NDT Advance Access originally published online on January 31, 2006
Nephrology Dialysis Transplantation 2006 21(4):1121-1122; doi:10.1093/ndt/gfk099
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© The Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Images In Nephrology
(Section Editor: G. H. Neild)
Green dialysate: asymptomatic perforated cholecystitis without peritonitis
1 Division of Nephrology and 2 Nuclear Medicine, Centre Hospitalier Universitaire de Québec, Hôtel-Dieu de Québec Hospital and Department of Medicine, Faculty of Medicine, Laval University, Québec, Canada
Correspondence and offprint requests to: Mohsen Agharazii, MD, Centre de Recherche de l'Hôtel Dieu de Québec, CHUQ-Hôtel-Dieu de Québec, 11, Côte du Palais, Quebec City, QC, G1R 2J6, Canada. Email: mohsen.agharazii{at}crhdq.ulaval.ca
Keywords: peritoneal dialysis; cholecystitis; peritonitis
Case
In peritoneal dialysis, the effluent dialysate is the window of the peritoneal cavity and usually allows for a rapid diagnosis of peritonitis and abdominal drama [1]. To our knowledge, there is only one reported case of perforation of the gallbladder in a patient on peritoneal dialysis with gram negative peritonitis [2]. We describe a case of asymptomatic perforated cholecystitis without peritonitis in a patient on continuous ambulatory peritoneal dialysis.
A 53-year-old male patient with type 1 diabetes, on peritoneal dialysis for 8 years, came to the dialysis clinic because of green dialysate. During the previous month, he had noticed black particles in his dialysate. He denied any abdominal pain, nausea, vomiting or anorexia. A cellular count and culture of the dialysis fluid were normal the week prior. The patient looked well, had normal blood pressure and normal temperature; the abdominal exam was unremarkable. Upon examination, the bag of dialysate was indeed dark green (Figure 1). Blood chemistry showed a white cell count of 12.5x109/l, a total bilirubin level of of 27 µmol/l (N = 3–17) (indirect 23), a GGT level of 82 U/l (N = 7–32), an alkaline phosphatase activity of 431 U/l (N = 32–120) and normal AST, ALT, amylase and lipase levels. The peritoneal fluid showed 46x109/l nucleated cells and a total bilirubin level of 10 µmol/l. Peritoneal fluid culture was again negative. A Tc99m-disofenin (IDA) cholecysto-scintigram did not show any direct biliary leak but the bag of dialysate did reveal a significant level of radioactivity, suggesting the passage of bile into the peritoneal cavity (Figure 2). An abdominal computed tomography scan revealed a gallbladder with thickened walls without free air but no signs of bowel perforation.
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The patient had a surgical consultation and immediate exploratory surgery was recommended. He initially refused the procedure, but changed his mind 2 days later. During these 2 days, he still had no abdominal pain or fever and he kept eating normally. The effluent was still green with total bilirubin level of 16 µmol/l and a white cell count of 96 x 109/l (54% neutrophils). An endoscopic retrograde cholecystopancreatography was done prior to surgery but the biliary tree could not be visualized. An exploratory laparoscopy revealed a perforated necrotizing cholecystitis and an open cholecystectomy was performed. The patient did well following the surgery except for a prolonged ileus and nosocomial pneumonia. He was switched to haemodialysis for 1 month before uneventfully resuming peritoneal dialysis.
Discussion
In peritoneal dialysis, an abnormal effluent dialysate is often the first sign of peritonitis and is an efficient tool for early diagnosis. In the context of peritoneal dialysis, it has been reported that anatomically documented visceral injury has an incidence rate of 0.1048 per patient-year [3]. Although multiorganism peritonitis is highly suggestive of an enteric origin, culture results can take up to 48 h to obtain. Peritonitis caused by visceral perforation has a much worse prognosis [3,4] and requires immediate surgical treatment. In a recent case report by Scarborough et al., the authors proposed using peritoneal fluid bilirubin levels as a bedside tool for diagnosis of visceral perforation [5]. Their patient, however, had a classical presentation of peritonitis with abdominal pain and elevated white cell counts in the peritoneal fluid. In our report, the patient denied any symptoms and his physical exam was normal. Most importantly, he had green dialysate effluent for nearly one week with two negative cultures of the peritoneal fluid. Left untreated, the patient would have developed peritonitis. The colour of the dialysate was almost the only clue to a diagnosis of perforated cholecystitis in an otherwise asymptomatic patient.
We conclude that green dialysate, even in an asymptomatic patient without peritonitis, warrants immediate investigation in order to prevent more serious and life-threatening complications.
Conflict of interest statement. None declared.
References
- Wellington JL, Rody K. Acute abdominal emergencies in patients on long-term ambulatory peritoneal dialysis. Can J Surg 1993; 36: 522–524[Medline]
- Geddes CC, Waterston A, Asari A, Smith WG. Perforation of the gall bladder in a patient on continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 1996; 11: 2493–2494
[Free Full Text] - Kern EO, Newman LN, Cacho CP, Schulak JA, Weiss MF. Abdominal catastrophe revisited: the risk and outcome of enteric peritoneal contamination. Perit Dial Int 2002; 22: 323–334
[Abstract/Free Full Text] - Harwell CM, Newman LN, Cacho CP et al. Abdominal catastrophe: visceral injury as a cause of peritonitis in patients treated by peritoneal dialysis. Perit Dial Int 1997; 17: 586–594
[Abstract/Free Full Text] - Scarborough H, Shrikanth S, Gokal R. Bedside testing of CAPD fluid for bilirubin to aid diagnosis of visceral perforation. Nephrol Dial Transplant 2005; 20: 1016–1017
[Free Full Text]
Accepted in revised form: 5. 1.06
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