- Email: [email protected]
Radiographically Documented Fecal Impaction Causing Peritoneal Dialysis Catheter Malfunction
0022-5347/95/1532-0445$03.00/0 THEJOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 153,445-446, February 1995 Printed in U.S.A.
RADIOGRAPHICALLY DOCUMENTED FECAL IMPACTION CAUSING PERITONEAL DIALYSIS CATHETER MALFUNCTION WILLIAM H. STONEHILL, D. PRESTON SMITH
AND
H. NORMAN NOE
From the Department of Urology, University of Tennessee, Memphis, Tennessee
ABSTRACT
Peritoneal dialysis catheter malfunction is most commonly caused by infection o r omental occlusion. To our knowledge we report the first case of radiologically confirmed fecal impaction resulting in peritoneal dialysis catheter malfunction, which resolved with medical management. In patients undergoing peritoneal dialysis fecal impaction should be considered in the differential diagnosis of catheter malfunction before surgical intervention. KEYWORDS:feces, impacted; peritoneal dialysis; colon; complications; catheterization
Peritoneal dialysis is an increasingly popular treatment for patients with renal failure. Although it is usually well tolerated, complications of peritonitis and catheter malfunction can occur. When conservative measures fail to resolve infection or catheter obstruction, surgical replacement may be necessary. To our knowledge we report the first case of radiologically confirmed fecal impaction causing reversible catheter malfunction, which resolved with medical management. CASE HISTORY
P. B., a 4-year-old white boy with end stage renal disease due to atypical hemolytic-uremic syndrome, underwent partial omentectomy and placement of a coiled pediatric dialysis catheter into the dependent pelvis. Nocturnal continuous cycler peritoneal dialysis was performed uneventfully for 2 months. An upper gastrointestinal barium study to evaluate persistent nausea was normal but 2 days later the peritoneal dialysis catheter failed to drain despite adequate infusions. No evidence of fibrin had been noted during the previous dialysis session. Urokinase was instilled and the patient was moved into various positions in an unsuccessful attempt to relieve the 1-way obstruction. A radiograph of the abdomen showed the catheter in good position in the pelvis but the coiled tip was obscured from view by a barium induced fecal impaction in the rectosigmoid colon (see figure). Due to this finding 2 glycerine suppositories and a pediatric Fleets enema were administered. A chalky white bowel movement resulted and the catheter began to drain with no evidence of fibrin in the spent dialysate. There have been no further drainage problems at 1-month followup. DISCUSSION
Curled catheter (arrow)in pelvis with barium impaction in redo-
Catheter malfunction due to obstruction occurs in up to sirnoid colon. 20% of cases i n longer term studies.' Two-way obstruction is usually due to fibrin or blood clots, which can be dislodged by forceful irrigation of fibrinolytic agents. Oneway obstruction may be due to fibrin, blood clots, omen- cated empirically in the past but no previous case of a tum, adhesions, an air lock or malposition of the catheter, radiographically proved obstruction due to stool in the of which omental obstruction of the catheter ports is most SitWoid has been We report a case in which 1-way obstruction of a peritocommon. Constipation and distended bowel loops have previously been proposed as the cause of transient obstruction neal dialysis catheter occurred due to fecal impaction. of peritoneal dialysis catheters.' Bowel stimulation with Omental occlusion was not suspected due to previous parenemas or oral administration of mannit01 has been advo- tial omentectomy. Fibrinolytic therapy and patient positioning were unsuccessful. Other etiologies for catheter malfunction were considered. The abdominal radiograph Accepted for publication May 13, 1994. 445
446
FECAL IMPACTION CAUSING PERITONEAL DIALYSIS CATHETER MALFUNCTION
documented excellent catheter position with the presence to Of a barium induced fecal impaction. relieve the impaction were performed with the return of normal catheter function. As a result, the patient avoided surgical intervention. In conclusion, fecal impaction should be included in the differential diagnosis for peritoneal dialysis catheter malfunction.
REFERENCES
1. Bullmaster, J, R,, Miller, S.F., Finley, R. &, Jr, and Jones, L. M.: Surgical aspects of the Tenckhoff peritoneal dialysis catheter. A 7 year experience. h e r . J. Surg., 149 339, 1985. 2. Tenckhoff, H.: Home peritoneal dialysis. In: Clinical Aspects of Uremia and Dialysis. Edited by S. G. Massry and A. L. Sellers. Springfield, Illinois: Thomas, pp. 583-615, 1976.
Vol. 153,445-446, February 1995 Printed in U.S.A.
RADIOGRAPHICALLY DOCUMENTED FECAL IMPACTION CAUSING PERITONEAL DIALYSIS CATHETER MALFUNCTION WILLIAM H. STONEHILL, D. PRESTON SMITH
AND
H. NORMAN NOE
From the Department of Urology, University of Tennessee, Memphis, Tennessee
ABSTRACT
Peritoneal dialysis catheter malfunction is most commonly caused by infection o r omental occlusion. To our knowledge we report the first case of radiologically confirmed fecal impaction resulting in peritoneal dialysis catheter malfunction, which resolved with medical management. In patients undergoing peritoneal dialysis fecal impaction should be considered in the differential diagnosis of catheter malfunction before surgical intervention. KEYWORDS:feces, impacted; peritoneal dialysis; colon; complications; catheterization
Peritoneal dialysis is an increasingly popular treatment for patients with renal failure. Although it is usually well tolerated, complications of peritonitis and catheter malfunction can occur. When conservative measures fail to resolve infection or catheter obstruction, surgical replacement may be necessary. To our knowledge we report the first case of radiologically confirmed fecal impaction causing reversible catheter malfunction, which resolved with medical management. CASE HISTORY
P. B., a 4-year-old white boy with end stage renal disease due to atypical hemolytic-uremic syndrome, underwent partial omentectomy and placement of a coiled pediatric dialysis catheter into the dependent pelvis. Nocturnal continuous cycler peritoneal dialysis was performed uneventfully for 2 months. An upper gastrointestinal barium study to evaluate persistent nausea was normal but 2 days later the peritoneal dialysis catheter failed to drain despite adequate infusions. No evidence of fibrin had been noted during the previous dialysis session. Urokinase was instilled and the patient was moved into various positions in an unsuccessful attempt to relieve the 1-way obstruction. A radiograph of the abdomen showed the catheter in good position in the pelvis but the coiled tip was obscured from view by a barium induced fecal impaction in the rectosigmoid colon (see figure). Due to this finding 2 glycerine suppositories and a pediatric Fleets enema were administered. A chalky white bowel movement resulted and the catheter began to drain with no evidence of fibrin in the spent dialysate. There have been no further drainage problems at 1-month followup. DISCUSSION
Curled catheter (arrow)in pelvis with barium impaction in redo-
Catheter malfunction due to obstruction occurs in up to sirnoid colon. 20% of cases i n longer term studies.' Two-way obstruction is usually due to fibrin or blood clots, which can be dislodged by forceful irrigation of fibrinolytic agents. Oneway obstruction may be due to fibrin, blood clots, omen- cated empirically in the past but no previous case of a tum, adhesions, an air lock or malposition of the catheter, radiographically proved obstruction due to stool in the of which omental obstruction of the catheter ports is most SitWoid has been We report a case in which 1-way obstruction of a peritocommon. Constipation and distended bowel loops have previously been proposed as the cause of transient obstruction neal dialysis catheter occurred due to fecal impaction. of peritoneal dialysis catheters.' Bowel stimulation with Omental occlusion was not suspected due to previous parenemas or oral administration of mannit01 has been advo- tial omentectomy. Fibrinolytic therapy and patient positioning were unsuccessful. Other etiologies for catheter malfunction were considered. The abdominal radiograph Accepted for publication May 13, 1994. 445
446
FECAL IMPACTION CAUSING PERITONEAL DIALYSIS CATHETER MALFUNCTION
documented excellent catheter position with the presence to Of a barium induced fecal impaction. relieve the impaction were performed with the return of normal catheter function. As a result, the patient avoided surgical intervention. In conclusion, fecal impaction should be included in the differential diagnosis for peritoneal dialysis catheter malfunction.
REFERENCES
1. Bullmaster, J, R,, Miller, S.F., Finley, R. &, Jr, and Jones, L. M.: Surgical aspects of the Tenckhoff peritoneal dialysis catheter. A 7 year experience. h e r . J. Surg., 149 339, 1985. 2. Tenckhoff, H.: Home peritoneal dialysis. In: Clinical Aspects of Uremia and Dialysis. Edited by S. G. Massry and A. L. Sellers. Springfield, Illinois: Thomas, pp. 583-615, 1976.