esul om con amina ion o he ca he e wi h pa hogenic skin bac e ia o om con amina ion o he pe i oneal dialysis p ocedu e i sel . Al hough EGD is conside ed sa e and e ec i e, complica ions occasionally occu such as B i ish Jou nal o Medicine & Medical Resea ch, 3(3): 784-789, 2013 787 pe o a ion. The isk o pe o a ion is inc eased i he endoscopy is associa ed wi h manipula ions such as biopsy, scle o he apy, and dila a ion. A s udy in a e ia y ca e cen e showed ha he a e o pe o a ion du ing endoscopy anged om 0.02% o 0.04% [3]. Pa ien s ha ing pe o a ion as a complica ion, who p esen wi h ypical pe i oni is o sep ic shock and ex a asa ion o con as on adiological s udies a e mo e likely o unde go su gical in e en ion, whe eas a mino i y o pa ien s can p esen wi hou con as ex a asa ion on adiological s udies wi h mild symp oms and can be ea ed non- ope a i ely. P omp app ecia ion o he mixed bac e ial lo a, s ongly sugges i e o in es inal o igin was c i ical o success ul ou come in ou case. Con amina ion o he ca he e and dialysis p ocedu e is p edominan ly associa ed wi h single o ganism, usually g am posi i e [1,4]. To ou knowledge, his is he i s epo ed case o mixed bac e ial pe i oni is a ibu able o suspec ed mic o-pe o a ion a e EGD. The pa ien desc ibed in his case epo was unable o inges he con as du ing adiological p ocedu e and no pe o a ion o he iscus was iden i iable du ing su gical explo a ion. A pe o a ion which is no ob ious o he naked eye wi hou signs o con as ex a asa ion can occu a e EGD wi h manipula ions and can lead o PD pe i oni is due o wi h comp omised hos immuni y, low PHand high glucose concen a ion o dialysa e, as well as he p esence o a o eign body in he abdomen (dialysis ca he e ). Polymic obial PD pe i oni is, a he han single-o ganism in ec ion, has been associa ed wi h wo se ou comes, including hospi aliza ion, dea h and PD modali y ailu e wi h pe manen ans e o hemodialysis [5]. I is impo an o no e ha his pa ien also had sys emic lupus e y hema osus wi h po en ial gas oin es inal mani es a ions adding o he isk o complica ions du ing EGD [6]. I is essen ial o ecognize he signi icance o an ibio ic p ophylaxis o dec ease he occu ence o in ec ious complica ions in PD pa ien s unde going gas oin es inal p ocedu es. Case epo s o simila e en s mos ly occu ed du ing colonoscopy p ocedu es o da e[7]. A Chinese se ies o lexible colonoscopy p ocedu es among PD pa ien s no ed a 6.3% incidence o pe i oni is wi hou p e-p ocedu al an ibio ics, while none in he pa ien s ecei ing an ibio ic p ophylaxis [8]. Cu en ecommenda ions [1,4,9,10] ha e ocused on an ibio ic p ophylaxis o PD pa ien s unde going lowe gas oin es inal p ocedu es, especially colonoscopy. To dec ease he isk o pe i oni is, ampicillin and an aminoglycoside wi h o wi hou anae obic co e age (me onidazole) should be gi en p io o he p ocedu e and he abdomen should also be emp ied o any dialysa e luid be o e s a ing he p ocedu e. In con as , he e a e no de ini i e da a o any speci ic guidelines o an ibio ic p ophylaxis in uppe GI p ocedu es on PD pa ien s. A single case epo desc ibed S i idans PD pe i oni is a e uppe GI endoscopy and scle o he apy o bleeding ulce [11] and ano he publica ion documen ed ecu en PD pe i oni is a e gynecological and gas oscopic examina ions, subsequen ly success ully p e en ed wi h p e-p ocedu e an ibio ics [12]. I should be no ed ha p o on-pump inhibi o exposu e, widely used and pe haps o e -used in he cu en clinical p ac ice, may p omo e bac e ial coloniza ion o he s omach and has been shown o be isk ac o o spon aneous bac e ial pe i oni is, a leas in li e diseases [13]. 4. CONCLUSION Pe o a ion may occu wi h GI p ocedu es and clinically mimics egula pe i oneal dialysis- associa ed pe i oni is. These pa ien s need ea ly ins i u ion o b oad an ibio ic co e age, including o anae obic o ganisms, immedia e su gical consul a ion and po en ial abdominal explo a ion, wi h conside a ion o PD ca he e emo al. Whe he p e-p ocedu e an ibio ics B i ish Jou nal o Medicine & Medical Resea ch, 3(3): 784-789, 2013 788 a e wa an ed o dec ease he occu ence o in ec ious complica ions in PD pa ien s unde going uppe gas oin es inal p ocedu es emains unce ain and no well s udied. In addi ion o con inued me iculous exi si e and PD ca he e ca e, key p e en i e measu es a e o emp y he pe i oneal space be o e he GI p ocedu e and no esume pe i oneal dialysis o se e al hou s a e he p ocedu e. CONSENT All au ho s decla e ha w i en in o med consen was ob ained om he app o ed pa ies o publica ion o his case epo . ETHICAL APPROVAL All au ho s he eby decla e ha all expe imen s ha e been examined and app o ed by he app op ia e e hics commi ee (Uni e si y o Mississippi Medical Cen e ’s Ins i u ional Re iew Boa d) and ha e he e o e been pe o med in acco dance wi h he e hical s anda ds laid down in he 1964 Decla a ion o Helsinki. ACKNOWLEDGEMENTS Pa o his pape has been p esen ed in pos e o ma a he Na ional Kidney Founda ion 2008 Sp ing Clinical Mee ing, Dallas, TX. Am J Kid Dis 2008;51(4):B79. COMPETING INTERESTS The au ho s ha e no compe ing in e es s o decla e. The au ho s ha e no unding om any sou ce. REFERENCES 1. Li PK, Sze o CC, Pi aino B, Be na dini J, Figuei edo AE, Gup a A, e al. Pe i oneal dialysis- ela ed in ec ions ecommenda ions: 2010 upda e. Pe i Dial In . 2010;30(4):393-423. 2. Chu KH, Choy WY, Cheung CC, Fung KS, Tang HL, Lee W, e al. A p ospec i e s udy o he e icacy o local applica ion o gen amicin e sus mupi ocin in he p e en ion o pe i oneal dialysis ca he e - ela ed in ec ions. Pe i Dial In . 2008;28(5):505-8. 3. Me chea A, Cullinane DC, Sawye MD, Iqbal CW, Ba on TH, Wigle D, e al. Esophagogas oduodenoscopy - associa ed gas oin es inal pe o a ions : a single - cen e expe ience. Su ge y. 2010;148(4):876-82. 4. S ippoli GF, Tong A, Johnson D, Schena FP, C aig JC. 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Am J Gas oen e ol. 2009;104(5):1130-4. © 2013 A usula e al.; This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License (h p://c ea i ecommons.o g/licenses/by/3.0), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. Pee - e iew his o y: The pee e iew his o y o his pape can be accessed he e: h p://www.sciencedomain.o g/ e iew-his o y.php?iid=194&id=12&aid=1046