Accurate definition and management of idiopathic sclerosing encapsulating peritonitis

AIM

To review the literature on idiopathic sclerosing encapsulating peritonitis (SEP), also known as abdominal cocoon syndrome.

METHODS

The PubMed, MEDLINE, Google Scholar, and Google databases were searched using specific key words to identify articles related to idiopathic SEP. These key words were "sclerosing encapsulating peritonitis," "idiopathic sclerosing encapsulating peritonitis," "abdominal cocoon," and "abdominal cocoon syndrome." The search included letters to the editor, case reports, review articles, original articles, and meeting presentations published in the English-language literature from January 2000 to May 2014. Articles or abstracts containing adequate information about age, sex, symptom duration, initial diagnosis, radiological tools, and surgical approaches were included in the study. Papers with missing or inadequate data were excluded.

RESULTS

The literature search yielded 73 articles on idiopathic (primary) SEP published in 23 countries. The four countries that published the greatest number of articles were India (n = 21), Turkey (n = 14), China (n = 8) and Nigeria (n = 3). The four countries that reported the greatest number of cases were China (n = 104; 53.88%), India (n = 35; 18.13%), Turkey (n = 17; 8.80%) and Nigeria (n = 5; 2.59%). The present study included 193 patients. Data on age could be obtained for 184 patients (range: 7-87 years; mean ± SD, 34.7 ± 19.2 years), but were unavailable for nine patients. Of the 184 patients, 122 were male and 62 were female; sex data could not be accessed in the remaining nine patients. Of the 149 patients whose preoperative diagnosis information could be obtained, 65 (43.6%) underwent operations for abdominal cocoon, while the majority of the remaining patients underwent operations for a presumed diagnosis of intestinal obstruction and/or abdominal mass. Management information could be retrieved for 115 patients. Of these, 68 underwent excision + adhesiolysis (one laparoscopic); 24 underwent prophylactic appendectomy in addition to excision + adhesiolysis. Twenty patients underwent various resection and repair techniques along with excision + adhesiolysis. The remaining three patients were managed with antituberculosis therapy (n = 2) and immunosuppressive therapy (n = 1).

CONCLUSION

Idiopathic SEP is a rare disorder characterized by frequently recurring bouts of intestinal obstruction. Surgical therapy is the gold standard management strategy.

Encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a debilitating condition characterized by a fibrocollagenous membrane encasing the small intestine, resulting in recurrent small bowel obstructions. EPS is most commonly associated with long-term peritoneal dialysis, though medications, peritoneal infection, and systemic inflammatory disorders have been implicated. Many cases remain idiopathic. Diagnosis is often delayed given the rarity of the disorder combined with non-specific symptoms and laboratory findings. Although cross-sectional imaging with computed tomography of the abdomen can be suggestive of the disorder, many patients undergo exploratory laparotomy for diagnosis. Mortality approaches 50% one year after diagnosis. Treatment for EPS involves treating the underlying condition or eliminating possible inciting agents (i.e. peritoneal dialysis, medications, infections) and nutritional support, frequently with total parenteral nutrition. EPS-specific treatment depends on the disease stage. In the inflammatory stage, corticosteroids are the treatment of choice, while in the fibrotic stage, tamoxifen may be beneficial. In practice, distinguishing between stages may be difficult and both may be used. Surgical intervention, consisting of peritonectomy and enterolysis, is time-consuming and high-risk and is reserved for situations in which conservative medical therapy fails in institutions with surgical expertise in this area. Herein we review the available literature of the etiology, pathogenesis, diagnosis, and treatment of this rare, but potentially devastating disease.

Abdominal cocoon: a case series

We describe a series of 18 cases of abdominal cocoon in patients presenting with features of small intestinal obstruction or perforative peritonitis, nine of whom had tubercular aetiology while the rest were idiopathic. Manifestations of abdominal tuberculosis such as mesenteric abscesses, enlarged and caseating mesenteric lymph nodes, and tubercles over the bowel serosa were found in only 55% patients who were ultimately diagnosed to have Tubercular aetiology. We conclude that a high index of suspicion for this rare cause of a common surgical emergency is desirable.

Vascular Endothelial Cell Injury Is an Important Factor in the Development of Encapsulating Peritoneal Sclerosis in Long-Term Peritoneal Dialysis Patients

Background and Objectives

Encapsulating peritoneal sclerosis (EPS) is a rare but serious and life-threatening complication of peritoneal dialysis (PD). However, the precise pathogenesis remains unclear; in addition, predictors and early diagnostic biomarkers for EPS have not yet to be established.

Methods

Eighty-three peritoneal membrane samples taken at catheter removal were examined to identify pathological characteristics of chronic peritoneal deterioration, which promotes EPS in patients undergoing long-term PD treatment with low occurrence of peritonitis.

Results

According to univariable logistic regression analysis of the pathological findings, thickness of the peritoneal membrane (P = 0.045), new membrane formation score (P = 0.006), ratio of luminal diameter to vessel diameter (L/V ratio, P<0.001), presence of CD31-negative vessels (P = 0.021), fibrin deposition (P<0.001), and collagen volume fraction (P = 0.018) were associated with EPS development. In analyses of samples with and without EPS matched for PD treatment period, non-diabetes, and PD solution, univariable analysis identified L/V ratio (per 0.1 increase: odds ratio (OR) 0.44, P = 0.003) and fibrin deposition (OR 6.35, P = 0.027) as the factors associated with EPS. L/V ratio was lower in patients with fibrin exudation than in patients without fibrin exudation.

Conclusions

These findings suggest that damage to vascular endothelial cells, as represented by low L/V ratio, could be a predictive finding for the development of EPS, particularly in long-term PD patients unaffected by peritonitis.

Update on potential medical treatments for encapsulating peritoneal sclerosis; human and experimental data

Encapsulating peritoneal sclerosis (EPS) is an infrequent but serious complication of peritoneal dialysis (PD). The pathogenesis is unknown but speculation is ongoing. The current management of EPS focuses on prevention and treatment of the inflammatory and fibrotic changes at the level of the peritoneal membrane with immunosuppressive and antifibrotic agents, respectively. This article reviews the currently available human and animal data on potential agents to prevent and/or treat EPS. We propose a strategy for early diagnose EPS in an attempt to avoid the development of the full-blown and potentially life-threatening clinical syndrome of EPS. Future research should focus on studying potential prophylactic and therapeutic agents in humans in large, multicenter, randomized trials but also on early detection of EPS in the inflammatory phase by means of biomarkers and the establishment of a composite EPS score.

Lower mortality and inflammation from post-transplantation encapsulating peritoneal sclerosis compared to the classical form

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) may occur after kidney transplantation (post-transplantation EPS) or may be diagnosed during or after peritoneal dialysis treatment (classical EPS). The aim of the present study was to investigate to what extent both EPS entities differ in clinical presentation, radiological findings, outcome, and the systemic inflammatory response, as measured by plasma C-reactive protein (CRP) levels both prior to and after EPS diagnosis.

METHODS

We performed a retrospective analysis of 15 post-transplantation EPS and 19 classical EPS patients who were diagnosed at seven hospitals in the Netherlands between January 1, 2000, and January 1, 2011.

RESULTS

There were no inter-group differences in age, duration of peritoneal dialysis, clinical presentation, or radiology findings at diagnosis. Post-transplantation patients had experienced a lower number of peritonitis episodes per patient-year (0.2 (0.0-0.4) vs. 0.7 (0.3-1.2), p = 0.01) with a longer interval between the last peritonitis and EPS diagnosis (18.1 (4.6-34.3) vs. 4.4 (0.89-13.78) months, p = 0.01). Post-transplantation EPS patients showed a remarkably lower mortality rate (40.0 vs. 84.2%, p < 0.05). In both groups a pattern of elevated CRP values was observed, increasing within the year before EPS diagnosis. In the post-transplantation group the median CRP level at diagnosis was lower (56.0 vs. 144.50 mg/l, p < 0.05) than in the classical EPS group.

CONCLUSION

Post-transplantation EPS has a similar clinical presentation as classical EPS but with a lower systemic inflammatory response and better outcome.

Abdominal cocoon syndrome: Rare cause of intestinal obstruction-Case report and systematic review of literature

BACKGROUND

Abdominal cocoon or sclerosing encapsulating peritonitis is an uncommon condition in which the small bowel is completely or partially encased by a thick fibrotic membrane. Our study presents a case of sclerosing encapsulating peritonitis and conducts a literature review.

METHODS

A bibliographic research was conducted. Our research comprised 97 articles. Gender, age, symptoms, diagnostic procedures, and treatment were all included in the database of patient characteristics.

CASE PRESENTATION

A 51-year-old man complaining of a 2-day history of minor diffuse abdominal pain, loss of appetite, and constipation was presented in emergency department. Physical examination was indicative of intestinal obstruction. Laboratory tests were normal. Diffuse intraperitoneal fluid and dilated small intestinal loops were discovered on computed tomography (CT). An exploratory laparotomy was recommended, in which the sac membrane was removed and adhesiolysis was performed. He was discharged on the tenth postoperative day.

RESULTS

There were 240 cases of abdominal cocoon syndrome in total. In terms of gender, 151 of 240 (62.9%) were male and 89 of 240 (37%) were female. Ages between 20 and 40 are most affected. Symptoms include abdominal pain and obstruction signs. For the diagnosis of abdominal cocoon syndrome, CT may be the gold standard imaging method. The surgical operation was the treatment of choice in the vast majority of cases (96.7%). Only 69 of 239 patients (28.9%) were detected prior to surgery, and CT was applied in these cases.

CONCLUSION

Abdominal cocoon is a rare condition marked by recurrent episodes of intestinal obstruction. Surgical therapy is the most effective treatment option.

The use of computed tomography in the diagnosis of abdominal cocoon

BACKGROUND

Literature on the diagnosis of abdominal cocoon using computed tomography (CT) outside the setting of continuous ambulatory peritoneal dialysis is sparse.

METHODS

We did a retrospective analysis of contrast enhanced CT done for patients treated for abdominal cocoon. The clinical features, radiological findings, underlying etiology and outcomes were recorded.

RESULTS

Of the 22 patients analyzed, 19 had tuberculosis, 2 had malignancy and 1 was idiopathic. The basis of diagnosis of cocoon was CT in 18 and CT and surgery in 4. Types 1, 2 and 3 cocoon were found in 3 (13.63%), 6 (27.27%) and 13 (59.09%) respectively. The bowel findings were clumped loops in 21 (95%), inter-bowel fluid in 13 (59%), bowel wall thickening/enhancement in 6 (27%) and stricture in 1 (5%). Peritoneal thickening and nodularity were seen in 14 (64%) and 2 (9%) while omental thickening, nodularity and mass in 9 (41%), 5 (21%) and 1 (5%). Cauliflower sign was seen in 14 (64%), concertina pattern in 5 (23%) and Bottle Gourd sign in 6 (23%) patients. Of 12 with imaging done during episode of IO, 11 (92%) had cauliflower sign, 4 (80%) had concertina appearance and 6 (100%) had bottle gourd sign. Post treatment weight gain with anti-tubercular therapy was seen in 14 (63.63%), resolution of ascites in 12 (54.54%) and 2 patients had complete resolution of cocoon on repeat imaging.

CONCLUSION

CT is a valuable tool for pre-operative diagnosis of abdominal cocoon. The classical described signs are seen more frequently in patients with IO.

Encapsulating peritoneal sclerosis: case series from a university center

BACKGROUND/AIMS

Encapsulating peritoneal sclerosis (EPS) is an often-fatal complication of long-term peritoneal dialysis (PD). We here report the clinical features of EPS in Korean PD patients from a single university center.

METHODS

The data were collected retrospectively from 606 PD patients at Kyungpook National University Hospital, between August 2001 and August 2011. The diagnosis of EPS was based on clinical signs and symptoms, and confirmed by radiological findings.

RESULTS

Eight patients (1.3%, four males) were diagnosed with EPS. The mean age of the patients was 48.5 years (range, 33 to 65). The mean duration of PD was 111.8 months (range, 23 to 186). All patients except for one had three or more episodes of peritonitis. Seven patients were diagnosed with EPS after stopping PD, and only one stayed on PD after initial diagnosis and treatment. Total parenteral nutrition and corticosteroids, in addition to tamoxifen therapy, were used to treat most of the patients, and one patient underwent surgery (adhesiolysis). The overall mortality rate was 50%.

CONCLUSIONS

EPS is a serious, life-threatening complication in patients on long-term PD. To reduce the incidence and mortality rate of EPS, careful monitoring and early diagnosis is needed.

The enigma of primary and secondary encapsulating peritoneal sclerosis

BACKGROUND

Encapsulating Peritoneal Sclerosis (EPS) describes a variety of diseases that are frequently confused with different names and different etiopathogeneses. The aim of this article is to report personal experience of focusing on correct classification and the status of current diagnosis and treatment.

METHODS

A retrospective analysis was performed. Age, sex, ethnic origin, past medical history, symptoms and their duration, radiological tools and signs, laboratory tests, preoperative diagnosis, surgical approach, intraoperative findings, pathological findings, hospital stay, morbidity and mortality were studied.

RESULTS

A total of seven patients, including six males and one female, aged from 24 to 72 years were observed. Four patients had recurrent abdominal colic pain for 3 months, 1, 2 and 9 years; two patients also reported recurrent attacks but without any specification of the duration. All seven patients presented at the emergency department with abdominal pain that was mainly diffused over the entire abdomen. Six patients were submitted to a CT scan. Only in two patients was the diagnosis of EPS made preoperatively. All seven patients were submitted to open surgery. The hospital stay was between 4 and 60 days. One patient had morbidity, and one patient died of MOF.

CONCLUSIONS

Currently, the correct identification of EPS is more easily possible than in the past, but the diagnosis is still a challenge. Surgery must be performed as soon as possible to avoid a poorer quality of life.

Idiopathic abdominal cocoon syndrome with unilateral abdominal cryptorchidism and greater omentum hypoplasia in a young case of small bowel obstruction

Abdominal cocoon syndrome (ACS) is a rare cause of intestinal obstruction due to total or partial encapsulation of the small intestine by a fibrocollagenous membrane. Idiopathic ACS with abdominal cryptorchidism and greater omentum hypoplasia is even rarer clinically. We successfully treated a 26-year-old male case of small bowel obstruction with acute peritonitis. He was finally diagnosed with idiopathic ACS with unilateral abdominal cryptorchidism and greater omentum hypoplasia during exploratory laparotomy. He then underwent enterolysis, cryptorchidectomy, and appendectomy. He recovered gradually from the operations and early postoperative inflammatory ileus. There has been no recurrence of intestinal obstruction since the operation, and he is still in follow-up. We analyzed his clinical data and retrospectively reviewed the literature, and our findings may be helpful for the clinical diagnosis and treatment on ACS.

m-TOR inhibitors may be useful in the treatment of encapsulating peritoneal sclerosis (EPS)

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of long-term peritoneal dialysis, often occurring after patients have been shifted to haemodialysis or undergone renal transplantation. EPS is still associated with high morbidity and mortality but, although various treatment modalities have been tried, the optimal therapy is still debated. The present paper reports a 16-year-old patient who developed EPS 6 months after shifting to haemodialysis and, following adhesiolysis, was successfully treated with a combination of steroids, tamoxifen and everolimus, this last drug chosen for its antiproliferative effect through mammalian target of rapamycin (mTOR) inhibition and its ability to block vascular endothelial growth factor and neoangiogenesis. EPS progressively improved and the patient successfully underwent renal transplantation 5 years later. The case suggests that, in view of their mechanism of action, mTOR inhibitors should be considered as an immunosuppressive agent after renal transplantation in patients at risk and merit investigation in future trials on this condition.

Long-Term Success with Adhesiolysis in Post-Transplant Encapsulating Peritoneal Sclerosis: A Retrospective Case Series of 4 Patients and Review of the Literature

Encapsulating peritoneal sclerosis (EPS) is an occasional and serious complication for peritoneal dialysis (PD) patients for whom no evidence-based management strategies have yet been established. Encapsulating peritoneal sclerosis could appear after kidney transplantation in patients who previously underwent long-term PD. In this report, we present our experience in four PD patients diagnosed with EPS after kidney transplantation. Adhesiolysis provided improvement in their acute clinical conditions and allograft functions, despite the long-term follow-up. Surgical intervention may be a safe modality for this specific group of patients.

Prognosis of patients on continuous ambulatory peritoneal dialysis (CAPD) for over 10 years

BACKGROUND

Patients who have been on continuous ambulatory peritoneal dialysis (CAPD) for over 10 years are known to have a risk of developing encapsulating peritoneal sclerosis (EPS). However, the prognosis of patients on CAPD for over 10 years remains unclear.

METHODS

To better understand the efficacy of a variety of treatments for EPS, we retrospectively reviewed 25 patients who started CAPD at Toranomon Hospital from 1981 to 1997 and continued it for longer than 10 years.

RESULTS

The CAPD catheter was removed without peritoneal lavage in the initial 3 patients and they developed massive ascites. They all died of infection without resolution of the ascites. Accordingly, in the remaining 13 patients who did not undergo kidney transplantation, peritoneal lavage therapy was performed for 12 months before removing the CAPD catheter. As a result, 4 patients did not develop EPS. However, 9 patients had EPS with ascites, among whom 4 died of EPS-related diseases and 5 are alive. Five patients underwent cadaveric donor kidney transplantation. At the time of surgery, the CAPD catheter was removed without peritoneal lavage; 1 patient suffered from massive ascites immediately, although this subsided within 3 months after kidney transplantation, and 4 patients remain free from EPS-related symptoms and are doing well.

CONCLUSION

Kidney transplantation may be an option for preventing EPS. This study showed that improvement of the uremic state as well as treatment with immunosuppressants including corticosteroids may contribute to preventing EPS.

Encapsulating Peritoneal Sclerosis: A Case Report and Literature Review

BACKGROUND Encapsulating peritoneal sclerosis (EPS) is a rare, life-threatening, and serious complication of long-term peritoneal dialysis (PD). No evidence-based management strategy has been established until now. Surgical management, including enterolysis and excision of the sclerotic and obstructing adhesions, should be considered as soon as conservative management fails to work. We report a case of EPS soon after transplantation in a patient with end-stage kidney disease who had been on long-term PD. CASE REPORT A 26-year-old man had been found to have advanced chronic kidney disease secondary to glomerulonephritis on pre-employment investigation. He was on continuous ambulatory PD for 5 years, after which he underwent a living donor renal transplant from his full HLA-matched sibling. He did well postoperatively, with excellent graft function. One month after transplantation, he repeatedly presented to our Emergency Department with signs and symptoms of complete small-bowel obstruction. Computed tomography of the abdomen showed features of small-bowel obstruction secondary to interloop adhesions. The patient was initially managed conservatively; however, as his condition continued to deteriorate, an exploratory laparotomy was carried out. Operative findings were suggestive of early EPS localized to the terminal ileum. Total enterolysis along with peritonectomy was performed along with resection of the diseased and obstructing terminal ileum. The patient did well, and he was discharged home day 10 postoperatively. CONCLUSIONS EPS remains a serious and fatal complication of long-term PD. Early definitive diagnosis, treatment, and ultimately surgical intervention may be required to prevent the morbidity and mortality associated with this condition.

Pathophysiology of encapsulating peritoneal sclerosis: lessons from findings of the past three decades in Japan

Encapsulating peritoneal sclerosis (EPS), a condition with a high mortality rate, is a serious complication of peritoneal dialysis (PD). In Japan, EPS became a central issue in the clinical setting during the mid-90s and the beginning of this century. However, following the introduction of biocompatible neutral PD solutions containing lower levels of glucose degradation products, the incidence and clinical severity of EPS has been greatly lessened. During the past three decades, the etiology of EPS has been elucidated by findings obtained by peritoneal biopsy, laparoscopy, and surgical intervention. Accumulating findings suggest the need for a paradigm change on the nature of EPS pathophysiology; notably, EPS appears not to reflect peritoneal sclerosis per se, but rather the formation of a neo-membrane as a biological reaction to peritoneal injury. This narrative review looks back on the history of EPS in Japan, and discusses EPS pathophysiology, the impact of neutral PD solution on peritoneal protection, and a future novel diagnostic approach, ultra-fine endoscope, for the identification of patients at high risk of EPS.

Left paramesocolic hernia presenting as post appendicectomy abdominal cocoon

We describe a rare case of left mesocolic hernia presenting as post appendicectomy intestinal obstruction in a girl. Laparotomy confirmed partial peritoneal encapsulation of upper small bowel due to herniation of jejunal loops into the left mesocolic hernia sac. Reduction of contents, resection of the sac and repair of the defect concluded the procedure uneventfully.

Clinical risk factors and outcomes of massive ascites accumulation after discontinuation of peritoneal dialysis

Background: Encapsulating peritoneal sclerosis (EPS) is a serious complication of peritoneal dialysis (PD), with high morbidity and mortality that requires an early diagnosis for effective treatment. PD withdrawal and bacterial peritonitis are important triggers for the onset of EPS. However, few studies have focused on cases of PD withdrawal without a clinical diagnosis of peritonitis, cirrhosis, or carcinomatosis. We aimed to compare the clinical characteristics and computed tomography (CT) images of patients with or without ascites in such situations and assess clinical outcomes in terms of mortality.Methods: Our retrospective review included 78 patients who withdraw PD between January 2000 and December 2017.Results: Ten patients had ascites, and 68 did not have a significant intra-abdominal collection. The ascites group had a significantly longer PD duration (months; 134.41 [range, 35.43-181.80] vs. 32.42 [733-183.47], p < 0.001) and higher peritoneal membrane transport status based on the dialysate-to-plasma ratios of creatinine (0.78 ± 0.08 vs. 0.68 ± 0.11, p = 0.009) and glucose (0.27 ± 0.07 vs. 0.636 ± 0.08, p = 0.001) than the control group. CT parameters, including peritoneal calcification, thickness, bowel tethering, or bowel dilatation, were not all present in each patient with ascites and EPS. During the 12-month study period, the ascites group had a higher risk for developing EPS (70% vs. 0%, p < 0.001) and a higher 12-month all-cause mortality (30% vs. 0%, p = 0.002).Conclusions: Ascites accumulation was not rare after PD discontinuation. A longer PD duration and high peritoneal membrane transport status could predict subsequent ascites accumulation. Furthermore, patients with ascites were at a higher risk of EPS.

Management of encapsulating peritoneal sclerosis: a guideline on optimal and uniform treatment

Encapsulating peritoneal sclerosis (EPS) represents a rare complication of long-term peritoneal dialysis (PD). It is characterised by diffuse peritoneal membrane fibrosis, progressive intestinal encapsulation and the clinical spectrum of intestinal obstruction. The pathogenesis is as yet not well understood but includes inflammation, angiogenesis and fibrosis. The current diagnosis of EPS lacks specificity and relies on clinical, radiographic or macroscopic evaluation. There is no general agreement on managing EPS although accumulating clinical data suggest drug treatment (steroids, tamoxifen), surgery (enterolysis) or a combination of both. Here, we provide a short overview on the current knowledge of EPS, with a focus on treatment. Moreover, we present a diagnostic and a therapeutic algorithm for EPS based on the best available published data and our combined experience.

Encapsulating peritoneal sclerosis--a complication of peritoneal dialysis

Encapsulating peritoneal sclerosis (EPS) is a rare complication of peritoneal dialysis. It often presents with non-specific symptoms, leading to a delay in diagnosis and a poor prognosis. Here we report a case of EPS in a patient treated with peritoneal dialysis and discuss the risk factors, diagnostic challenges and treatment options available.

The value of osmotic conductance and free water transport in the prediction of encapsulating peritoneal sclerosis

Qualitative assessments in long-term patients and in those with encapsulating peritoneal sclerosis (EPS) have shown that impaired osmotic conductance is likely a factor contributing to the presence of ultrafiltration failure in those individuals. In the present study, we investigated the value of osmotic conductance, its components LpA and the reflection coefficient sigma, and free water transport (FWT) in 12 patients with EPS, in 21 patients with long-term ultrafiltration failure, and in 26 time-restricted control subjects with normal ultrafiltration. A decrease in all parameters was observed during a period of 4 years in patients with EPS and ultrafiltration failure, with FWT showing the largest difference between all three groups; however, the receiver operating curves showed that only FWT appeared to be a significant predictor of EPS. Because its measurement is simple, FWT should be included in the regular assessment of peritoneal function.

A New Experience With Encapsulating Peritoneal Sclerosis: Role of Early Intervention

After 20 years of peritoneal dialysis in Iran, we have encountered with several cases of encapsulating peritoneal sclerosis (EPS) in past few years. Many of these cases remained undiagnosed until advanced stages due to lack of suspicion. In centers with more experience about EPS, mortality has decreased by early diagnostic interventions. Peritoneal dialysis nurses may not be aware of EPS and radiologists are usually not familiar with EPS, either. To increase knowledge about this condition, we decided to present this review article with the case study of one of the 1st patients with EPS at our center. Currently, we have had no data registry of EPS in Iran, yet. Our plan is to develop a national EPS registry in our country which will help to closely monitor these patients.