Version May 2024
INTRODUCTION — Bloody peritoneal dialysate (hemoperitoneum) in the peritoneal dialysis patient is a common occurrence. The etiology, diagnosis, and treatment of this problem will be reviewed here. Other abdominal disorders in dialysis patients, including abnormalities requiring immediate surgical therapy, are discussed separately. (See "Unique aspects of gastrointestinal disease in patients on dialysis".)
ETIOLOGY AND EPIDEMIOLOGY — The incidence of hemoperitoneum in patients on peritoneal dialysis varies from 6 percent overall to as high as 57 percent in premenopausal women [1,2]. Bloody peritoneal dialysate may be related to the peritoneal dialysis catheter, the peritoneal dialysis procedure, underlying kidney disease (such as polycystic kidney disease or acquired cystic changes), or factors unrelated to kidney disease (table 1). Performance of peritoneal dialysis exchanges allows for earlier detection of intra-abdominal bleeding, including mild bleeding that might otherwise be clinically silent.
Causes of hemoperitoneum were reviewed in a single-center series of 424 patients; 26 patients (6 percent) developed one or more episodes of hemoperitoneum [1]. Based upon severity and cause of bleeding, patients could be divided into different groups:
●In the largest group (n = 21) of cases, bleeding was mild, asymptomatic, and resulted in pinkish or red discoloration of the fluid. These patients were treated conservatively and did not receive extensive evaluation. Menstrual bleeding was believed responsible in seven cases, while a bleeding diathesis (use of warfarin or thrombocytopenia) was responsible in four patients.
●Peritoneal bleeding after transplant nephrectomy, increased physical activity, catheter repositioning, and femoral hematoma were responsible for single cases.
●Minor bleeding with significant pathology was found in single patients with pancreatitis, sclerosing peritonitis, and postcolonoscopy, respectively.
●Severe bleeding requiring intervention was observed in six patients, three with likely ovarian cyst rupture, one post-splenectomy, one post-catheter placement, and one with sclerosing peritonitis.
●The cause was uncertain in six patients.
Some patients can have recurrent hemoperitoneum. In an observational study of 21 patients with recurrent hemoperitoneum, two-thirds of the patients were female [3]. Among the females, the most common cause was retrograde menstruation. Most cases among males were idiopathic. One-third of the patients in the entire cohort were taking aspirin or therapeutic doses of warfarin.
Menstrual bleeding — Benign hemoperitoneum occurs in over one-half of menstruating women on peritoneal dialysis; this is likely caused by ovulation, retrograde menstruation, or endometriosis [2-4]. In one study of 27 reproductive-age women undergoing continuous ambulatory peritoneal dialysis (CAPD) for more than three months, four of seven who menstruated developed hemoperitoneum [2]. Of 37 episodes of hemoperitoneum, 22 and 15 occurred at midcycle and with menstruation, respectively.
Such intra-abdominal bleeding would rarely be observed if peritoneal dialysis was not being performed. It is important to note that a very small amount of blood (<1 mL) is enough to make 2 liters of peritoneal dialysate appear blood-tinged.
When such episodes occur, the woman should be reassured that the hemoperitoneum is benign and that it will likely resolve spontaneously. Rapid flushes (instillation of 500 mL to 1 L of dialysate allowed to dwell over one hour) and instillation of heparin (typically 500 units/L of instilled volume) in the dialysate to prevent catheter clotting are usually done. Infusing cool dialysate (ie, room temperature) may also be helpful [5]. Most commonly, the hemoperitoneum will clear after one to three rapid flushes. (See 'Treatment' below.)
Catheter-related — After insertion of the peritoneal catheter, bleeding into the peritoneal cavity occurs in <5 percent of cases [1,2]. Such bleeding is usually mild and resolves with the performance of several exchanges. (See "Placement of the peritoneal dialysis catheter".)
Rarely, the peritoneal dialysis catheter may cause enough blunt trauma to result in a local laceration. There is one case report of a peritoneal catheter eroding into a mesenteric artery [6]. There have also been several reports of splenic lacerations resulting in massive hemoperitoneum [7,8]. Catheter-related hemoperitoneum is less common with the use of "coiled tip (intra-abdominal segment)" rather than "straight tip (intra-abdominal segment)" peritoneal dialysis catheters. More commonly, but still rarely, the peritoneal dialysis catheter may cause a mild contusion of the surface of the peritoneal cavity, resulting in some bleeding.
Intra-abdominal pathology — Hemoperitoneum may also develop as the result of intra-abdominal pathology similar to that which occurs in nondialysis patients. Potential causes include:
●Splenic rupture and infarct [9,10]
●Carcinomatosis of the liver or peritoneal metastases from metastatic cancer [11]
●Liver rupture and liver cyst rupture [10]
●Retroperitoneal hematoma [12]
●Iliopsoas hematoma [13]
●Intrauterine or ectopic pregnancy [14]
●Hemorrhagic luteal cyst or ovarian cyst rupture [15]
●Spontaneous rectal sheath hematoma [16]
●Post-cardiac catheterization from a retroperitoneal hematoma [17]
●Intra-abdominal organ injury or vascular laceration due to cardiopulmonary resuscitation [18,19]
●Aneurysm rupture or other vascular catastrophe [10]
Retroperitoneal pathology — Hemoperitoneum may be the result of pathology in the retroperitoneum, often involving the kidney. Cyst rupture in patients with autosomal dominant polycystic kidney disease, acquired cystic disease [20], and kidney tumors are potential causes of bloody dialysate [21,22]. These patients may also have hematuria. Although very rare, and in this case unrelated to the peritoneal dialysis catheter, hemoperitoneum was reported in a peritoneal dialysis patient as a result of a leaking and subsequently ruptured aortic aneurysm [23].
●(See "Autosomal dominant polycystic kidney disease (ADPKD): Kidney manifestations".)
●(See "Acquired cystic disease of the kidney in adults".)
●(See "Clinical manifestations, evaluation, and staging of renal cell carcinoma".)
Additional causes — Encapsulating peritoneal sclerosis (EPS) is an important and ominous cause of hemoperitoneum. It generally occurs in patients who have been on peritoneal dialysis for longer than one year; the risk for EPS increases with time on peritoneal dialysis. Bleeding in EPS is usually due to peritoneal inflammation and may be an early indicator of this condition [24]. (See "Encapsulating peritoneal sclerosis in patients on peritoneal dialysis", section on 'Clinical features'.)
Peritoneal calcification has also been associated with bloody peritoneal dialysate [25] (see "Inadequate solute clearance in peritoneal dialysis").
Other conditions associated with bloody peritoneal dialysate include thrombocytopenia or coagulopathy [1], scurvy [26], post-colonoscopy state [10,27], peritonitis [28], or if peritoneal dialysis is resumed after a prolonged break.
EVALUATION AND DIAGNOSIS — In peritoneal dialysis patients presenting with bloody peritoneal dialysate (hemoperitoneum), the goal of evaluation is to identify the underlying cause of bleeding in order to direct therapy. As an initial step, the clinician must distinguish patients who require urgent and rapid assessment for an acute intra-abdominal process in an emergency department from those who can be evaluated less urgently in the outpatient setting. However, in many cases, a cause for the bleeding cannot be established in spite of extensive evaluation.
Assessment for alarm findings — In peritoneal dialysis patients who present with bloody peritoneal dialysate (hemoperitoneum), we begin with a careful history and physical examination to determine if the patient has any clinical features ("alarm findings") that suggest more significant intra-abdominal pathology (algorithm 1). Although such causes of hemoperitoneum are generally infrequent, they may be life-threatening and, therefore, require prompt recognition and management. (See 'Patients with alarm findings' below.)
Alarm findings include the following:
●Bleeding that is heavy (ie, causes peritoneal dialysate to no longer be translucent), persistent (ie, occurs with two or more exchanges), or recurrent
●Severe, unexplained abdominal pain
●Fever
●Hypotension
●Abdominal tenderness, distension, guarding, or rebound tenderness
●History of abdominal trauma of any kind within the past week
●History of abdominal procedure, such as colonoscopy [10,29], within the past month
Patients with alarm findings — Patients with hemoperitoneum and alarm findings (see 'Assessment for alarm findings' above) require urgent evaluation to exclude an underlying intra-abdominal process, such as cyst rupture or a vascular catastrophe (see 'Intra-abdominal pathology' above). Such patients should be immediately referred to the emergency department for further assessment and management, which should include the following (algorithm 1):
●Computed tomography (CT) scan of the abdomen and pelvis. If the patient's vital signs are stable, the CT scan should be obtained after the patient has been instructed to wear a drain bag and to change positions periodically for at least one hour to ensure that all peritoneal dialysate fluid has been drained (ie, dry abdomen). However, if the patient is hemodynamically unstable, the CT scan should be performed immediately without delay. Among patients with residual kidney function, the clinician should weigh the potential risks and benefits of intravenous (IV) contrast administration. (See "Patient evaluation prior to oral or iodinated intravenous contrast for computed tomography", section on 'Patients receiving dialysis'.)
●Peritoneal fluid spun hematocrit (>2 percent suggests significant intraperitoneal pathology)
●Peritoneal fluid cell count and differential
●Peritoneal fluid amylase (>50 units/L is suggestive of an intra-abdominal process such as perforated ulcer, gall bladder or biliary tract disease, or ischemic bowel).
●Peripheral blood complete blood count (CBC)
Based upon this evaluation, our subsequent approach is as follows:
●In patients with imaging findings consistent with an acute intra-abdominal process that could potentially require surgical intervention, patients with a peritoneal fluid amylase >50 units/L, or patients with a decrease in hemoglobin of >2 g/dL, we obtain a surgical consultation. Although not all of these patients will require an intervention, their presenting clinical findings are concerning enough to warrant a surgical evaluation.
●In patients with peritoneal fluid findings consistent with peritonitis, we admit the patient for close monitoring and treat as appropriate with antibiotics. We reassess the patient upon completion of antibiotic therapy.
•(See "Microbiology and therapy of peritonitis in peritoneal dialysis", section on 'Antimicrobial therapy'.)
●In patients who do not have an identifiable potential cause for hemoperitoneum based upon imaging and laboratory findings, a surgical consultation for diagnostic laparoscopy is a reasonable option. If no surgical intervention is needed at the time of the initial evaluation, we advise inpatient admission and observation for at least 24 hours.
Patients whose primary alarm findings are severe abdominal pain, fever, or hypotension may require additional evaluation for these presenting symptoms, as discussed elsewhere:
●(See "Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department".)
●(See "Evaluation and management of suspected sepsis and septic shock in adults".)
Patients without alarm findings — In patients with hemoperitoneum who do not have alarm findings (see 'Assessment for alarm findings' above), the cause of hemoperitoneum is usually benign. Patients without alarm findings can generally be evaluated in the outpatient setting.
Our diagnostic approach is as follows (algorithm 1):
●If the patient is a premenopausal woman who is experiencing menstrual bleeding or is in the middle of her menstrual cycle (ie, during ovulation), we attribute the cause of bleeding to retrograde menstruation or ovulation, respectively (see 'Menstrual bleeding' above). We provide reassurance that the hemoperitoneum is most likely benign, treat with supportive measures (see 'Treatment' below), and reassess the patient upon completion of menses or, if the patient is midcycle, ovulation. If bleeding resolves, we resume routine care and monitoring with no additional testing. If bleeding remains persistent, the patient should be evaluated for other possible causes of hemoperitoneum, as discussed below.
For the woman who has bleeding associated with ovulation or menstruation, it is important to note that ovulation frequently stops as the patient begins dialysis; thus, continued menstrual bleeding after several months on dialysis may be the result of an ovarian cyst or tumor. Imaging of the ovaries and gynecologic consultation are appropriate in this setting.
●If the patient is not experiencing menstrual bleeding and is not midcycle, we perform the following evaluation:
•We examine the peritoneal dialysis catheter and exit-site for bleeding or other drainage. In patients with a history of recent peritoneal catheter insertion or manipulation, we generally attribute the hemoperitoneum to mild, blunt, catheter-related trauma and administer supportive measures. (See 'Treatment' below.)
•We obtain a peritoneal fluid cell count and differential and culture to rule out a diagnosis of peritonitis. If the peritoneal fluid findings are consistent with peritonitis, we treat as appropriate with antimicrobial agents, administer supportive measures for hemoperitoneum (see 'Treatment' below), and reassess the patient after completion of therapy. In general, hemoperitoneum is not a common presenting symptom of peritonitis in patients on peritoneal dialysis but has been anecdotally reported.
-(See "Microbiology and therapy of peritonitis in peritoneal dialysis".)
•In patients who do not have any identifiable causes of hemoperitoneum based upon history, physical examination, and laboratory testing, we treat with supportive measures (see 'Treatment' below) and monitor the patient for recurrent bleeding.
If bleeding resolves with supportive measures, we resume routine care and monitoring. If the patient has recurrent bleeding, we obtain a CT scan of the abdomen and pelvis to evaluate for an underlying intra-abdominal process. CT of the abdomen and pelvis should be performed after the patient has been instructed to wear a drain bag and to change positions periodically for at least one hour to ensure that all peritoneal dialysate fluid has been drained (ie, dry abdomen). Among patients with residual kidney function, the clinician should weigh the potential risks and benefits of IV contrast administration. Further evaluation and management of the patient is guided by the imaging findings on CT. If the CT does not identify any cause for hemoperitoneum, we obtain a surgical consultation for possible diagnostic laparoscopy or laparotomy. (See "Patient evaluation prior to oral or iodinated intravenous contrast for computed tomography".)
TREATMENT — In peritoneal dialysis patients with bloody peritoneal dialysate (hemoperitoneum), treatment depends upon the underlying cause of hemoperitoneum. In most cases, bleeding is mild to moderate and resolves spontaneously, and supportive measures are usually sufficient to control the bleeding. Patients with heavy bleeding from an intra-abdominal process may require surgical intervention to stop the hemorrhage.
Regardless of the cause of hemoperitoneum, we suggest the following approach to management:
●In patients whose dialysate appears pink or blood tinged, we provide reassurance to the patient and advise the patient to resume routine dialysis.
●In patients whose dialysate appears frankly bloody, we perform the following supportive measures:
•We instill heparin (500 units/L) in the dialysate to prevent clotting in the peritoneal catheter. Heparin is not systemically absorbed by the peritoneum and does not increase the risk of bleeding.
•We advise the patient to perform two or three rapid exchanges with room-temperature dialysate to cause peritoneal vasoconstriction and decrease bleeding [29].
•In patients taking aspirin, antiplatelet agents, or anticoagulants, discontinuation of the agent(s) should be balanced against the therapeutic indications in the individual patient.
•In women who are menstruating, we offer the option of oral contraceptives, which may prevent ovulation and control bleeding [2]. (See "Pregnancy in patients on dialysis", section on 'Contraception'.)
PROGNOSIS — In most patients, bloody peritoneal dialysate is related to menstrual bleeding. If bleeding is mild and results in blood-tinged dialysate, it usually resolves on its own and is associated with a good prognosis. In patients with more severe bleeding, the prognosis depends upon the underlying cause of the bloody dialysate. Although data are limited, one study of patients on continuous ambulatory peritoneal dialysis (CAPD) found that recurrent hemoperitoneum was not associated with any long-term effects on patient survival, predisposition to peritonitis, or ultrafiltration failure [3].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis".)
SUMMARY AND RECOMMENDATIONS
●Epidemiology – The incidence of bloody peritoneal dialysate (hemoperitoneum) in the peritoneal dialysis patient varies from 6 percent overall to as high as 57 percent in premenopausal women. (See 'Etiology and epidemiology' above.)
●Etiology – Ovulation, retrograde menstruation, and endometriosis are common, benign causes of hemoperitoneum among menstruating women. Such bleeding generally resolves spontaneously. Other causes of hemoperitoneum include catheter-related problems (eg, lacerations or contusions), intra-abdominal pathology (eg, splenic rupture and infarct, carcinomatosis of the liver, liver cyst rupture), retroperitoneal pathology (eg, cyst rupture or kidney tumors), and encapsulating peritoneal sclerosis (EPS) (table 1). (See 'Etiology and epidemiology' above.)
●Assessment for alarm findings – In peritoneal dialysis patients who present with bloody peritoneal dialysate, we begin with a careful history and physical examination to determine if the patient has any clinical features ("alarm findings") that suggest more significant intra-abdominal pathology (algorithm 1). Although such causes of hemoperitoneum are generally infrequent, they may be life threatening and therefore require prompt recognition and management. Alarm findings include the following (See 'Assessment for alarm findings' above.):
•Bleeding that is heavy (ie, causes peritoneal dialysate to no longer be translucent), persistent (ie, occurs with two or more exchanges), or recurrent
•Severe, unexplained abdominal pain
•Fever
•Hypotension
•Abdominal tenderness, distension, guarding, or rebound tenderness
•History of recent abdominal trauma of any kind
•History of recent abdominal procedure, such as colonoscopy
●Patients with alarm findings – Patients with hemoperitoneum and alarm findings require urgent evaluation to exclude an underlying intra-abdominal process, such as cyst rupture or a vascular catastrophe. Such patients should be immediately referred to the emergency department for further assessment and management. (See 'Patients with alarm findings' above.)
●Patients without alarm findings – In patients with hemoperitoneum who do not have alarm findings, the cause of hemoperitoneum is usually benign. Patients without alarm findings can generally be evaluated in the outpatient setting. (See 'Patients without alarm findings' above.)
●Treatment – Treatment depends upon the underlying cause of hemoperitoneum. In most cases, bleeding is mild to moderate and resolves spontaneously, and supportive measures are usually sufficient to control the bleeding. Patients with heavy bleeding from an intra-abdominal process may require surgical intervention to stop the hemorrhage. (See 'Treatment' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges John Burkart, MD, who contributed to earlier versions of this topic review.
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