A hemodialysis patient with severe vomiting

Abstract

A 59-year-old lady, who had switched to hemodialysis for 4 years after a severe continuous ambulatory peritoneal dialysis (CAPD) peritonitis, complained of repeated vomiting. She had significant weight loss secondary to poor oral intake. There was no other associated gastrointestinal symptom. She was adequately dialyzed with KT/V 4.58/week. Drug history was carefully reviewed and no emetic drug identified. Esophagogastroscopy showed reflux esophagitis (grade B). X-ray of the abdomen was unremarkable. However, computer tomography showed dilated stomach and proximal small bowel. There was also large amount of peritoneal fluid collection with possible compression in superior mesenteric artery (SMA) region resulting in obstruction equivalent to SMA syndrome (Figure 1). Barium meal and follow-through showed a delay in transit through the duodenum with dilated D1 and D2 and indentation at D3, compatible with partial duodenal obstruction secondary to intra-abdominal collection (Figure 2). Aspiration of the intra-abdominal collection was performed repeatedly. However, the patients’ symptoms persisted. Insertion of nasojejunal feeding tube under esophagogastroscopy guidance was attempted twice to bypass the obstruction but the feeding tube slipped out. Finally the patient underwent laparotomy and gastrojejunostomy. Postoperatively, the patient could tolerate oral feeding with no significant vomiting. Vomiting is a common complaint in dialysis patient. Differential diagnosis of vomiting includes functional vomiting, effect of uremia, drug effect, and upper gastrointestinal obstruction such as SMA syndrome. In patient with history of refractory CAPD peritonitis, mechanical obstruction secondary to loculated intra-abdominal collection or adhesion needs to be suspected. Our case demonstrated that intra-abdominal collection could take place up to 4 years after termination of peritoneal dialysis.