VISCUS PERFORATION IN PERITONEAL-DIALYSIS PATIENTS - DIAGNOSIS AND OUTCOME

Objective:To determine the incidence and outcome of spontaneous viscus perforation in peritoneal dialysis (PD) patients and which factors co uld facilitate early diagnosis. Design: A retrospective chart review w as done on all patients with viscus perforation and an a control group with peritonitis secondary to gram-negative organisms. Setting: A ter tiary care University Hospital Peritoneal Dialysis program. Patients: All patients with surgically proven spontaneous viscus perforation fro m 1978 to June 1992 (n = 15). A group of control patients (n = 15) wit h gram-negative bacterial peritonitis was also reviewed for comparison . Interventions: None. Main Outcome Measures: Hospital days, patient s urvival after perforation, and return to peritoneal dialysis were the main outcomes measured. Peripheral white blood cell (WBC) count, PD fl uid WBC count with differential, PD fluid cultures, radiologic informa tion, and surgical intervention were also evaluated. Data were analyze d using the Mann-Whitney test to determine significant differences bet ween the two groups. Results: Viscus perforation occurred in 15 of the 431 patients on PD from 1978 to June 1992 (3.5%). In comparison to th e control group, patients with viscus perforation had a significantly higher peripheral WBC count (p = .016), a higher mean PD fluid WBC cou nt (p = .006), and a higher mean percentage of polymorphonuclear cells in the PD effluent (p = .038). Multiple organisms on PD fluid culture s were noted in 12 of 15 patients with perforation and in only 3 contr ol patients. Pneumoperitoneum was seen on abdominal or chest radiograp h or computerized tomographic (CT) scan in 10 of 15 patients with perf oration and in only 1 of 15 patients in the control group. All patient s with viscus perforation required surgery and 6 expired. Only 1 death occurred in the control group. Only 1 of the 9 patients surviving per foration was able to resume PD, in contrast to 13 of 14 surviving cont rol patients. Conclusion: We conclude that viscus perforation is assoc iated with high morbidity, mortality, and technique failure. Diagnosis may be made by repeatedly searching for intraperitoneal free air on r adiograph or CT scan in patients with persistently elevated peripheral and PD fluid WBC count, and for multiple organisms on PD fluid cultur e.