Delayed intestinal perforation caused by overheated peritoneal dialysate: A disease prone to missed diagnosis and misdiagnosis
When managing acute abdominal pathology in a patient on PD who has received dialysate from a potentially compromised source, maintain a high index of suspicion for thermal injury even if the presentation is delayed. Don't assume perforation is due to typical causes; consider equipment malfunction as an etiology. Always review the history of fluid warming devices.
This article addresses the rare but potentially catastrophic complication of delayed intestinal perforation stemming from exposure to overheated peritoneal dialysate. The authors emphasize that thermal injury from this source is frequently missed or misdiagnosed, leading to significant morbidity and mortality. They present a fatal case report illustrating how a malfunction in a dialysate warmer can lead to severe bowel compromise hours after the initial event. This highlights the critical need for heightened clinical suspicion when a patient presents with unexplained abdominal pain or perforation signs following peritoneal dialysis procedures. Given its rarity and severity, recognizing this etiology is paramount for timely intervention.