Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Gastrointestinal disease in dialysis patients

Thomas A Golper, MD
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD


Symptoms of gastrointestinal distress are common among patients undergoing regular dialysis, with almost 80 percent of dialysis patients reporting such complaints [1]. Underlying these symptoms is an increased frequency of both upper gastrointestinal tract disorders, such as gastritis and gastroparesis, and lower gastrointestinal diseases, such as diverticular disease and colonic perforation [2-6]. Although currently rare, idiopathic dialysis ascites, also known as nephrogenic ascites, is a peculiar condition that occurs exclusively in hemodialysis patients.

A review of gastrointestinal disorders in patients on dialysis with an emphasis upon those diseases that either occur with an increased frequency or are associated with severe complications is presented here. General and detailed discussions of these disorders in patients without renal failure can be found separately.


Dyspepsia is a nonspecific symptom that occurs frequently in patients with end-stage renal disease (ESRD). In a study involving 102 dialysis patients, dyspepsia suggestive of a reflux, ulcer, or motility disorder was reported in 12, 19, and 17 percent of patients, respectively [1]. In this study, however, the prevalence of dyspepsia in dialysis patients was no different from the general population. (See "Approach to the adult with dyspepsia".)

Clinical considerations concerning dyspepsia caused by gastroesophageal reflux or delayed gastric emptying in patients undergoing chronic peritoneal dialysis are presented separately. (See "Noninfectious complications of continuous peritoneal dialysis".)


Although chronic renal failure was previously associated with an increased incidence of peptic ulcer disease (which is a frequent cause of dyspepsia) [7], endoscopic studies have found that the disorder is no more frequent in dialysis than in nondialysis patients [8,9]. In an endoscopic study of 114 dialysis patients, peptic ulcer was only found in two, although 51 percent had evidence of mild gastritis [9]. (See "Unusual causes of peptic ulcer disease".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2017. | This topic last updated: Mar 24, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Hammer J, Oesterreicher C, Hammer K, et al. Chronic gastrointestinal symptoms in hemodialysis patients. Wien Klin Wochenschr 1998; 110:287.
  2. Boyle JM, Johnston B. Acute upper gastrointestinal hemorrhage in patients with chronic renal disease. Am J Med 1983; 75:409.
  3. Dinoso VP Jr, Murthy SN, Saris AL, et al. Gastric and pancreatic function in patients with end-stage renal disease. J Clin Gastroenterol 1982; 4:321.
  4. Margolis DM, Saylor JL, Geisse G, et al. Upper gastrointestinal disease in chronic renal failure. A prospective evaluation. Arch Intern Med 1978; 138:1214.
  5. Scheff RT, Zuckerman G, Harter H, et al. Diverticular disease in patients with chronic renal failure due to polycystic kidney disease. Ann Intern Med 1980; 92:202.
  6. Navab F, Masters P, Subramani R, et al. Angiodysplasia in patients with renal insufficiency. Am J Gastroenterol 1989; 84:1297.
  7. Milito G, Taccone-Gallucci M, Brancaleone C, et al. Assessment of the upper gastrointestinal tract in hemodialysis patients awaiting renal transplantation. Am J Gastroenterol 1983; 78:328.
  8. Andriulli A, Malfi B, Recchia S, et al. Patients with chronic renal failure are not at a risk of developing chronic peptic ulcers. Clin Nephrol 1985; 23:245.
  9. Kang JY, Wu AY, Sutherland IH, Vathsala A. Prevalence of peptic ulcer in patients undergoing maintenance hemodialysis. Dig Dis Sci 1988; 33:774.
  10. Sheu BS, Huang JJ. Helicobacter pylori infection in hemodialysis patients. Int J Artif Organs 2001; 24:669.
  11. Davenport A, Shallcross TM, Crabtree JE, et al. Prevalence of Helicobacter pylori in patients with end-stage renal failure and renal transplant recipients. Nephron 1991; 59:597.
  12. Rowe PA, el Nujumi AM, Williams C, et al. The diagnosis of Helicobacter pylori infection in uremic patients. Am J Kidney Dis 1992; 20:574.
  13. Nakajima F, Sakaguchi M, Amemoto K, et al. Helicobacter pylori in patients receiving long-term dialysis. Am J Nephrol 2002; 22:468.
  14. Huang JJ, Huang CJ, Ruaan MK, et al. Diagnostic efficacy of (13)C-urea breath test for Helicobacter pylori infection in hemodialysis patients. Am J Kidney Dis 2000; 36:124.
  15. Wang YL, Sheu BS, Huang JJ, Yang HB. Noninvasive stool antigen assay can effectively screen Helicobacter pylori Infection and assess success of eradication therapy in hemodialysis patients. Am J Kidney Dis 2001; 38:98.
  16. Tamura H, Tokushima H, Murakawa M, et al. Eradication of Helicobacter pylori in patients with end-stage renal disease under dialysis treatment. Am J Kidney Dis 1997; 29:86.
  17. Fabrizi F, Martin P. Helicobacter pylori infection in patients with end-stage renal disease. Int J Artif Organs 2000; 23:157.
  18. Howden CW, Hunt RH. Guidelines for the management of Helicobacter pylori infection. Ad Hoc Committee on Practice Parameters of the American College of Gastroenterology. Am J Gastroenterol 1998; 93:2330.
  19. Mak SK, Loo CK, Wong AM, et al. Efficacy of a 1-week course of proton-pump inhibitor-based triple therapy for eradicating Helicobacter pylori in patients with and without chronic renal failure. Am J Kidney Dis 2002; 40:576.
  20. Muñoz de Bustillo E, Sánchez Tomero JA, Sanz JC, et al. Eradication and follow-up of Helicobacter pylori infection in hemodialysis patients. Nephron 1998; 79:55.
  21. Itatsu T, Miwa H, Nagahara A, et al. Eradication of Helicobacter pylori in hemodialysis patients. Ren Fail 2007; 29:97.
  22. Di Minno G, Martinez J, McKean ML, et al. Platelet dysfunction in uremia. Multifaceted defect partially corrected by dialysis. Am J Med 1985; 79:552.
  23. Zuckerman GR, Cornette GL, Clouse RE, Harter HR. Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med 1985; 102:588.
  24. Yang JY, Lee TC, Montez-Rath ME, et al. Trends in acute nonvariceal upper gastrointestinal bleeding in dialysis patients. J Am Soc Nephrol 2012; 23:495.
  25. Jutabha R, Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Med Clin North Am 1996; 80:1035.
  26. Alvarez L, Puleo J, Balint JA. Investigation of gastrointestinal bleeding in patients with end stage renal disease. Am J Gastroenterol 1993; 88:30.
  27. Chalasani N, Cotsonis G, Wilcox CM. Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia. Am J Gastroenterol 1996; 91:2329.
  28. Gaspari F, Viganò G, Orisio S, et al. Aspirin prolongs bleeding time in uremia by a mechanism distinct from platelet cyclooxygenase inhibition. J Clin Invest 1987; 79:1788.
  29. Viganò G, Remuzzi G. Low-dose aspirin and bleeding in uremia. Am J Hematol 1993; 42:235.
  30. Blam ME, Kobrin S, Siegelman ES, Scotiniotis IA. "Downhill" esophageal varices as an iatrogenic complication of upper extremity hemodialysis access. Am J Gastroenterol 2002; 97:216.
  31. Chandra A, Tso R, Cynamon J, Miller G. Massive upper GI bleeding in a long-term hemodialysis patient. Chest 2005; 128:1868.
  32. Bronner MH, Pate MB, Cunningham JT, Marsh WH. Estrogen-progesterone therapy for bleeding gastrointestinal telangiectasias in chronic renal failure. An uncontrolled trial. Ann Intern Med 1986; 105:371.
  33. Granieri R, Mazzulla JP, Yarborough GW. Estrogen-progesterone therapy for recurrent gastrointestinal bleeding secondary to gastrointestinal angiodysplasia. Am J Gastroenterol 1988; 83:556.
  34. Lewis BS, Salomon P, Rivera-MacMurray S, et al. Does hormonal therapy have any benefit for bleeding angiodysplasia? J Clin Gastroenterol 1992; 15:99.
  35. Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993; 88:807.
  36. Richardson JD, Lordon RE. Gastrointestinal bleeding caused by angiodysplasia: a difficult problem in patients with chronic renal failure receiving hemodialysis therapy. Am Surg 1993; 59:636.
  37. Keshavarzian A, Iber FL. Gastrointestinal involvement in insulin-requiring diabetes mellitus. J Clin Gastroenterol 1987; 9:685.
  38. McNamee PT, Moore GW, McGeown MG, et al. Gastric emptying in chronic renal failure. Br Med J (Clin Res Ed) 1985; 291:310.
  39. Van Vlem B, Schoonjans R, Vanholder R, et al. Delayed gastric emptying in dyspeptic chronic hemodialysis patients. Am J Kidney Dis 2000; 36:962.
  40. Bateman DN, Gokal R, Dodd TR, Blain PG. The pharmacokinetics of single doses of metoclopramide in renal failure. Eur J Clin Pharmacol 1981; 19:437.
  41. Wysowski DK, Bacsanyi J. Cisapride and fatal arrhythmia. N Engl J Med 1996; 335:290.
  42. Li Vecchi M, Cesare S, Soresi M, et al. Prevalence of biliary lithiasis in a Sicilian population of hemodialysis patients. Clin Nephrol 2001; 55:127.
  43. Hojs R. Cholecystolithiasis in patients with end-stage renal disease treated with haemodialysis: a study of prevalence. Am J Nephrol 1995; 15:15.
  44. Mirza MM, Wall BM. Emphysematous cholecystitis in a CAPD patient. Perit Dial Int 1997; 17:305.
  45. Ishikawa I, Chikamoto E, Nakamura M, et al. High incidence of common bile duct dilatation in autosomal dominant polycystic kidney disease patients. Am J Kidney Dis 1996; 27:321.
  46. Yeh CN, Chen MF, Jan YY. Laparoscopic cholecystectomy for 58 end stage renal disease patients. Surg Endosc 2005; 19:915.
  47. Padilla B, Pollak VE, Pesce A, et al. Pancreatitis in patients with end-stage renal disease. Medicine (Baltimore) 1994; 73:8.
  48. Gupta A, Yuan ZY, Balaskas EV, et al. CAPD and pancreatitis: no connection. Perit Dial Int 1992; 12:309.
  49. Rutsky EA, Robards M, Van Dyke JA, Rostand SG. Acute pancreatitis in patients with end-stage renal disease without transplantation. Arch Intern Med 1986; 146:1741.
  50. Caruana RJ, Wolfman NT, Karstaedt N, Wilson DJ. Pancreatitis: an important cause of abdominal symptoms in patients on peritoneal dialysis. Am J Kidney Dis 1986; 7:135.
  51. Bruno MJ, van Westerloo DJ, van Dorp WT, et al. Acute pancreatitis in peritoneal dialysis and haemodialysis: risk, clinical course, outcome, and possible aetiology. Gut 2000; 46:385.
  52. Flynn CT, Chandran P, Shadur C. Recurrent pancreatitis in a patient on CAPD (letter). Perit Dial Bull 1986; 6:1060.
  53. Joglar FM, Saadé M. Outcome of pancreatitis in CAPD and HD patients. Perit Dial Int 1995; 15:264.
  54. Moreiras Plaza M, Rodríguez Goyanes G, Cuiña L, Alonso R. On the toxicity of valproic-acid. Clin Nephrol 1999; 51:187.
  55. Kishino T, Nakamura K, Mori H, et al. Acute pancreatitis during haemodialysis. Nephrol Dial Transplant 2005; 20:2012.
  56. Kheda MF, Szerlip HM. Two cases of iodixanol-induced pancreatitis. NDT Plus 2008; 5:296.
  57. Lankisch PG, Weber-Dany B, Maisonneuve P, Lowenfels AB. Frequency and severity of acute pancreatitis in chronic dialysis patients. Nephrol Dial Transplant 2008; 23:1401.
  58. Pannekeet MM, Krediet RT, Boeschoten EW, Arisz L. Acute pancreatitis during CAPD in The Netherlands. Nephrol Dial Transplant 1993; 8:1376.
  59. Donnelly S, Levy M, Prichard S. Acute pancreatitis in continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1988; 8:187.
  60. Burkart J, Haigler S, Caruana R, Hylander B. Usefulness of peritoneal fluid amylase levels in the differential diagnosis of peritonitis in peritoneal dialysis patients. J Am Soc Nephrol 1991; 1:1186.
  61. Silverstein W, Isikoff MB, Hill MC, Barkin J. Diagnostic imaging of acute pancreatitis: prospective study using CT and sonography. AJR Am J Roentgenol 1981; 137:497.
  62. Tokars JI, Alter MJ, Favero MS, et al. National surveillance of hemodialysis associated diseases in the United States, 1990. ASAIO J 1993; 39:71.
  63. Bini EJ, Kinkhabwala A, Goldfarb DS. Predictive value of a positive fecal occult blood test increases as the severity of CKD worsens. Am J Kidney Dis 2006; 48:580.
  64. Brown KM. Isolated ascending colon ulceration in a patient with chronic renal insufficiency. J Natl Med Assoc 1992; 84:185.
  65. Milito G, Taccone-Gallucci M, Brancaleone C, et al. The gastrointestinal tract in uremic patients on long-term hemodialysis. Kidney Int Suppl 1985; 17:S157.
  66. Bassilios N, Menoyo V, Berger A, et al. Mesenteric ischaemia in haemodialysis patients: a case/control study. Nephrol Dial Transplant 2003; 18:911.
  67. Dahlberg PJ, Kisken WA, Newcomer KL, Yutuc WR. Mesenteric ischemia in chronic dialysis patients. Am J Nephrol 1985; 5:327.
  68. Ori Y, Chagnac A, Schwartz A, et al. Non-occlusive mesenteric ischemia in chronically dialyzed patients: a disease with multiple risk factors. Nephron Clin Pract 2005; 101:c87.
  69. Flobert C, Cellier C, Berger A, et al. Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis. Am J Gastroenterol 2000; 95:195.
  70. Wellington JL, Rody K. Acute abdominal emergencies in patients on long-term ambulatory peritoneal dialysis. Can J Surg 1993; 36:522.
  71. Archodovassilis F, Lagoudiannakis EE, Tsekouras DK, et al. Nonocclusive mesenteric ischemia: a lethal complication in peritoneal dialysis patients. Perit Dial Int 2007; 27:136.
  72. Bischel MD, Reese T, Engel J. Spontaneous perforation of the colon in a hemodialysis patient. Am J Gastroenterol 1980; 74:182.
  73. Church JM, Fazio VW, Braun WE, et al. Perforation of the colon in renal homograft recipients. A report of 11 cases and a review of the literature. Ann Surg 1986; 203:69.
  74. Galbraith P, Bagg MN, Schabel SI, Rajagopalan PR. Diverticular complications of renal failure. Gastrointest Radiol 1990; 15:259.
  75. Abramson SJ, Berdon WE, Laffey K, et al. Colonic diverticulitis in young patients with chronic renal failure and transplantation. Pediatr Radiol 1991; 21:352.
  76. Starnes HF Jr, Lazarus JM, Vineyard G. Surgery for diverticulitis in renal failure. Dis Colon Rectum 1985; 28:827.
  77. ReMine SG, McIlrath DC. Bowel perforation in steroid-treated patients. Ann Surg 1980; 192:581.
  78. Ikegaya N, Kobayashi S, Hishida A, et al. Colonic dilatation due to dialysis-related amyloidosis. Am J Kidney Dis 1995; 25:807.
  79. Borczuk A, Mannion C, Dickson D, Alt E. Intestinal pseudo-obstruction and ischemia secondary to both beta 2-microglobulin and serum A amyloid deposition. Mod Pathol 1995; 8:577.
  80. Araki H, Muramoto H, Oda K, et al. Severe gastrointestinal complications of dialysis-related amyloidosis in two patients on long-term hemodialysis. Am J Nephrol 1996; 16:149.
  81. Cintin C, Joffe P. Nephrogenic ascites. Case report and review of the literature. Scand J Urol Nephrol 1994; 28:311.
  82. Rodriguez HJ, Walls J, Slatopolsky E, Klahr S. Recurrent ascites following peritoneal dialysis. A new syndrome? Arch Intern Med 1974; 134:283.
  83. Hammond TC, Takiyyuddin MA. Nephrogenic ascites: a poorly understood syndrome. J Am Soc Nephrol 1994; 5:1173.
  84. Rubin J, Rust P, Brown P, et al. A comparison of peritoneal transport in patients with psoriasis and uremia. Nephron 1981; 29:185.
  85. Nasr EM, Joubran NI. Is nephrogenic ascites related to secondary hyperparathyroidism? Am J Kidney Dis 2001; 37:E16.
  86. Gunal AI, Karaca I, Celiker H, et al. Strict volume control in the treatment of nephrogenic ascites. Nephrol Dial Transplant 2002; 17:1248.
  87. Holm A, Rutsky EA, Aldrete JS. Short- and long-term effectiveness, morbidity, and mortality of peritoneovenous shunt inserted to treat massive refractory ascites of nephrogenic origin analysis of 14 cases. Am Surg 1989; 55:645.
  88. Popli S, Chen WT, Nakamoto S, et al. Hemodialysis ascites in anephric patients. Clin Nephrol 1981; 15:203.
  89. Melero M, Rodriguez M, Araque A, et al. Idiopathic dialysis ascites in the nineties: resolution after renal transplantation. Am J Kidney Dis 1995; 26:668.
  90. Glück Z, Nolph KD. Ascites associated with end-stage renal disease. Am J Kidney Dis 1987; 10:9.
  91. Feingold LN, Gutman RA, Walsh FX, Gunnells JC. Control of cachexia and ascites in hemodialysis patients by binephrectomy. Arch Intern Med 1974; 134:989.