Miss T was a 49-year-old lady, and she was first diagnosed with end stage renal failure of unknown cause in 7/2012. With “PD first policy” in Hong Kong, continuous ambulatory peritoneal dialysis (CAPD) was started since 7/2012. With recurrent MSSA peritonitis, she then later developed membrane failure and changed to chronic haemodialysis since 9/2018. Tenckhoff (TK) catheter was removed in 11/2018.

In 1/2019, she presented with subacute onset of abdominal distension, nausea with poor appetite for 2 weeks. Nasogastric tube was inserted with output of 1.5L bile-stained fluid on first day. Urgent CT abdomen and pelvis showed huge unilocular fluid collection of size 24.8x10.2x31cm over antero-lateral aspect of peritoneal cavity, with mass effect over liver, stomach and bowel.

Diagnostic abdominal paracentesis was performed, and it yielded bloody ascitic fluid. Clinically it was a case of encapsulating peritoneal sclerosis, likely due to prolong duration of PD. Double cuff Tenckhoff catheter was inserted for drainage of bloody ascites. 6L bloody ascitic fluid was drained on first day. Tamoxifen 20mg daily was started as medical treatment, with less side effects compared to immunosuppressive agents. Intradialytic parenteral nutrition was started in view of malnutrition with serum albumin only 25g/L. On the third day of ascitic fluid drainage, patient resumed oral intake and tolerated well.

Nutrition support with IDPN is crucial in EPS cases, as most patients had poor appetite and oral intake. Home TPN can also be considered in patients who are mentally fit with good hand dexterity. Tamoxifen is the medical treatment with least side effects and most worth trying. Regular drainage of ascitic fluid through TK catheter is needed. Intestinal obstruction due to cocooning of bowel is known complication. Adhesiolysis in EPS cases is not common practice in Hong Kong with high complication risk. Multidisciplinary care is necessary in EPS cases.