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Abstract: FR-PO480

The Green Menace: Biliary Peritonitis due to Acute Cholecystitis in Peritoneal Dialysis

Session Information

Category: Dialysis

  • 702 Dialysis: Home Dialysis and Peritoneal Dialysis

Authors

  • Yekula, Anuroop, Saint Vincent Hospital, Worcester, Massachusetts, United States
  • Soni, Aakriti, Saint Vincent Hospital, Worcester, Massachusetts, United States
  • Martin, Suzanne Gwen, Saint Vincent Hospital, Worcester, Massachusetts, United States

Group or Team Name

  • Pees in a pod.
Introduction

The incidence of acute cholecystitis is significantly higher in dialysis patients compared with the general population (5.8 vs 0.92 per 1000 patient-years). Gallbladder (GB) perforation is a life-threatening complication of acute cholecystitis with an incidence of 2-11%. The dialysate effluent in peritoneal dialysis (PD) is a window into the peritoneal cavity and can help identify this intra-abdominal pathology.

Case Description

57M with ESRD on PD for over 10 years presented with diffuse abdominal pain. Peritoneal fluid analysis revealed straw-colored, hazy fluid with a WBC count of >6000 cells/mL with 70% PMNs. CT abdomen showed a mildly distended gallbladder containing gallstones but no evidence of cholecystitis. There was a mild dilation of the common bile duct (8mm). PD fluid cultures grew Staphylococcus epidermidis, and the patient was treated with intraperitoneal (IP) vancomycin for 2 weeks with symptom improvement.

Five days after discharge, he developed worsening right upper quadrant pain and green dialysate. Peritoneal fluid analysis showed greenish-amber fluid with a WBC count of 1500 cells/mL with 86% PMNs. PD fluid culture was negative. Repeat CT abdomen showed a markedly distended and thickened GB with cholelithiasis. Ultrasound was concerning for acute cholecystitis, which was confirmed by a HIDA scan, and he was started on IV piperacillin-tazobactam and IP vancomycin. As the patient was at high risk for surgery, a cholecystostomy tube was placed to decompress the gallbladder. PD was held initially and successfully resumed as his symptoms improved. The dialysate fluid cleared within 24 hours.

Discussion

Green dialysate is a sign of biliary leak into the peritoneal cavity and reflects an abdominal catastrophe. Appropriate and timely surgical intervention should be employed to ensure definitive therapy and prevent morbidity and mortality. Most reported cases were treated with cholecystectomy with PD catheter removal and transition to hemodialysis. This transition is usually temporary, and patients can resume PD after healing from surgery. In our case, the patient was able to continue PD successfully, as he did not undergo cholecystectomy.