Peritonitis following endoscopic polypectomy in a peritoneal dialysis patient: the need for antibiotic prophylaxis.

Colonoscopy performed by an experienced endoscopist is a remarkably safe procedure. The incidence of perforation of the colon as a result of colonoscopy has been estimated to be between 0.1-0.8% for diagnostic examinations and 0.5-3% for therapeutic procedures [1]. We report a patient, treated with peritoneal dialysis because of end-stage renal failure, who developed peritonitis following intestinal endoscopy and polypectomy. Peritonitis is a major complication in patients treated with Continuous Ambulatory Peritoneal Dialysis (CAPD) [2]. It is caused mainly by bacteria from skin flora, entering the peritoneal cavity intraluminally or extraluminally via the catheter tunnel. In addition, intestinal perforation due to diverticulitis can cause severe peritonitis, necessitating laparotomy and removal of the catheter. In the last few years several cases of endoscopy induced peritonitis in CAPD patients have been reported [3-7]. The pathophysiological mechanisms involved are discussed. We recommend prophylactic treatment with antibiotics for CAPD patients undergoing intestinal endoscopy and polypectomy. A 51-year-old female patient had been maintained on Continuous Cyclic Peritoneal Dialysis, another modality of peritoneal dialysis, since 1990. In 1982 the patient started on chronic intermittent hemodialysis because of end stage renal disease secondary to nephrolithiasis and recurrent pyelonephritis. She underwent kidney transplantation three times. In May 1992 she developed symptomatic anemia due to fecal blood loss. A colonoscopy was performed with an Olympus type Q20 after polyethylene glycol purgation. In the sigmoid both a sessile and a pedunculated polyp with dimeters of 3-4 mm were removed with the hot biopsy forceps. Histologic examination revealed hyperplastic polyps. Within 12 h after the procedure the patient developed abdominal pains, fever and a cloudy dialysate outflow. The abdomen was diffusely tender with rebound tenderness, but without abdominal muscle rigidity. Radiographic examination did not demonstrate free air in the abdomen. Dialysate cell counts showed an increased number of leukocytes (2.0 x 109/1) with 89% polymorphonuclears (PMNs) at differential counting. A Gram stain of the fluid showed gram-negative rods. The patient was treated with intraperitoneal cefuroxime and tobramycin. The dialysate leukocyte count returned to normal (< 0.1 x 109/1) within 3 days. After 5 days of treatment the leukocytes in the peritoneal fluid rose again to 3.7 x 109 celts/1 on day6 and to 24.8 x 109 cells/1 on day 7 with more than 80% PMNs at differential counting, with a concomitant increase in abdominal symptoms. Culture results of the peritoneal dialysate taken on the first day after colonoscopy showed three types of anaerobes (Peptostreptococcus asaccharolyticus, Bacteroides disiens and Bacteroides ureolyticus). On day 6 after colonoscopy Bacteroides disiens was cultured again from the dialysate. The antibiotics were changed to cefltroxime and metronidazole, administered intraperitoneally and intravenously respectively. Within 7 days the dialysate leukocyte counts returned to normal again and abdominal symptoms gradually disappeared. The antibiotic treatment was given for a period of 17 days. In view of the number of cases reported (Table 1) peritoneal dialysis patients would seem to have an increased risk of developing peritoneal infections following lower-intestinal endoscopy [3-7]. There is a number of potential reasons for this increased risk. Table 1: Peritonitis following colonoscopy in peritoneal dialysis patients.