Unique aspects of gastrointestinal disease in dialysis patients
- Thomas A Golper, MD
Thomas A Golper, MD
- Section Editor — Dialysis
- Professor of Medicine
- Vanderbilt University Medical Center
- Lawrence S Friedman, MD
Lawrence S Friedman, MD
- Section Editor — General Gastroenterology
- Professor of Medicine
- Harvard Medical School
- Tufts University School of Medicine
- Section Editor
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- Deputy Editors
- Alice M Sheridan, MD
Alice M Sheridan, MD
- Deputy Editor — Nephrology
- Assistant Professor of Medicine
- Harvard Medical School
- Shilpa Grover, MD, MPH, AGAF
Shilpa Grover, MD, MPH, AGAF
- Deputy Editor — Gastroenterology/Hepatology
- Assistant Professor of Medicine, Part-time
- Harvard Medical School
Gastrointestinal (GI) symptoms are reported in up to 80 percent of dialysis patients [1-3]. This topic reviews GI disorders that occur with a higher prevalence or have clinical features that are unique dialysis patients. We also discuss management considerations that are specific to GI diseases in patients on dialysis.
ESOPHAGUS AND STOMACH
Angiodysplasia — Angiodysplasias are the most common vascular anomalies encountered in the GI tract. While their presentation and management are in most respects similar to the non-end-stage renal disease (ESRD) population, patients with ESRD and chronic GI bleeding may benefit from estrogen therapy.
●Prevalence – Angiodysplasias account for approximately 20 and 30 percent of episodes of upper and lower GI bleeding, respectively, and for approximately one-half of recurrent episodes of upper GI bleeding in patients with ESRD . It is unclear if the prevalence of angiodysplasia is higher among ESRD patients as compared with the general population or if angiodysplastic lesions are detected more frequently in patients on hemodialysis due to exposure to anticoagulants and uremia-induced platelet dysfunction [4-7]. (See "Angiodysplasia of the gastrointestinal tract" and "Angiodysplasia of the gastrointestinal tract", section on 'End-stage renal disease'.)
●Clinical presentation and diagnosis – Patients usually present with chronic GI bleeding, although severe acute bleeding may also occur. Angiodysplastic lesions may also be found incidentally during endoscopic evaluation performed for other indications. The clinical presentation and diagnosis of angiodysplasia of the GI tract are discussed elsewhere. (See "Angiodysplasia of the gastrointestinal tract", section on 'Clinical manifestations' and "Angiodysplasia of the gastrointestinal tract", section on 'Diagnosis'.)
●Management – Dialysis patients with chronic GI bleeding can benefit from administration of conjugated estrogens. Small case series have suggested that estrogens may prevent recurrent bleeding from angiodysplasia and reduce transfusion requirements [8,9]. The management of GI bleeding in dialysis patients is otherwise similar to nondialysis patients and is discussed in detail separately. (See "Approach to acute upper gastrointestinal bleeding in adults" and "Platelet dysfunction in uremia", section on 'Estrogen'.)
- Hammer J, Oesterreicher C, Hammer K, et al. Chronic gastrointestinal symptoms in hemodialysis patients. Wien Klin Wochenschr 1998; 110:287.
- Chong VH. Impact of duration of hemodialysis on gastrointestinal symptoms in patients with end stage renal failure. J Gastrointestin Liver Dis 2010; 19:462.
- Van Vlem B, Schoonjans R, Vanholder R, et al. Delayed gastric emptying in dyspeptic chronic hemodialysis patients. Am J Kidney Dis 2000; 36:962.
- Zuckerman GR, Cornette GL, Clouse RE, Harter HR. Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med 1985; 102:588.
- Navab F, Masters P, Subramani R, et al. Angiodysplasia in patients with renal insufficiency. Am J Gastroenterol 1989; 84:1297.
- 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.
- Alvarez L, Puleo J, Balint JA. Investigation of gastrointestinal bleeding in patients with end stage renal disease. Am J Gastroenterol 1993; 88:30.
- 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.
- 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.
- 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.
- Chandra A, Tso R, Cynamon J, Miller G. Massive upper GI bleeding in a long-term hemodialysis patient. Chest 2005; 128:1868.
- Loudin M, Anderson S, Schlansky B. Bleeding 'downhill' esophageal varices associated with benign superior vena cava obstruction: case report and literature review. BMC Gastroenterol 2016; 16:134.
- Keshavarzian A, Iber FL. Gastrointestinal involvement in insulin-requiring diabetes mellitus. J Clin Gastroenterol 1987; 9:685.
- McNamee PT, Moore GW, McGeown MG, et al. Gastric emptying in chronic renal failure. Br Med J (Clin Res Ed) 1985; 291:310.
- Ross EA, Koo LC. Improved nutrition after the detection and treatment of occult gastroparesis in nondiabetic dialysis patients. Am J Kidney Dis 1998; 31:62.
- Chen HJ, Wang JJ, Tsay WI, et al. Epidemiology and outcome of acute pancreatitis in end-stage renal disease dialysis patients: a 10-year national cohort study. Nephrol Dial Transplant 2017.
- Padilla B, Pollak VE, Pesce A, et al. Pancreatitis in patients with end-stage renal disease. Medicine (Baltimore) 1994; 73:8.
- 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.
- 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.
- 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.
- 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.
- Joglar FM, Saadé M. Outcome of pancreatitis in CAPD and HD patients. Perit Dial Int 1995; 15:264.
- Moreiras Plaza M, Rodríguez Goyanes G, Cuiña L, Alonso R. On the toxicity of valproic-acid. Clin Nephrol 1999; 51:187.
- Kishino T, Nakamura K, Mori H, et al. Acute pancreatitis during haemodialysis. Nephrol Dial Transplant 2005; 20:2012.
- Kheda MF, Szerlip HM. Two cases of iodixanol-induced pancreatitis. NDT Plus 2008; 1:296.
- Rubinstein S, Franjul R, Surana S, Fogel J. Icodextrin-induced acute pancreatitis in a peritoneal dialysis patient: a case report and literature review . Clin Nephrol 2016; 86 (2016):283.
- Hayat A, Thaneeru P, Priest P, Wilson R. Recurrent pancreatitis in an icodextrin-based peritoneal dialysis patient. Yet another case report. N Z Med J 2013; 126:67.
- Pannekeet MM, Krediet RT, Boeschoten EW, Arisz L. Acute pancreatitis during CAPD in The Netherlands. Nephrol Dial Transplant 1993; 8:1376.
- Quraishi ER, Goel S, Gupta M, et al. Acute pancreatitis in patients on chronic peritoneal dialysis: an increased risk? Am J Gastroenterol 2005; 100:2288.
- Griesche-Philippi J, Otto J, Schwörer H, et al. Exocrine pancreatic function in patients with end-stage renal disease. Clin Nephrol 2010; 74:457.
- Li SY, Chen YT, Chen TJ, et al. Mesenteric ischemia in patients with end-stage renal disease: a nationwide longitudinal study. Am J Nephrol 2012; 35:491.
- Bassilios N, Menoyo V, Berger A, et al. Mesenteric ischaemia in haemodialysis patients: a case/control study. Nephrol Dial Transplant 2003; 18:911.
- Dahlberg PJ, Kisken WA, Newcomer KL, Yutuc WR. Mesenteric ischemia in chronic dialysis patients. Am J Nephrol 1985; 5:327.
- 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.
- 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.
- Wellington JL, Rody K. Acute abdominal emergencies in patients on long-term ambulatory peritoneal dialysis. Can J Surg 1993; 36:522.
- Archodovassilis F, Lagoudiannakis EE, Tsekouras DK, et al. Nonocclusive mesenteric ischemia: a lethal complication in peritoneal dialysis patients. Perit Dial Int 2007; 27:136.
- 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.
- 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.
- Galbraith P, Bagg MN, Schabel SI, Rajagopalan PR. Diverticular complications of renal failure. Gastrointest Radiol 1990; 15:259.
- Chang SS, Huang N, Hu HY. Patients with end-stage renal disease were at an increased risk of hospitalization for acute diverticulitis. Medicine (Baltimore) 2016; 95:e4881.
- Moran-Atkin E, Stem M, Lidor AO. Surgery for diverticulitis is associated with high risk of in-hospital mortality and morbidity in older patients with end-stage renal disease. Surgery 2014; 156:361.
- Jimenez RE, Price DA, Pinkus GS, et al. Development of gastrointestinal beta2-microglobulin amyloidosis correlates with time on dialysis. Am J Surg Pathol 1998; 22:729.
- Brown KM. Isolated ascending colon ulceration in a patient with chronic renal insufficiency. J Natl Med Assoc 1992; 84:185.
- Bischel MD, Reese T, Engel J. Spontaneous perforation of the colon in a hemodialysis patient. Am J Gastroenterol 1980; 74:182.
- 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.
- Cintin C, Joffe P. Nephrogenic ascites. Case report and review of the literature. Scand J Urol Nephrol 1994; 28:311.
- Rodriguez HJ, Walls J, Slatopolsky E, Klahr S. Recurrent ascites following peritoneal dialysis. A new syndrome? Arch Intern Med 1974; 134:283.
- Hammond TC, Takiyyuddin MA. Nephrogenic ascites: a poorly understood syndrome. J Am Soc Nephrol 1994; 5:1173.
- Rubin J, Rust P, Brown P, et al. A comparison of peritoneal transport in patients with psoriasis and uremia. Nephron 1981; 29:185.
- Nasr EM, Joubran NI. Is nephrogenic ascites related to secondary hyperparathyroidism? Am J Kidney Dis 2001; 37:E16.
- Gunal AI, Karaca I, Celiker H, et al. Strict volume control in the treatment of nephrogenic ascites. Nephrol Dial Transplant 2002; 17:1248.
- 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.
- Morgan AG, Sivapragasam S, Fletcher P, Terry SI. Hemodynamic improvement after peritoneovenous shunting in nephrogenic ascites. South Med J 1982; 75:373.
- Glück Z, Nolph KD. Ascites associated with end-stage renal disease. Am J Kidney Dis 1987; 10:9.
- Feingold LN, Gutman RA, Walsh FX, Gunnells JC. Control of cachexia and ascites in hemodialysis patients by binephrectomy. Arch Intern Med 1974; 134:989.
- Popli S, Chen WT, Nakamoto S, et al. Hemodialysis ascites in anephric patients. Clin Nephrol 1981; 15:203.
- 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.
- ESOPHAGUS AND STOMACH
- Esophageal varices
- Acute pancreatitis
- Exocrine pancreatic insufficiency/chronic pancreatitis
- SMALL INTESTINE AND COLON
- Intestinal ischemia
- Constipation/fecal impaction
- Acute diverticulitis
- Other rare gastrointestinal diseases
- Bowel preparation for lower gastrointestinal endoscopy
- Hemodialysis-associated ascites
- SUMMARY AND RECOMMENDATIONS