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

Idiopathic Sclerosing Encapsulating Peritonitis in a Patient with Atypical Symptoms and Imaging Findings

Sclerosing encapsulating peritonitis is a rare condition caused by a fibrotic membrane covering the small bowel which may lead to abdominal pain or obstruction. The cause may be primary and idiopathic or secondary to several diseases, treatments, and/or medications. The condition typically presents with bowel obstruction, and only one previous case has described ascites as the presenting sign. Sclerosing encapsulating peritonitis is typically diagnosed intraoperatively. We present a case of a patient who presented with atypical clinical symptoms including respiratory distress, recurrent abdominal ascites, and failure to thrive who was diagnosed nonoperatively.

Peritoneal Dialysis in Japan: The Issue of Encapsulating Peritoneal Sclerosis and Future Challenges

Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of peritoneal dialysis (PD). The overall prevalence of EPS in Japanese PD patients is 2.3%. Among patients on PD for less than 5 years, the rate is 0.9%; among patients on PD for 5 – 10 years, the rate is 3.8%; and among patients on PD for >10 years, it is 11.5%. Thus, the longer the treatment duration, the higher the prevalence of EPS.

Encapsulating peritoneal sclerosis does not result solely from the natural progression of peritoneal sclerosis. A “second hit” event, such as bacterial peritonitis, abdominal bleeding, or abdominal surgery may be needed to trigger the onset of EPS in the face of advanced peritoneal sclerosis.

To prevent development of EPS, PD treatment is replaced by other treatments when patients reached high-transport status. Peritoneal lavage and prednisolone administration have been reported to be effective in preventing or stopping the progress of EPS. When bowel obstruction has occurred, total enterolysis to remove the fibrous capsule from the bowel is indicated.

To maximize overall quality of life, patients with end-stage renal disease (ESRD) should have the choice to make use of all the treatment modalities available: PD, hemodialysis (HD), and transplantation. Furthermore, the development of truly biocompatible PD equipment—including peritoneal catheters, solutions, and systems—are desirable to extend PD treatment for the long term. The cost of individual products could decrease significantly if PD use were to increase to 30% from 10% among ESRD patients worldwide. As practitioners, we have to further improve the technical survival rate and functional duration of PD treatment so that adequate peritoneal function can be maintained for 10 years in at least 40% of PD patients. The goal is to place PD on par with HD using high-flux dialysis membranes and ultrapure dialysis solution.

Recommendations on the Management of Encapsulating Peritoneal Sclerosis in Japan, 2005: Diagnosis, Predictive Markers, Treatment, and Preventive Measures

This comprehensive update on the management of encapsulating peritoneal sclerosis incorporates insights gained from recently published findings and the accumulated experience of the authors. Aspects covered include diagnosis, risk factors and predictive markers, treatment, and prevention, including criteria for withdrawal from peritoneal dialysis.

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.

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.

Sclerosing encapsulating peritonitis: a case report

Sclerosing encapsulating peritonitis, a rare cause of bowel obstruction, was described as a complication associated with peritoneal dialysis which is much feared because of its severity. The authors report a case where radiological findings in association with clinical symptoms have allowed for a noninvasive diagnosis of sclerosing encapsulating peritonitis, emphasizing the high sensitivity and specificity of computed tomography to demonstrate the characteristic findings of such a condition.

Imaging in encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a rare but very severe complication of long-term peritoneal dialysis (PD). Since the first reports on this disease in the eighties, several imaging techniques have been used for its diagnosis. Because of the rarity of this condition, uniformity in modality and protocols for abdominal imaging for diagnosis has been lacking overtime. Nowadays, computed tomography (CT) is most often used. In this review, we provide an overview of all imaging modalities that have been used overtime to diagnose EPS as a late complication of PD. Imaging features characteristic for EPS and advantages as well as shortcomings of all modalities are discussed. We believe that when EPS is suspected, CT with contrast enhancement should be the modality of first choice in clinical practice.

Encapsulating Peritoneal Sclerosis Complicated by an Intra-abdominal Abscess

We present a case of a 68-year-old woman who developed encapsulating peritoneal sclerosis (EPS) with an intra-abdominal abscess. The patient was referred to our hospital with abdominal pain, nausea, and vomiting. She had end-stage kidney disease secondary to diabetes mellitus that had been treated with continuous ambulatory peritoneal dialysis for 9 years. EPS had been diagnosed 1 year ago, and she had been treated with prednisone daily. On presentation, a computed tomographic scan showed a calcified peritoneum and intra-abdominal abscess, and surgery showed that the abscess was caused by a bowel perforation. The perforated bowel could not be sutured or resected because of the presence of fibrotic tissue and peritoneal calcification. She was treated with bowel rest with total parenteral nutrition, as well as general antibiotic therapy and drainage for 8 months. However, the site of perforation did not heal, and she died of septic shock. Because treatment of EPS complicated by bowel perforation is very difficult, it is necessary to diagnose and treat the early stages of EPS to prevent bowel perforation. Imaging techniques are important in making an early diagnosis and successfully managing EPS.

Imaging features of encapsulating peritoneal sclerosis in continuous ambulatory peritoneal dialysis patients. AJR Am J Roentgenol. 2010;195:W50-W54. [PMID: 20566781 DOI: 10.2214/ajr.09.3175]

OBJECTIVE

The purpose of this article is to present the spectrum of radiologic findings of encapsulating peritoneal sclerosis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

CONCLUSION

Although a rare diagnosis, encapsulating peritoneal sclerosis in patients undergoing CAPD has a high morbidity and mortality. Diagnosis is often delayed because clinical features are insidious and nonspecific. Radiologic imaging may be helpful in the early diagnosis of encapsulating peritoneal sclerosis and in facilitating timely intervention for CAPD patients with encapsulating peritoneal sclerosis.

Computed Tomographic Findings Characteristic for Encapsulating Peritoneal Sclerosis: A Case-Control Study

Background

Computed tomography (CT) is often used to confirm the diagnosis of encapsulating peritoneal sclerosis (EPS) but there is no consensus on specific CT abnormalities. To establish CT findings characteristic for EPS, we compared CT findings between EPS patients and long-term peritoneal dialysis (PD) patients without EPS.

Methods

We included as cases all EPS patients in our center from 1996 to 2008 that underwent a CT scan at the time of diagnosis. Controls were all other long-term PD patients (PD duration ≥ 4 years) without EPS that had a CT scan for different reasons. The CT scans were blindly and independently reviewed by 3 radiologists: 2 abdominal radiologists with PD knowledge (Observers 1 and 2) and 1 radiologist without PD experience (Observer 3).

Results

We included 15 EPS patients and 16 controls. Observer 1 found 6 CT findings that were significantly more often present in EPS than in controls ( p ≤ 0.05): peritoneal enhancement, thickening, and calcifications; adhesions of bowel loops; signs of obstruction; and fluid loculation/septation. Observer 2 scored almost identically but Observer 3 scored differently. The sensitivity and specificity of a combination of specific CT findings were, respectively, 100% and 94% for Observers 1 and 2, and 79% and 88% for Observer 3.

Conclusion

CT scans showed characteristic abnormalities that were significantly more often present in EPS patients compared to long-term PD control patients. CT can be used to confirm the diagnosis of EPS when experienced radiologists apply a combination of specific CT findings.

Idiopathic sclerosing encapsulating peritonitis--is a preoperative diagnosis possible? Report of three cases

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is usually diagnosed during a laparotomy; however, a preoperative diagnosis is possible. Sclerosing encapsulating peritonitis can be classified as primary or idiopathic and secondary types and only about 70 cases of idiopathic type have been reported since it was first described. It is characterized by a total or partial encasement of the small bowel by a thick fibrotic membrane. This report presents a series of three cases in which a diagnosis of idiopathic SEP was made preoperatively based on the clinical features and radiological findings, which were confirmed by a laparotomy and histopathology. All of the cases were successfully managed by the excision of the membrane. This report demonstrates that based on the clinical features and radiological investigations, in the absence of other plausible etiologies for intestinal obstruction, it is possible to suspect a preoperative diagnosis of SEP, thereby preventing a "surprise" finding during a laparotomy and allowing for better management.