Small Intestinal Perforation Leading to Peritonitis in a Patient Undergoing Peritoneal Dialysis Combined with Hemodialysis: A Rare Case Report and Literature Review

Introduction: The incidence of peritonitis caused by intestinal perforation in patients undergoing peritoneal dialysis (PD) is low, but it often leads to delayed diagnosis and poor prognosis. Case presentation: We report a case of a 63-year-old patient on combined PD and hemodialysis (HD) who presented with abdominal pain, turbid peritoneal fluid, and bloody ascites. Abdominal CT revealed extensive atherosclerosis of the superior mesenteric artery. The patient was diagnosed with PD-related peritonitis, and ascites cultures grew Enterococcus. Despite anti-infective treatment, the patient's condition did not improve. On the tenth day of admission, fecal ascites were drained, and a repeat abdominal CT showed new pneumoperitoneum, suggesting intestinal perforation. Emergency laparotomy confirmed superior mesenteric artery ischemia leading to small bowel perforation. Postoperative ascites cultures grew Candida krusei and Enterococcus faecium. The patient was transferred to the ICU for aggressive treatment but ultimately succumbed to septicemia. Conclusion: Currently, it is difficult to distinguish clinically between perforative peritonitis and PD-related peritonitis in PD patients, and imaging findings are often non-specific. Laparoscopic catheter removal or early laparotomy for refractory or fungal peritonitis may aid in early identification.