Delayed intestinal perforation caused by overheated peritoneal dialysate: A disease prone to missed diagnosis and misdiagnosis.
Limin Zhang, Juan Li, Jiaomei Zhu et al.
✦ AI-curated · Sources linked
Case in brief
A 62-year-old woman on continuous ambulatory peritoneal dialysis presented with abdominal pain after receiving dialysate heated to 49 °C due to a malfunction. Initial assessments showed unremarkable effluent and minimal free air on CT. After discharge, she returned with worsening symptoms and was diagnosed with bowel perforation. Despite recommendations for surgery, her family declined, and she died shortly thereafter.
What made this case unusual
The case highlights the rare occurrence of delayed intestinal perforation due to overheated peritoneal dialysis fluid, which can be easily overlooked in clinical practice.
Diagnostic / clinical pearl
Clinicians should inquire about the heating method of dialysate in patients with abdominal pain on peritoneal dialysis, as thermal injuries can lead to serious complications.
Why it matters
This case underscores the importance of recognizing subtle signs of thermal injury in peritoneal dialysis patients, which can lead to life-threatening conditions if misdiagnosed.