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Case report: Computed tomographic appearance of sclerosing peritonitis with gross peritoneal calcification
ClinicalRadiology (1997) 52, 557-558
Case Report: Computed Tomographic Appearance of Sclerosing Peritonitis With Gross Peritoneal Calcification G. J. LOUGHREY, J. M. H A W N A U R and P. S A M B R O O K
Department of Radiology, Withington Hospital, South Manchester University Hospitals NHS Trust, Manchester, UK CASE REPORT A 19-year-old woman presented in 1980 with end-stage renal failure secondary to chronic pyelonephritis. She was initially managed by peritoneal dialysis but, following three episodes of bacterial peritonitis within 5 months, treatment was changed to haemodialysis. She received a cadaveric renal transplant in 1983 which failed in 1988 following several episodes of rejection. Peritoneal dialysis was recommenced in 1989 after a brief period on haemodialysis. Problems with ultrafiltration were first noted early in 1991 although formal peritoneal clearance studies were not carried out. Two episodes of catheter-related bacterial peritonitis occurred later in the same year. The patient developed repeated episodes of abdominal pain and vomiting from the end of 1993, and by April 1994 she was losing weight and her serum albumin had fallen to 19gin/1 (normal range 34-48 gm/l). At this stage, there was biochemical evidence of secondary hyperparathyroidism with a serum calcium of 2.27 mmol/1 (normal range 2.15-2.65 mmol/1) and a serum parathormone of 93pg/ml (normal range 15 65pg/ml). An undiagnosed pyrexia developed and the decision was made to remove the Tenckhoff catheter and commence haemodialysis and parenteral nutrition. She continued to experience repeated episodes of colicky abdominal pain thought to be due to intermittent subacute bowel obstruction Peritoneal calcification was first noted on an abdominal radiograph in March 1994 (Fig. 1). Computed tomography (CT) of the abdomen performed in December 1992 to investigate poor dialysis returns had shown no evidence of peritoneal calcification (Fig. 2). Subsequent CT performed in November 1994 demonstrated extensive calcification of the peritoneal membranes and distention of the peritoneal cavity by relatively dense (25 HU) fluid, with evidence of layering of calcium in dependent portions of the peritoneal cavity (Fig. 3). CT also demonstrated clumping together of large and small bowel on the posterior abdominal wall and a moderate degree of small bowel dilatation consistent with partial obstruction. Ultrasound-guided peritoneal aspirations revealed 'milky' fluid which was bacteriologically sterile with no growth of organisms including Mycobacterium tuberculosis. Cytological examination was also negative and a peritoneal biopsy was reported as showing only fibrous tissue.
DISCUSSION C o n t i n u o u s ambulatory peritoneal dialysis ( C A P D ) m a y be c o m p l i c a t e d by bacterial peritonitis, aseptic peritonitis, sclerosing peritonitis and, rarely, calcifying peritonitis. Our patient has features of both selerosing and c a l c i f y i n g peritonitis, disorders w h i c h m a y represent different m a n i f e s tations o f a similar underlying pathological process. S c l e r o s i n g peritonitis as a c o m p l i c a t i o n of C A P D was first r e p o r t e d in 1980 [1]. The condition starts insidiously and w o r s e n s progressively. The early clinical features of this c o n d i t i o n include colicky a b d o m i n a l pain and p r o g r e s s i v e loss of ultrafiltration, leading e v e n t u a l l y to acute intestinal obstruction necessitating surgery. The prognosis is p o o r with death usually occuring within a few w e e k s or m o n t h s f o l l o w i n g surgery, Mortality m a y be as h i g h as 80% [2]. U l t r a s o u n d findings in sclerosing peritonitis include a characteristic trilaminar appearance o f the b o w e l wall, tethering o f the b o w e l to the posterior a b d o m i n a l wall, dilation and fixation o f small b o w e l loops, ascites and m e m b r a n e f o r m a tion [3,4]. B a r i u m studies in the encapsulating f o r m o f sclerosing peritonitis show varying lengths of small b o w e l Correspondence to: Dr J. Hawnaur, Department of Diagnostic Radiology, Stopford Building, Oxford Road, Manchester MI3 9PT, UK. © 1997 The Royal Collegeof Radiologists.
Fig. 1 - Supine abdominal radiograph demonstrating curvilinear plaques of calcification outlining the peritoneum and extending between loops of bowel (arrows). Clips on the right pelvic side wall indicate the site of previous renal transplant.
Fig. 2 - Section from abdominal CT in 1992 shows no evidence of peritoneal calcification or ascites.
558
CLINICAL RADIOLOGY
(a)
peritoneal infection and secondary hyperparathyroidism. Cox e t al. [9] reported a case of extensive peritoneal calcification that proved to be ultimately fatal; unlike the other reported cases, peritonitis and disordered calcium phosphate metabolism were not associated. The aetiology of calcifying peritonitis remains unclear. No single agent has been identified in its development but several have been implicated. Recurrent episodes of infective peritonitis and the presence of acetate buffer in the dialysate may play important roles [7]. Our patient was never exposed to acetate buffer, lactate being used as the buffering agent. Abnormalities of calcium balance could also be a factor, and our patient had biochemical evidence of secondary hyperparathyroidism at the time when peritoneal calcification was first noted on an abdominal radiograph. Peritoneal calcification is a recognized feature of other conditions associated with peritoneal inflammation such as tuberculous peritonitis, pseudomyxoma peritonei and, in neonates, meconium peritonitis. Deposits of tumour on the peritoneum may calcify, particularly those associated with ovarian cystadenoma, and focal calcification may occur in peritoneal mesothelioma. In conclusion, sclerosing peritonitis and calcifying peritonitis are rare but serious complications of peritoneal dialysis which have a high mortality rate. Any patients receiving maintenance peritoneal dialysis who suffer from recurrent peritonitis, or have prolonged or unexplained bowel symptoms or bowel obstruction, should be referred for early abdominal X-ray and/or CT scan. As more patients achieve long-term success with peritoneal dialysis, these rare complications may be seen more frequently. Increased awareness of these conditions by both clinicians and radiologists is essential, as early diagnosis may be important in reducing the high mortality.
(b) REFERENCES
Fig. 3 - (a) Section from abdominal CT in 1994 at L2 level shows extensive peritoneal calcification and distention of the peritoneal cavity by relatively dense fluid (25 HU) with layering of calcific density posteriorly (arrow). Moderate distension of small bowel loops is apparent. Small native kidneys are visible in the retroperitoneum. (b) A more caudal section shows clumping of bowel centrally with extensive calcification between large and small bowel loops.
tightly enclosed in a 'cocoon' of thickened peritoneum, proximal small bowel dilatation and an increased transit time [5]. The CT features include toculated fluid collections, thickening of the bowel wall and/or peritoneal membranes and, occasionally, peritoneal calcifications [4,6[. The complication of calcifying peritonitis was first reported in 1987 [7], and subsequently by other authors [8,9]. Marichal et al. [7] reported two patients with calcifying peritonitis, both of whom had had disordered calcium phosphate balance and multiple episodes of bacterial peritonitis. They developed abdominal pain and disordered bowel function and were transferred to haemodialysis. Francis et al. [8] reported a similar case of calcifying peritonitis in a patient on CAPD complicated by recurrent
1 Gandhi VC, Humayun HM, Ing JS et al. Sclerotic thickening of the peritoneal membrane in maintenance peritoneal dialysis patients. Archives of Internal Medicine 1980;140:1201-1203. 2 Novello AC, Port FK. Sclerosing encapsulating peritonitis. International Journal of Artificial Organs 1986;9:393-396. 3 Hollman AS, McMillan MA, Briggs JD et aL Ultrasound changes in sclerosing peritonitis following continuous ambulatory peritoneal dialysis. Clinical Radiology 1991;43:176-179. 4 Campbell S, Clarke P, Hawley C et aL Sclerosing peritonitis: identification of diagnostic, clinical, and radiological features. American Journal of Kidney Disease 1994;24(5):819-825. 5 Holland P. Sclerosing encapsulating peritonitis in chronic ambulatory peritoneal dialysis. Clinical Radiology 1990;41:19-23. 6 Krestin GP, Kacl G, Hoffmann R et al. The imaging diagnosis of sclerosing peritonitis (SP) following continuous ambulatory peritoneal dialysis (CAPD) (abstract). Rofo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Neuen Bildgebenden Verfahren 1992; 157:506-511. 7 Marichal JF, Failer B, Brignon P e t al. Progressive calcifying peritonitis: a new complication of CAPD. Nephron 1987;45:229-232. 8 Francis DMA, Busmanis I, Becker G. Peritoneal calcification in a peritoneal dialysis patient: a case report. Peritoneal Dialysis International 1990;10:237-240. 9 Cox SV, Lai J, Suranyi M e t al. Sclerosing peritonitis with gross peritoneal calcification: a case report. American Journal of Kidney Diseases 1992;20:637-642.
© 1997 The Royal College of Radiologists, ClinicalRadiology, 52, 557 558.
Case Report: Computed Tomographic Appearance of Sclerosing Peritonitis With Gross Peritoneal Calcification G. J. LOUGHREY, J. M. H A W N A U R and P. S A M B R O O K
Department of Radiology, Withington Hospital, South Manchester University Hospitals NHS Trust, Manchester, UK CASE REPORT A 19-year-old woman presented in 1980 with end-stage renal failure secondary to chronic pyelonephritis. She was initially managed by peritoneal dialysis but, following three episodes of bacterial peritonitis within 5 months, treatment was changed to haemodialysis. She received a cadaveric renal transplant in 1983 which failed in 1988 following several episodes of rejection. Peritoneal dialysis was recommenced in 1989 after a brief period on haemodialysis. Problems with ultrafiltration were first noted early in 1991 although formal peritoneal clearance studies were not carried out. Two episodes of catheter-related bacterial peritonitis occurred later in the same year. The patient developed repeated episodes of abdominal pain and vomiting from the end of 1993, and by April 1994 she was losing weight and her serum albumin had fallen to 19gin/1 (normal range 34-48 gm/l). At this stage, there was biochemical evidence of secondary hyperparathyroidism with a serum calcium of 2.27 mmol/1 (normal range 2.15-2.65 mmol/1) and a serum parathormone of 93pg/ml (normal range 15 65pg/ml). An undiagnosed pyrexia developed and the decision was made to remove the Tenckhoff catheter and commence haemodialysis and parenteral nutrition. She continued to experience repeated episodes of colicky abdominal pain thought to be due to intermittent subacute bowel obstruction Peritoneal calcification was first noted on an abdominal radiograph in March 1994 (Fig. 1). Computed tomography (CT) of the abdomen performed in December 1992 to investigate poor dialysis returns had shown no evidence of peritoneal calcification (Fig. 2). Subsequent CT performed in November 1994 demonstrated extensive calcification of the peritoneal membranes and distention of the peritoneal cavity by relatively dense (25 HU) fluid, with evidence of layering of calcium in dependent portions of the peritoneal cavity (Fig. 3). CT also demonstrated clumping together of large and small bowel on the posterior abdominal wall and a moderate degree of small bowel dilatation consistent with partial obstruction. Ultrasound-guided peritoneal aspirations revealed 'milky' fluid which was bacteriologically sterile with no growth of organisms including Mycobacterium tuberculosis. Cytological examination was also negative and a peritoneal biopsy was reported as showing only fibrous tissue.
DISCUSSION C o n t i n u o u s ambulatory peritoneal dialysis ( C A P D ) m a y be c o m p l i c a t e d by bacterial peritonitis, aseptic peritonitis, sclerosing peritonitis and, rarely, calcifying peritonitis. Our patient has features of both selerosing and c a l c i f y i n g peritonitis, disorders w h i c h m a y represent different m a n i f e s tations o f a similar underlying pathological process. S c l e r o s i n g peritonitis as a c o m p l i c a t i o n of C A P D was first r e p o r t e d in 1980 [1]. The condition starts insidiously and w o r s e n s progressively. The early clinical features of this c o n d i t i o n include colicky a b d o m i n a l pain and p r o g r e s s i v e loss of ultrafiltration, leading e v e n t u a l l y to acute intestinal obstruction necessitating surgery. The prognosis is p o o r with death usually occuring within a few w e e k s or m o n t h s f o l l o w i n g surgery, Mortality m a y be as h i g h as 80% [2]. U l t r a s o u n d findings in sclerosing peritonitis include a characteristic trilaminar appearance o f the b o w e l wall, tethering o f the b o w e l to the posterior a b d o m i n a l wall, dilation and fixation o f small b o w e l loops, ascites and m e m b r a n e f o r m a tion [3,4]. B a r i u m studies in the encapsulating f o r m o f sclerosing peritonitis show varying lengths of small b o w e l Correspondence to: Dr J. Hawnaur, Department of Diagnostic Radiology, Stopford Building, Oxford Road, Manchester MI3 9PT, UK. © 1997 The Royal Collegeof Radiologists.
Fig. 1 - Supine abdominal radiograph demonstrating curvilinear plaques of calcification outlining the peritoneum and extending between loops of bowel (arrows). Clips on the right pelvic side wall indicate the site of previous renal transplant.
Fig. 2 - Section from abdominal CT in 1992 shows no evidence of peritoneal calcification or ascites.
558
CLINICAL RADIOLOGY
(a)
peritoneal infection and secondary hyperparathyroidism. Cox e t al. [9] reported a case of extensive peritoneal calcification that proved to be ultimately fatal; unlike the other reported cases, peritonitis and disordered calcium phosphate metabolism were not associated. The aetiology of calcifying peritonitis remains unclear. No single agent has been identified in its development but several have been implicated. Recurrent episodes of infective peritonitis and the presence of acetate buffer in the dialysate may play important roles [7]. Our patient was never exposed to acetate buffer, lactate being used as the buffering agent. Abnormalities of calcium balance could also be a factor, and our patient had biochemical evidence of secondary hyperparathyroidism at the time when peritoneal calcification was first noted on an abdominal radiograph. Peritoneal calcification is a recognized feature of other conditions associated with peritoneal inflammation such as tuberculous peritonitis, pseudomyxoma peritonei and, in neonates, meconium peritonitis. Deposits of tumour on the peritoneum may calcify, particularly those associated with ovarian cystadenoma, and focal calcification may occur in peritoneal mesothelioma. In conclusion, sclerosing peritonitis and calcifying peritonitis are rare but serious complications of peritoneal dialysis which have a high mortality rate. Any patients receiving maintenance peritoneal dialysis who suffer from recurrent peritonitis, or have prolonged or unexplained bowel symptoms or bowel obstruction, should be referred for early abdominal X-ray and/or CT scan. As more patients achieve long-term success with peritoneal dialysis, these rare complications may be seen more frequently. Increased awareness of these conditions by both clinicians and radiologists is essential, as early diagnosis may be important in reducing the high mortality.
(b) REFERENCES
Fig. 3 - (a) Section from abdominal CT in 1994 at L2 level shows extensive peritoneal calcification and distention of the peritoneal cavity by relatively dense fluid (25 HU) with layering of calcific density posteriorly (arrow). Moderate distension of small bowel loops is apparent. Small native kidneys are visible in the retroperitoneum. (b) A more caudal section shows clumping of bowel centrally with extensive calcification between large and small bowel loops.
tightly enclosed in a 'cocoon' of thickened peritoneum, proximal small bowel dilatation and an increased transit time [5]. The CT features include toculated fluid collections, thickening of the bowel wall and/or peritoneal membranes and, occasionally, peritoneal calcifications [4,6[. The complication of calcifying peritonitis was first reported in 1987 [7], and subsequently by other authors [8,9]. Marichal et al. [7] reported two patients with calcifying peritonitis, both of whom had had disordered calcium phosphate balance and multiple episodes of bacterial peritonitis. They developed abdominal pain and disordered bowel function and were transferred to haemodialysis. Francis et al. [8] reported a similar case of calcifying peritonitis in a patient on CAPD complicated by recurrent
1 Gandhi VC, Humayun HM, Ing JS et al. Sclerotic thickening of the peritoneal membrane in maintenance peritoneal dialysis patients. Archives of Internal Medicine 1980;140:1201-1203. 2 Novello AC, Port FK. Sclerosing encapsulating peritonitis. International Journal of Artificial Organs 1986;9:393-396. 3 Hollman AS, McMillan MA, Briggs JD et aL Ultrasound changes in sclerosing peritonitis following continuous ambulatory peritoneal dialysis. Clinical Radiology 1991;43:176-179. 4 Campbell S, Clarke P, Hawley C et aL Sclerosing peritonitis: identification of diagnostic, clinical, and radiological features. American Journal of Kidney Disease 1994;24(5):819-825. 5 Holland P. Sclerosing encapsulating peritonitis in chronic ambulatory peritoneal dialysis. Clinical Radiology 1990;41:19-23. 6 Krestin GP, Kacl G, Hoffmann R et al. The imaging diagnosis of sclerosing peritonitis (SP) following continuous ambulatory peritoneal dialysis (CAPD) (abstract). Rofo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Neuen Bildgebenden Verfahren 1992; 157:506-511. 7 Marichal JF, Failer B, Brignon P e t al. Progressive calcifying peritonitis: a new complication of CAPD. Nephron 1987;45:229-232. 8 Francis DMA, Busmanis I, Becker G. Peritoneal calcification in a peritoneal dialysis patient: a case report. Peritoneal Dialysis International 1990;10:237-240. 9 Cox SV, Lai J, Suranyi M e t al. Sclerosing peritonitis with gross peritoneal calcification: a case report. American Journal of Kidney Diseases 1992;20:637-642.
© 1997 The Royal College of Radiologists, ClinicalRadiology, 52, 557 558.