Sclerosing encapsulating peritonitis: a case successfully treated with immunosuppression.

Sclerosing encapsulating peritonitis (SEP) associated with peritoneal dialysis (PD) has been reported frequently since its initial description by Gandhi in 1980 (1). The etiology remains elusive: peritonitis might be the most important risk factor, but acetatebased dialysis solutions, chlorhexidine as a disinfectant, and β−blocking drugs have also been implicated as causative agents. Sclerosing encapsulating peritonitis, a particular presentation of sclerosing peritonitis (SP) should be distinguished from simple peritoneal sclerosis (SS). The latter is almost always present, in variable degrees, in PD patients for more than a few months and leads to a deterioration of membrane permeability. Bioincompatibility of solutions and time on PD are its presumed etiological factors. Usually, SEP presents as small bowel obstruction, malnutrition, sometimes with bloodstained dialysate, and is characterized by cocooning of the small bowel by a very thick fibrous sheath, often with sparse calcified plates lining the peritoneum. The mean SP incidence in recently published studies ranged between 3.5 (2) and 4.2/1000 patients/year (3). Sclerosing encapsulating peritonitis is a severe complication, although rare, with a mortality rate exceeding 60%, due to sepsis and malnutrition. The treatment is still debated: surgical management is difficult and frequently leads to fatal bowel perforation. Immunosuppressive agents have been associated with some success, supporting the hypothesis that SEP could be immunologically mediated. We report a clinical case of a continuous ambulatory peritoneal dialysis (CAPD) patient, with clinical and radiological signs of SEP, successfully treated with prednisone and azathioprine, parenteral nutrition, and transfer to hemodialysis (HD). She recovered from the intestinal obstruction and remains asymptomatic 18 months later.