Peritoneal dialysis is widely used in patients with chronic renal failure because of its safety and effectiveness. However, complications, such as peritonitis, abdominal pain, and intestinal fistula, may occur [1, 2]. Even with strict operating standards, complications cannot be avoided. The diagnostic features of intestinal perforation in peritoneal dialysis patients include watery diarrhea, difficulty in drainage of the peritoneal dialysis fluid, and symptoms and signs of peritonitis . If treatment is delayed, the consequences can be serious; the reported mortality rate is as high as 46–57% . Once an intestinal fistula occurs, it must be treated as soon as possible, and the peritoneal dialysis catheter should be removed promptly. Surgical repair of the fistula may be needed. Most dialysis-associated perforations occur in the colon, followed by the cecum and rectum [1, 2, 4,5,6], whereas perforation of the small intestine is rare.
Intestinal perforation associated with peritoneal dialysis can be divided into acute and chronic forms. Acute perforation may occur with implantation of the dialysis catheter. Extensive peritoneal calcification, which may develop after repeated peritonitis, can predispose to bowel perforation . In our patient, we suspect that repeated peritoneal dialysis-related peritonitis led to the intestinal perforation, which has rarely been reported. Other factors include intestinal tumors, mesenteric ischemic diseases, which may also cause intestinal perforation . Patients with recurrent abdominal infections are prone to bacterial or fungal peritonitis and are also at high risk for intestinal perforation. Enlargement of the kidneys caused by polycystic kidney disease may lead to increased intra-abdominal pressure and intestinal perforation . Perforation of an inflamed intestinal diverticulum is regarded as a major cause of intestinal perforation. The reported incidence of colonic diverticula in patients with end-stage polycystic kidney disease is high, at approximately 80% .
In addition to intestinal perforation from catheter implantation, catheters can play a role in perforation due to factors such as improper position of the catheter, retention of the catheter for a long time after the cessation of peritoneal dialysis, and repeated rubbing of the catheter against the bowel wall . Catheter insertion methods include percutaneous procedure with or without image guidance, open surgical dissection, peritoneoscopic procedure, and surgical laparoscopy . Brown et al.  reported that in a series of 435 patients who had catheters implanted by using these techniques, the Moncrief and Popovich method alone may not induce intestinal perforation. Rubin et al.  reported an incidence of perforation of 0.1% using the Moncrief and Popovich technique. Fujiwara et al.  emphasized that catheter-related intestinal perforation can be due to the presence of unused catheters, typically 1.6–48 months after the use has ceased. It is proposed that long duration of an immobile catheter in the peritoneal cavity containing little fluid may cause pressure necrosis of the bowel. Thus, if peritoneal dialysis is no longer being performed, the catheter should be removed or flushed regularly. Unidirectional intestinal fistula present after removal of the catheter is safe because if the intestinal fistula is not open, diffuse peritonitis will not occur.
It is often difficult to determine whether clinically suspected peritonitis in patients on peritoneal dialysis is due to dialysis . Moreover, intestinal perforation in such patients may be unrecognized because of the lack of symptoms [15, 16]. Therefore, it is important to use imaging and endoscopic methods for detecting intestinal perforation in these patients.
A case of intestinal perforation associated with long-term peritoneal dialysis and repeated episodes of inadequately treated peritonitis is presented. This associated complication of peritoneal dialysis may be difficult to diagnose; however, it should be suspected, and when present, it should be treated promptly.