Sclerosing encapsulating peritonitis associated with continuous ambulatory peritoneal dialysis: surgical management

Prediction of surgical outcomes in severe encapsulating peritoneal sclerosis using a computed tomography scoring system

BACKGROUND/PURPOSE

Encapsulating peritoneal sclerosis (EPS) is a rare and potential lethal complication of peritoneal dialysis characterized by bowel obstruction. Surgical enterolysis is the only curative therapy. Currently, there are no tools for predicting postsurgical prognosis. This study aimed to identify a computed tomography (CT) scoring system that could predict mortality after surgery in patients with severe EPS.

METHODS

This retrospective study enrolled patients with severe EPS who underwent surgical enterolysis in a tertiary referral medical center. The association of CT score with surgical outcomes including mortality, blood loss, and bowel perforation was analyzed.

RESULTS

Thirty-four patients who underwent 37 procedures were recruited and divided into a survivor and non-survivor group. The survivor group had higher body mass indices (BMIs, 18.1 vs. 16.7 kg/m2, p = 0.035) and lower CT scores (11 vs. 17, p < 0.001) than the non-survivor group. The receiver operating characteristic curve revealed that a CT score of ≥15 could be considered a cutoff point to predict surgical mortality, with an area under the curve of 0.93, sensitivity of 88.9%, and specificity of 82.1%. Compared with the group with CT scores of <15, the group with CT scores of ≥15 had a lower BMI (19.7 vs. 16.2 kg/m2, p = 0.004), higher mortality (4.2% vs. 61.5%, p < 0.001), greater blood loss (50 vs. 400 mL, p = 0.007), and higher incidence of bowel perforation (12.5% vs. 61.5%, p = 0.006).

CONCLUSION

The CT scoring system could be useful in predicting surgical risk in patients with severe EPS receiving enterolysis.

Encapsulating Peritoneal Sclerosis—A Clinician's Approach to Diagnosis and Medical Treatment

Encapsulating peritoneal sclerosis (EPS) is recognized as a serious complication of continuous peritoneal dialysis. A preliminary diagnosis of EPS is usually based on clinical signs and symptoms, which commonly include abdominal pain, nausea, vomiting, anorexia, abdominal fullness, an abdominal mass, bowel obstruction, and radiologic findings, including abdominal roentgenogram, contrast studies, ultrasound studies, and computed tomography. The diagnosis is confirmed by laparoscopy or laparotomy showing the characteristic gross thickening of the peritoneum enclosing some or all of the small intestine in a cocoon of opaque tissue.

A variety of therapeutic approaches to EPS have been reported. This review discusses medical treatment of EPS and includes an overview of the clinical features and diagnostic aspects of the condition.

Successful Surgical Management of Encapsulating Peritoneal Sclerosis

♦ Background

Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis (PD). The mortality rate for EPS has been high, primarily because of complications related to bowel obstruction. Also, therapeutic guidelines for EPS have not yet been established. In our hospital, favorable postoperative results were obtained in 50 patients whose EPS was treated surgically.

♦ Patients

All patients had chronic glomerulonephritis as the underlying kidney disease. All had undergone PD for between 29 months and 220 months (average: 113.9 months). During the course of PD, 3 patients developed EPS and were subsequently transferred to hemodialysis (HD). The other 47 patients (94.0%) developed EPS after discontinuation of PD. The reasons for transfer to HD were inadequate ultrafiltration (26 patients), bacterial peritonitis (16 patients), hypoalbuminemia (2 patients), renal transplantation (3 patients), and occurrence of EPS (3 patients).

♦ Intervention

At laparotomy, a definitive diagnosis of EPS was established in all patients by the presence of clumped intestine cocooned with a dense sclerotic membrane. In all cases, the small intestine was completely released by ablation of the capsules, resulting in resolution of the bowel obstruction symptoms. In 5 patients, the large intestine was ablated solely at the region of the sigmoid colon. The operating time varied from 3 hours to 18 hours (average: 6.9 hours). Oral food intake was initiated 5 – 60 days (average: 10.2 days) after surgery.

♦ Results

Perforation of the small intestine was detected postoperatively in 2 patients, who died 26 days and 37 days after surgery. The remaining 48 patients were followed for between 9 months and 107 months (average: 34.6 months). During follow-up, 6 – 12 months after the initial surgery, 4 patients experienced a recurrence of bowel obstruction symptoms that required a second laparotomy with enterolysis. Excluding the 2 patients with fatal outcomes, 46 patients (96%) experienced complete relief from bowel obstruction symptoms. The remaining 2 patients continued to experience mild, sub-acute bowel obstruction symptoms that could be successfully controlled solely by diet.

♦ Conclusions

Surgical treatment of 50 patients with EPS produced successful outcomes in all but 2 patients (96% success). Encapsulating peritoneal sclerosis should be actively treated by surgeons who genuinely understand this pathologic condition.

A Historical Review of Encapsulating Peritoneal Sclerosis

Publications providing insights into the pathophysiology of, and therapeutic strategies for, EPS are the focus of the present review. Referenced publications are limited to those written in English.

Recommendations for pathological diagnosis on biopsy samples from peritoneal dialysis patients

Peritoneal dialysis (PD) has been established as an essential renal replacement therapy for patients with end stage renal disease during the past half century. Histological evaluation of the peritoneal membrane has contributed to the pathophysiological understanding of PD-related peritoneal injury such as peritonitis, fibrosis, and encapsulating peritoneal sclerosis (EPS). Hyalinizing peritoneal sclerosis (HPS), also known as simple sclerosis, is observed in almost all of PD patients. HPS is morphologically characterized by fibrosis of the submesothelial interstitium and hyalinizing vascular wall, particularly of the post-capillary venule (PCV). Two histological factors, the thickness of submesothelial compact zone (SMC) and the lumen/vessel ratio (L/V) at the PCV, have been used for the quantitative evaluation of HPS. The measuring system on SMC thickness and L/V ratio is easy and useful for evaluating the severity of HPS. On the other hand, EPS is characterized by unique encapsulation of the intestines by an "encapsulating membrane". This newly formed membranous structure covers the visceral peritoneum of the intestines, which contains fibrin deposition, angiogenesis, and proliferation of fibroblast-like cells and other inflammatory cells. This review will cover the common understandings of PD-related peritoneal alterations and provide a basic platform for clinical applications and future studies in this field.

Peritoneal dialysis associated infections: An update on diagnosis and management

Peritoneal dialysis (PD) is associated with a high risk of infection of the peritoneum, subcutaneous tunnel and catheter exit site. Although quality standards demand an infection rate < 0.67 episodes/patient/year on dialysis, the reported overall rate of PD associated infection is 0.24-1.66 episodes/patient/year. It is estimated that for every 0.5-per-year increase in peritonitis rate, the risk of death increases by 4% and 18% of the episodes resulted in removal of the PD catheter and 3.5% resulted in death. Improved diagnosis, increased awareness of causative agents in addition to other measures will facilitate prompt management of PD associated infection and salvage of PD modality. The aims of this review are to determine the magnitude of the infection problem, identify possible risk factors and provide an update on the diagnosis and management of PD associated infection. Gram-positive cocci such as Staphylococcus epidermidis, other coagulase negative staphylococcoci, and Staphylococcus aureus (S. aureus) are the most frequent aetiological agents of PD-associated peritonitis worldwide. Empiric antibiotic therapy must cover both gram-positive and gram-negative organisms. However, use of systemic vancomycin and ciprofloxacin administration for example, is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis - success rate of 77%. However, for fungal PD peritonitis, it is now standard practice to remove PD catheters in addition to antifungal treatment for a minimum of 3 wk and subsequent transfer to hemodialysis. To prevent PD associated infections, prophylactic antibiotic administration before catheter placement, adequate patient training, exit-site care, and treatment for S. aureus nasal carriage should be employed. Mupirocin treatment can reduce the risk of exit site infection by 46% but it cannot decrease the risk of peritonitis due to all organisms.

CT in predicting abdominal cocoon in patients on peritoneal dialysis

AIM

To evaluate the computed tomography (CT) signs of encapsulating peritoneal sclerosis (EPS) in patients on peritoneal dialysis (PD) as predictive factors for the evolution to abdominal cocoon (AC).

MATERIALS AND METHODS

Clinical features and CT signs of 90 patients on PD were retrospectively reviewed. According to the clinical features, they were divided into three groups (asymptomatic, moderate, or severe). Clinical results were correlated with previously reported CT signs of EPS, i.e., peritoneal thickening, peritoneal calcifications, loculated fluids, small bowel faeces sign, small bowel obstruction, clustered bowel loops, pseudo sac, signs of bowel ischaemia or necrosis. AC was defined at CT by the association of clustered bowel loops and a pseudo sac. Statistical analysis was performed using the Fisher's exact test and the t-test.

RESULTS

Although demonstrated in symptomatic patients (p=0.041), the occurrence of AC was not correlated with the severity of the symptoms (p=0.16). Among the CT signs, the presence of loculated fluids (p=0.011), a small bowel faeces sign (p=0.002); and small bowel obstruction (p=0.0001) were found to be statistically correlated with the appearance of an AC. Moreover, the association of loculated fluids, small bowel faeces sign, small bowel obstruction was extremely sensitive and specific in the development of AC (sensitivity=67%, specifity=100%, positive predictive value=100%, negative predictive value=96%).

CONCLUSION

CT should be carried out in every symptomatic patient on PD. Indeed, the association of loculated fluid, small bowel faeces sign, and small bowel obstruction enables the prediction of the development of AC, which is likely to curtail PD and require surgery.

The Pan-Thames EPS study: treatment and outcomes of encapsulating peritoneal sclerosis

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) is a disease process that can occur as a complication of peritoneal dialysis (PD). The aim of this study was to make a general assessment of the clinical features, diagnosis, management and outcome of PD-related EPS cases from London and South-East England.

METHODS

Questionnaires were sent to 11 PD units in March 2007; cases were identified retrospectively. Outcome data on surviving patients were collected in March 2008.

RESULTS

A total of 111 patients were identified; the mean time on PD was 82 months (range 8-247). Mortality increased with length of time on PD, being 42% at <3 years (n = 12), 32% at 3-4 years (n = 19), 61% at 5-6 years (n = 31), 54% at 7-8 years (n = 24), 75% at 9-10 years (n = 8) and 59% at >10 years (n = 17). Twelve patients had no previous peritonitis episodes, 28 had one previous episode, 30 had two previous episodes and 33 had three or more previous episodes. Of the patients with PD details available, 41/63 were high (>0.81) transporters and 44/71 had ultrafiltration <1 l/24 h, but 7/63 were low average transporters (0.5-<0.65) and 27/71 had ultrafiltration >1 l/24 h and a few had significant residual renal function. Sixty-five (59%) patients had their PD discontinued prior to diagnosis (51 HD; 14 transplanted). CT scans were performed on 91 patients and laparotomy on 47 patients. Drug treatment consisted of tamoxifen, immunosuppression or both. The median survival was 15 months in patients treated with tamoxifen (n = 17), 12 months in patients treated with immunosuppression (n = 24) and 21 months in patients who received both (n = 13), against 13 months (n = 46) in patients who received no specific treatment. Adhesionolysis was performed in 5 patients, and 39 patients were given parenteral nutrition. The overall mortality was 53% with a median survival of 14 months and a median time to death of 7 months. Conclusion. This is one of the largest cohorts of patients with EPS in the literature. Long-term survival occurred in over 50%, regardless of the various treatments strategies undertaken by the centres.

[Sclerosing peritonitis]

Sclerosing peritonitis (also described as sclerosing obstructive peritonitis, encapsulating peritonitis, obliterative adhesive peritonitis, abdominal cocoon syndrome) is not well-known by the general surgeon; most reviews of this subject occur in the nephrology literature. Peritoneal dialysis and continuous hyperthermic peritoneal perfusion are the main causes. No controlled study exists to evaluate the optimal therapeutic approach. Pre-operative diagnosis is difficult since the clinical signs and radiologic findings are non-specific. Nevertheless, the diagnosis should be considered when small bowel obstruction with proximal dilatation, ascites, and thickened or calcified peritoneum are seen on imaging. The surgeon should recognize sclerosing peritonitis grossly when it is encountered and adapt his surgical strategy accordingly.

Single-center experience of encapsulating peritoneal sclerosis in patients on peritoneal dialysis for end-stage renal failure

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). It is characterized by a progressive, intra-abdominal, inflammatory process resulting in sheets of fibrous tissue that cover, bind, and constrict the viscera, thereby compromising the motility and function of the bowel. Although recent therapeutic approaches have been reported with variable success, the ability to detect reliably at an early stage patients at risk for EPS would be beneficial and allow treatment standardization. The aim of this study was to evaluate the clinical features of EPS and identify possible risk factors for its development in CAPD and APD patients.

METHODS

This was a review of all cases of EPS in a single center over the last 5 years.

RESULTS

There were 810 CAPD and APD patients, managed in our program over this period. We identified 27 cases of EPS, giving an overall of 3.3% in this population. The mean duration of CAPD before diagnosis of EPS was 72.6 +/- 39.7 months (range 16-172). Sixteen cases required surgical treatment and were classified as severe; others were treated conservatively (mild to moderate group). Ten patients received tamoxifen treatment with apparent benefit. The overall mortality rate was 29.6%. Eight patients from the severe group and the entire moderate group survived on hemodialysis or transplantation at 48.71 and 27.63 months follow-up, respectively. Peritonitis rates were not different between the 2 groups and peritoneal history was unremarkable compared to overall peritonitis rates in the unit. Data on small solute transport were not available in all patients in this retrospective analysis.

CONCLUSION

EPS is a serious, life-threatening complication of CAPD. Most cases had PD duration of more than 4 years. Careful monitoring by CT scans of the peritoneal membrane in patients beyond 5 years, and early catheter removal in patients with peritoneal thickening should be considered for long-term CAPD patients. Treatment with tamoxifen may be of benefit in these patients.

Encapsulating peritoneal sclerosis

Since the first peritoneal dialysis (PD) patients with encapsulating peritoneal sclerosis (EPS) were reported in 1980, EPS has been considered primarily a fatal complication. The incidence of EPS in PD patients has been reported to be from 0.7% to 7.3%, and the rate appears to be higher in patients receiving long-term treatment. Most data from Japan has shown an overall incidence of 2.5% with an evident negative effect of increasing duration of PD, which also augments mortality. Since EPS occurred after withdrawal from PD in more than half of the patients, strict monitoring is necessary when a long-term PD patient is withdrawn from PD. Maintaining patients on standard PD for more than 8 years using conventional solutions is associated with a substantial risk for development of EPS. Appropriate treatment according to the disease stage is most important in EPS treatment. Therefore, when examining a PD patient complaining of gastrointestinal symptoms, the possibility of EPS has to be kept in mind. Basic therapeutic tactics for EPS include appropriate use of steroids. If the state of bowel obstruction persists, laparotomy and enterolysis should be performed to obtain a complete cure. It is now recognized that EPS is not a fatal complication of PD.

Encapsulating peritoneal sclerosis in paediatric peritoneal dialysis patients

Encapsulating peritoneal sclerosis (EPS) is a serious complication of chronic peritoneal dialysis (CPD). In contrast to the adult population, there are few studies regarding EPS in paediatric CPD patients, and the majority of reported patients are from Japan. The aim of the present report is to define the incidence of EPS in our paediatric CPD patients and to describe the clinical and laboratory characteristics. A total of 104 paediatric patients were followed from November 1989 to November 2003 and two were diagnosed as EPS (1.9%). The dialysis periods of these patients were 45 and 53 months with 6 and 8 peritonitis episodes, respectively. Clinical signs of EPS developed 7 and 14 days after the removal of the dialysis catheter, and CPD was replaced by haemodialysis because of persistent peritonitis. One patient was well after surgical management but died 6 months later. The second patient who was treated with prednisolone remained well at 16 months. In conclusion, EPS is a rare but important complication of CPD. We recommend that all patients on CPD who develop ultrafiltration failure be evaluated radiologically for the occurrence of EPS. Management should be tailored to the individual patient.

Simple peritoneal sclerosis and sclerosing peritonitis: related or distinct entities?

AIM

The etiopathogenesis of sclerosing peritonitis is still debated, with some sustaining that it is a rare form of progression of simple peritoneal sclerosis and others that it is a primitive form. The aim of the present research was to clarify this question.

MATERIAL AND METHODS

438 peritoneal biopsies from 253 patients were re-examined. 174 were obtained prior to peritoneal dialysis and 224 after various periods of dialysis. Forty biopsies were from peritoneal dialysis patients who developed sclerosing peritonitis. Peritoneal morphology was studied for signs of transition from simple sclerosis to sclerosing peritonitis.

RESULTS

Evidence was found sustaining the hypothesis that simple sclerosis to sclerosing peritonitis patients have distinct pathologies.

CONCLUSIONS

The results confirm previous observations, excluding the existence of any type of relation between simple peritoneal sclerosis to sclerosing peritonitis.

The pathogenesis and therapeutic option of encapsulating peritoneal sclerosis

Since the first peritoneal dialysis (PD) patients with encapsulating peritoneal sclerosis (EPS) were reported in 1980, EPS has been considered primarily a fatal complication. The incidence of EPS in PD patients has been reported to be from 0.7% to 7.3%, and the rate appears to be higher in patients receiving long-term treatment. Most data from Japan has shown an overall incidence of 2.5% with an evident negative effect of increasing duration of PD, which also augments mortality. Since EPS occurred after withdrawal from PD in more than half of the patients, strict monitoring is necessary when a long-term PD patient is withdrawn from PD. Maintaining patients on standard PD for more than 8 years using conventional solutions is associated with a substantial risk for development of EPS. Appropriate treatment according to the disease stage is most important in EPS treatment. Therefore, when examining a PD patient complaining of gastrointestinal symptoms, the possibility of EPS has to be kept in mind. Basic therapeutic tactics for EPS include an appropriate use of steroids. If the state of bowel obstruction persists, laparotomy and enterolysis should be performed to obtain complete cure. It is now recognized that EPS is not a fatal complication of PD.

Large bowel obstruction caused by sclerosing peritonitis: contrast-enhanced CT findings

Sclerosing peritonitis (SP) is a rare but serious complication of chronic ambulatory peritoneal dialysis (CAPD). SP is characterized by thickening of the peritoneum that encloses some or all of the small intestine. However, the early clinical features of SP are non-specific and are often not recognized until the patient develops complications. The most common complications of SP appear to be partial or complete small bowel obstruction, small bowel necrosis, and enterocutaneous fistulae, all of which, necessitate surgical intervention and have high mortality rates. Although the CT findings of SP are well recognized, to our knowledge, large bowel obstruction due to SP without peritoneal change have not been reported. We report a case of large bowel obstruction due to peritoneal sclerosis following long-term CAPD.

Peritoneal sclerosis: one or two nosological entities?

The frequency, pathology, animal models, pathogenesis, clinical manifestations, diagnostic criteria, therapy and prevention of peritoneal sclerosis are reviewed. Many of these aspects have a bimodal configuration which suggests that peritoneal sclerosis, usually considered a single pathology in peritoneal dialysis, is actually two distinct nosological entities: simple sclerosis and sclerosing peritonitis. The former is very frequent, with minor anatomical alterations and low clinical impact; it is reproducible in animals by means of peritoneal dialysis, and is clearly due to the poor biocompatibility of peritoneal dialysis solutions. The latter is rare, with radical anatomical alterations and high mortality requiring valid methods of diagnosis, therapy and prevention; it can only be reproduced in animal models by means other than peritoneal dialysis and seems to be due to factors both related and unrelated to peritoneal dialysis.

Sclerosing encapsulating peritonitis and non-occlusive mesenteric infarction found at autopsy in a man who had undergone continuous ambulatory peritoneal dialysis: a histochemical and immunohistochemical study

This is a report of a post-mortem histological, histochemical, and immunohistochemical examination of a rare case of sclerosing encapsulating peritonitis (SEP) and non-occlusive mesenteric infarction (NOMI), two serious complications of continuous ambulatory peritoneal dialysis (CAPD), with which a man suffering hepatitis C virus (HCV)-induced liver cirrhosis for 7 years and trauma-induced paraplegia for 50 years had been treated for 1 year. The direct cause of death was encephalopathy caused by extreme hyperammonemia (11 250 microg/dL in serum). The autopsy revealed that the SEP had drastically reduced the length of the small intestine to 210 cm, 180 cm of which presented acute ischemic enteritis with Gram-negative bacterial infection. Histological examination of the SEP revealed that the exterior was composed of normal serosal elastic lamina, but with a cocoon-like appearance remarkably thickened by fibrosis to 3-8 times that of the normal subserosal layer and consisting of spindle cells and blood vessels, with some infiltration of mast cells and lymphocytes. The immunohistochemical examination of the spindle cells revealed few AE1/AE3(+) cells, HHF35(+) cells, and CD34(+) cells, many CD117(+) cells with slight proliferative activity based on MIB-1 positivity (proliferation index <1%), but no CD44(+) cells. It was concluded that either the few CD34(+) and/or the many CD117(+) cells were mesenteric stem cells that had originated from the serosa, proliferated, then differentiated into myofibroblasts or fibroblasts, producing collagen and hyaluronic acid in the matrix, leading to the gradual formation of the SEP, which was induced by the continual irritation of CAPD.

Sclerosing peritonitis in continuous ambulatory peritoneal dialysis patients: one center's experience and review of the literature

Sclerosing peritonitis (SP) is a severe life-threatening condition for patients undergoing continuous ambulatory peritoneal dialysis (CAPD). This report reviews our experience and that reported in the literature concerning the prevalence of SP in CAPD patients, predisposing factors, and in particular, the role of peritonitis, its clinical presentation, diagnosis, treatment, and prevention. A total of 1,288 end-stage renal disease (ESRD) patients entered our peritoneal dialysis (PD) program between September 1977 and September 1997, seven of whom (0.54%) developed SP. The annual incidence of SP was 0.37 per 1,000 patient years, male-to-female ratio was 2.5 (M/F:5/2), mean age was 39+/-16 (median, 37; range, 23 to 61) years, and the median duration on CAPD was 62 (range, 12 to 144) months. Five patients were on CAPD for > or =4 years and two for less than 4 years before they were diagnosed with SP. All SP patients presented with clinical symptoms suggestive of intestinal obstruction, and five patients had decreased solute or fluid removal and had to increase the daily dialysate volume (3/7) or the tonicity of the fluid (4.25%) (3/7) or to combine a regular hemodialysis (HD) session with CAPD (2/7). There was a mean weight loss of 5+/-6 (median, 2; range, 0 to 18) kg. All patients had an episode of peritonitis at a mean time of 2+/-1 (median, 1; range, 1 to 3) months before the diagnosis of SP. The peritonitis was due to Staphylococcus aureus in four and Staphylococcus epidermidis, fungi, and Escherichia coli in one each. The definitive diagnosis of SP was established by laparotomy in four patients or postmortem examination in one patient, while in the remaining two there was no surgical confirmation; however, we believe the diagnosis was extremely likely because of the presence of clinical and radiologic criteria for SP. After the diagnosis of SP, all patients had their catheters removed, CAPD was discontinued permanently, and they were transferred to HD. Although there are isolated case reports of successful outcomes after surgical intervention, especially in patients in whom a peritoneal "cocoon" is related to severe peritonitis, usually the prognosis following surgery is poor. Treatment with immunosuppressive agents has been reported to be beneficial in the treatment of SP, although this has not been confirmed by all investigators. Among our SP patients, five (72%) died of sepsis (3/5) in a mean period of 10+/-5 (median, 9; range, 6 to 17) months after the diagnosis of SP and two are still alive on HD. SP is a rare but serious complication of CAPD. Severe peritonitis, especially in patients on dialysis for more than 4 years, may lead to SP As the prevalence of SP increases in patients on long-term CAPD, early detection is important because of the high morbidity and mortality associated with this condition.