Endoscopy 2013; 45(S 02): E313-E314
DOI: 10.1055/s-0033-1344408
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

High mortality following gastrostomy tube insertion in adult peritoneal dialysis patients: case report and literature review

R. Dahlan
Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
,
M. Biyani
Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
,
B. B. McCormick
Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
› Author Affiliations
Further Information

Corresponding author

Dr B. McCormick
1967 Riverside Dr
Ottawa
Ontario K1H 7W9
Canada   
Fax: +613-738-82893   

Publication History

Publication Date:
05 September 2013 (online)

 

A 79-year-old woman on peritoneal dialysis was admitted to hospital on January 14, 2013, for management of bilateral nonhealing heel ulcers. During her hospital stay, her oral intake was very poor and her albumin level progressively declined to 8 g/L. On February 15, she underwent percutaneous endoscopic gastrostomy (PEG) tube insertion and was switched to hemodialysis. Prophylactic oral fluconazole and intravenous piperacillin/tazobactam were administered. On February 23, she developed fever, hypotension, and tachycardia, and subsequently had a cardiorespiratory arrest. She was resuscitated and transferred to the intensive care unit. A leak around the PEG tube site was noted and the PD catheter drained turbid fluid with a total white cell count of 9800 × 10–6/L and effluent culture grew Klebsiella oxytoca, Pseudomonas aeruginosa, Enterococcus species, and Candida albicans. Imaging showed no evidence of bowel perforation. The patient continued to deteriorate and she died on February 24, 2013.

A very limited number of case reports [1] [2] indicate that the insertion of peritoneal dialysis catheters in patients who have a preexistent and presumably well-healed PEG may be safe ([Table 1]), but that the insertion of gastrostomy tubes in patients receiving peritoneal dialysis is associated with major adverse outcomes including leaks and fatal or nonfatal peritonitis ([Table 2]) [2] [3]. With our patient, withholding peritoneal dialysis, switching to hemodialysis, and use of prophylactic antimicrobials did not prevent the development of fatal peritonitis. We hypothesize that residual peritoneal fluid may have prevented effective healing of the PEG site with subsequent spillage of gastric contents into the peritoneal space. It is uncertain whether surgical as opposed to endoscopic placement or a longer healing time would have resulted in a better outcome. We conclude that gastrostomy tubes should not be placed in adult patients on peritoneal dialysis, because of a very high rate of fatal peritonitis.

Table 1

Summary of case reports of patients on peritoneal dialysis and gastrostomy tube feeding by time elapsed between percutaneous endoscopic gastrostomy (PEG) and peritoneal dialysis (PD) catheter insertion.

Case report

Age in years

Sex

Cause of end-stage renal disease

Time elapsed between PEG and PD catheter insertion

Complications

Outcome

Lew et al., 2011

N/A

M

Amyloidosis

14 months

None

Later death due to unrelated cause

Fein et al., 2001

77

F

Vascular disease

N/A

Peritonitis × 2

Later death due to unrelated cause

Fein et al., 2001

69

M

Diabetes

4 years

None

Later death due to unrelated cause

F, female; M, male; N/A, data not available.

Table 2

Summary of case reports of patients on peritoneal dialysis and gastrostomy tube feeding providing duration of withholding peritoneal dialysis (PD) after percutaneous endoscopic gastrostomy (PEG) insertion.

Case report

Age in years

Sex

Cause of end-stage renal disease

Duration of withholding PD after PEG insertion

Complications (onset from time of insertion)

Outcome

Dahlan et al., 2013 (present study)

79

F

Multiple myeloma

Switched to hemodialysis

Leak, polymicrobial peritonitis (8 days)

Death due to peritonitis

Fein et al., 2001

37

M

Obstructive uropathy

48 hours

Leak, Klebsiella peritonitis

Recovered

Fein et al., 2001

81

F

Diabetes mellitus

2 weeks

Peritonitis while PD on hold (10 days)

Later death due to unrelated cause

Fein et al., 2001

44

M

? AIDS

Switched to hemodialysis

None

Later death due to unrelated cause

Fein et al., 2001

66

F

Diabetes mellitus

None

Leak, fungal peritonitis (< 1 day)

Death due to peritonitis

Fein et al., 2001

58

M

Diabetes mellitus

Switched to hemodialysis

Leak, polymicrobial peritonitis (7 days)

Death due to peritonitis

Fein et al., 2001

64

M

N/A

6 weeks

Fungal peritonitis (50 days)

Death due to peritonitis

Fein et al., 2001

86

M

N/A

Switched to hemodialysis

None

Later death due to unrelated cause

Fein et al., 2001

69

M

N/A

Switched to hemodialysis

None

Later death due to unrelated cause

Goel et al., 1998

N/A

N/A

N/A

N/A

Peritonitis

N/A

Goel et al., 1998

N/A

N/A

N/A

N/A

None

N/A

F, female; M, male; N/A, data not available.

Endoscopy_UCTN_Code_CPL_1AH_2AI


#

Competing interests: None


Corresponding author

Dr B. McCormick
1967 Riverside Dr
Ottawa
Ontario K1H 7W9
Canada   
Fax: +613-738-82893