JOURNAL OF DIALYSIS, 3(4), 331-335 (1979)

INTRA-ABDOMINAL ABSCESSES IN A PATIENT TREATED WITH MAINTENANCE PERITONEAL DIALYSIS

H. Humayun, J.T. Daugirdas, V.C. Gandhi, W.P. Geis, J. Giacchino and T.S. Ing Departments of Medicine and Surgery, Veterans Administration Edward Hines, Jr. Hospital, Hines, Illinois 60141; and

Loyola University Stritch School of Medicine Maywood, Illinois 60153.

INTRODUCTION

With the advent of permanent catheters and automated dialysate

delivery machines, more centers are resorting to maintenance peritoneal

dialysis for management of end-stage renal failure. Some complications

do occur [l] and we report here a patient who, while receiving main-

tenance peritoneal dialysis, developed intra-abdominal abscesses.

CASE REPORT

A 59-year-old male with chronic renal failure secondary to nephro-

sclerosis had been on hemodialysis since 1972.

because of difficulties with vascular access, he was begun on maintenance

peritoneal dialysis.

delivery machine through a Tenckhoff double-cuff catheter.

In August of 1975,

Treatments were given by automated dialysate

On October 16, 1975, he developed abdominal cramps and fever of

37.3' C. Examination of the abdomen revealed diffuse direct and rebound

331

Copyright 0 1980 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher,

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332 HUMAYUN ET AL.

tenderness and hypo-active bowel sounds. On microscopic examination,

the peritoneal fluid was found to contain 480 leucocytes per mm', of

which 76% were polymorphonuclear cells. Cultures of the peritoneal

fluid grew aerobic diphtheroids. The patient was treated with anti-

biotics given both orally and by peritoneal lavage. The latter, per-

formed continuously during the first 3 days, consisted of hourly ex-

changes of 2 liters of dialysate to which 100 mg per liter of ceph-

alothin had been added. Beginning on the fourth day, cultures of the

peritoneal fluid were sterile. Consequently, intermittent peritoneal

lavage with cephalothin was instituted. The intermittent therapy,

performed three times per week, consisted of exchanges of lavage fluid

every 30 minutes for 10 hours. The total duration of oral and intra-

peritoneal antibiotic therapy was two weeks. The patient seemed to

respond adequately to this treatment. On November 18th, however, he was

again admitted with clinical and laboratory findings of 'peritonitis.

Cultures of the peritoneal fluid grew aerobic diphtheroids. He was

treated in similar fashion with intraperitoneal cephalothin from No-

vember 18th to November 30th, with resolution of all his symptoms.

Sterilization of his peritoneal fluid was achieved after the first 2

days of therapy.

On December 18th, the patient presented a third time with abdominal

pain. His temperature was 38.0' C. On examination, his abdomen evi-

denced diffuse tenderness, guarding and marked rebound. Bowel sounds

were diminished. Analysis of peritoneal fluid revealed 1,012 leucocytes

per mm3 with 85% polymorphonuclear cells.

fluid again produced aerobic diphtheroids which were sensitive to both

cephalothin and gentamicin. He was treated by peritoneal lavage with

cephalothin added to the lavage fluid. Fever and signs of peritonitis

Cultures of the peritoneal

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INTRA-ABDOMINAL ABSCESSES 333

persisted, however, and the patient developed diarrhea. On December

20th, cephalothin was discontinued and gentamicin 8 mg per liter was

added to the dialysate. No improvement was noted. At that time,

proctoscopic examination was normal.

gastrointestinal tract was unremarkable,

hours failed to demonstrate any localized area of increased uptake. An

ultrasound of the abdomen, however, revealed 2 cystic masses. One of

these was located in the right upper abdomen and measured 6 x 10 x

10 cm.

iliac crest. On January 26th, because of persistent abdominal findings,

the patient underwent exploratory laparotomy. Two abscesses, corres-

ponding in location to the cystic areas seen on ultrasound, were found.

The abscess cavities communicated with each other and also with the

peritoneal dialysis catheter. Many adhesions to the bowel were present.

Aerobic cultures of the abscess fluid grew diphtheroids.

thioglycollate broth for anaerobic bacteria were sterile.

were drained and the patient recovered uneventfully. He was subsequently

maintained on hemodialysis until he expired of unrelated causes a year

later.

Radiography of the upper and lower

A gallium scan at 6 and 48

The other, measuring 5 x 7 x 11 cm, was seen just above the

Cultures in

The abscesses

DISCUSSION

Maintenance peritoneal dialysis is not infrequently complicated by

the occurrence of peritonitis [l-31. Infection of the peritoneal membrane

can result in the development of intra-abdominal abscesses. However, in

several recent reviews describing peritonitis in association with peritoneal

dialysis [ 4 , 5 ] , the problem of abscess formation has only been briefly

mentioned.

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334 HUMAYUN ET AL.

We treated our patient's initial two episodes of peritonitis with

continuous antibiotic lavage until cultures became sterile, and then

with intermittent antibiotic lavage for an additional 12 to 15 days.

believe that the choice of antibacterial agent was an appropriate one,

since the diphtheroids isolated from the peritoneal fluid were always

sensitive to cephalothin, and since a clinical response was initially

obtained. The total duration of treatment of each of these episodes,

however, was less than the 3 to 4 weeks currently recommended [ 4 ] . It

is for this reason, we surmise, that the peritonitis recurred in our

patient. Recurrent infection must have caused adhesions and compart-

mentalization of infected fluid. Ultimately, an abscess was formed.

Our patient's treatment may also have been less than optimal in

several other respects. Tenckhoff recommends that the peritoneal catheter

be replaced if relapse of peritonitis occurs 141.

Black et al. [5] suggest that combined systemic and intraperitoneal

antibiotic therapy in treating peritonitis results in high drug levels

in tissues along the path of the dialysis catheter and in loculated

areas of the peritoneal cavity. They speculate that the use of combined

therapy might curb the tendency to abscess formation. Systemic anti-

biotics were given during the first episode of peritonitis in our patient,

but were not administered when the peritonitis recurred. Lack of

systemic therapy may have contributed to abscess development in our

patient although it should be noted that routine use of systemic anti-

biotics in treating peritonitis associated with chronic peritoneal

dialysis remains controversial [ 5 ] .

We

This was not done.

In conclusion, we suggest that treatment of dialysis-associated

peritonitis should not be abbreviated, even if prompt clinical improvement

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INTRA-ABDOMINAL ABSCESSES 335

is observed. Otherwise, not only recurrence, but abscess formation may

result.

REFERENCES

1.

2.

3.

4.

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Roxe, D.M., Argy, W.P., Frost, B., et al., South. Med. J. 69: 584-587, 1976.

Golper, T.A., Bennett, W.M., and Jones, S.R., Dial. & Transplant., - 7~1173-1178, 1978.

Sherrard, D.J., Curtis, F.K., Hansen, P., et al., Dial. & Transplant., - 6:28-30, 1977.

Tenckhoff, H . , Chronic Peritoneal Dialysis Manual. University of Washington, Seattle, Washington, 1974.

Black, H.R., Finkelstein, F.O., and Lee, R.V., Trans. her. S O C . Artif. Intern. Organs, 0:115-119, 1974.

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