Green dialysate: asymptomatic perforated cholecystitis without peritonitis.

In peritoneal dialysis, the effluent dialysate is the window of the peritoneal cavity and usually allows for a rapid diagnosis of peritonitis and abdominal drama [1]. To our knowledge, there is only one reported case of perforation of the gallbladder in a patient on peritoneal dialysis with gram negative peritonitis [2]. We describe a case of asymptomatic perforated cholecystitis without peritonitis in a patient on continuous ambulatory peritoneal dialysis. A 53-year-old male patient with type 1 diabetes, on peritoneal dialysis for 8 years, came to the dialysis clinic because of green dialysate. During the previous month, he had noticed black particles in his dialysate. He denied any abdominal pain, nausea, vomiting or anorexia. A cellular count and culture of the dialysis fluid were normal the week prior. The patient looked well, had normal blood pressure and normal temperature; the abdominal exam was unremarkable. Upon examination, the bag of dialysate was indeed dark green (Figure 1). Blood chemistry showed a white cell count of 12.5 10/l, a total bilirubin level of of 27 mmol/l (N1⁄4 3–17) (indirect 23), a GGT level of 82U/l (N1⁄4 7–32), an alkaline phosphatase activity of 431U/l (N1⁄4 32–120) and normal AST, ALT, amylase and lipase levels. The peritoneal fluid showed 46 10/l nucleated cells and a total bilirubin level of 10 mmol/l. Peritoneal fluid culture was again negative. A Tc99m-disofenin (IDA) cholecysto-scintigram did not show any direct biliary leak but the bag of dialysate did reveal a significant level of radioactivity, suggesting the passage of bile into the peritoneal cavity (Figure 2). An abdominal computed tomography scan revealed a gallbladder with thickened walls without free air but no signs of bowel perforation.