Bacterial Peritonitis Following Esophagogastroduodenoscopy in a Patient on Peritoneal Dialysis

Aims: To recognize the importance of considering perforation of viscus in the differential of peritonitis after upper gastrointestinal endoscopy in peritoneal dialysis patients and to address the potential benefit of antibiotic prophylaxis in PD patients undergoing upper GI procedures.
Presentation of Case: We report the case of a 54-year-old African American female with end-stage renal disease on peritoneal dialysis presenting with generalized abdominal pain, along with nausea and vomiting. Peritoneal fluid revealed a WBC count of 1,499/mm3. Two days earlier, she had undergone an esophagogastroduodenoscopy with biopsy. Broad spectrum antibiotics were started to treat possible peritonitis. Surgical exploration revealed no perforation but murky peritoneal fluid was noted and gram stain showed mixed flora (both gram negative and gram positive rods); however, blood and peritoneal fluid culture grew only Streptococcus pneumoniae.
Discussion and Conclusion: An occult perforation, which may not be obvious to the naked eye or signs of contrast extravasation can occur after esophagogastroduodenoscopy with manipulations and can lead to peritonitis, especially in high-risk patients such as those with end-stage renal disease on peritoneal dialysis. To our knowledge, this is the first reported case of mixed peritonitis attributable to suspected micro-perforation after esophagogastroduodenoscopy. Whether pre-procedure antibiotics are warranted to decrease the occurrence of infectious complications in PD patients undergoing upper gastrointestinal procedures remains uncertain and not well studied. The prompt recognition of possible mixed bacterial infection remains essential after these procedures.