Delayed intestinal perforation caused by overheated peritoneal dialysate: A disease prone to missed diagnosis and...

Thermal injury caused by overheated peritoneal dialysis fluid is extremely rare and often overlooked. However, delayed intestinal perforation is life-threatening and associated with high mortality. We report a fatal case of delayed bowel perforation caused by overheated peritoneal dialysis fluid resulting from a dialysate warmer malfunction, highlighting the diagnostic challenges.

A 62-year-old woman receiving continuous ambulatory peritoneal dialysis (CAPD) for 8 years presented with abdominal pain 1 h after intraperitoneal infusion of dialysate inadvertently heated to 49 °C because of a dialysate warmer malfunction. Initial peritoneal effluent analysis was unremarkable, whereas abdominal CT revealed a small amount of free intraperitoneal air. As her symptoms improved, she was discharged without specific treatment. Nine days later, she returned with abdominal pain and fever and was admitted with presumed peritoneal dialysis-associated peritonitis. Intraperitoneal antibiotics were initiated, with initial clinical improvement. She subsequently developed severe abdominal pain, high fever, and feculent peritoneal effluent. Repeat abdominal CT confirmed bowel perforation. Surgery was recommended but declined by her family. She was discharged against medical advice and died shortly thereafter. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS ENTITY?: Overheated peritoneal dialysate can cause delayed bowel perforation with subtle early manifestations. In patients receiving peritoneal dialysis who present with abdominal pain, clinicians should ask how the dialysate was heated and whether it felt unusually hot. If thermal injury is suspected, prompt abdominal CT, discontinuation of peritoneal dialysis, antibiotics, and early surgical consultation are essential.