Approach to the patient with bloody peritoneal dialysate (hemoperitoneum)

CT: computed tomography; CBC: complete blood count.
* Heavy bleeding is present when bleeding causes peritoneal dialysate to no longer be translucent. Persistent bleeding is bleeding that occurs with 2 or more exchanges.
¶ Urgent evaluation should be performed in an emergency department setting. Patients whose primary alarm findings are severe abdominal pain, fever, or hypotension may require additional evaluation for these presenting symptoms. Refer to UpToDate topics on evaluation and management of patients with abdominal pain, suspected sepsis and septic shock, and undifferentiated hypotension and shock.
Δ If the patient's vital signs are stable, the CT of the abdomen should be obtained after the patient has been instructed to wear a drain bag in all positions for at least 1 hour (ie, dry abdomen). However, if the patient is hemodynamically unstable, the CT scan should be performed immediately without delay. Among patients with residual renal function, the clinician should weigh the potential risks and benefits of intravenous contrast administration.
◊ Ovulation frequently stops as the patient begins dialysis. Thus, continued menstrual bleeding may be the result of an ovarian cyst or tumor. Imaging of the ovaries and gynecologic consultation may be appropriate in this setting.
§ Supportive measures include instillation of heparin into the dialysate to prevent clotting in the peritoneal catheter and more frequent exchanges.
¥ Findings consistent with peritonitis in patients on peritoneal dialysis include consistent clinical features (abdominal pain or cloudy effluent), a peritoneal fluid white count >100 cells/mm³ and percentage of neutrophils >50%, and/or a positive dialysate culture.
‡ Refer to UpToDate topics on the treatment of peritonitis in patients on peritoneal dialysis.