Encapsulating peritoneal sclerosis (EPS) is a rare disease in patients who have undergone peritoneal dialysis (PD). We report a case of EPS following renal transplantation that highlights important clinical issues. Initially, a presumptive diagnosis of EPS was made following surgical and pathological findings at the time of cholecystectomy. CT imaging at this time did not confirm the diagnosis. The patient continued PD and commenced tamoxifen. Prior to and immediately following transplantation, further CT imaging demonstrated no evidence of EPS. Acute bowel obstruction occurred 5 months post-transplantation and a diagnosis of EPS was made both clinically and on CT imaging, despite immunosuppression and tamoxifen. The role of these therapies in managing EPS post-transplant is discussed, in addition to the need for a high index of clinical suspicion to make the diagnosis.

Background Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis (PD). Gastrointestinal (GI) symptoms affect appetite and dietary intake. Adequate nutrition is especially important if surgical interventions are required. Aim To investigate the nutritional management of 23 EPS patients that underwent surgical intervention between 1999 and 2005 at Manchester Royal Infirmary, United Kingdom. Methods EPS was recognized by GI symptoms and diagnostically confirmed by laparotomy, computed tomographic scanning, or biopsy. Results Mean time on PD was 74 months (interquartile range 42 – 89 months). During the 12 months pre-diagnosis, 65% of the group showed significant weight loss ( p = 0.0001), with 8 patients losing >10% of body weight; 74% of patients experienced significant albumin decrease ( p = 0.001); and 56% of patients experienced GI symptoms during the 6 months pre-diagnosis. Nasogastric (NG) feeding was recommended for 8 patients but continued in only 1. 15 patients (mean albumin 27 g/L) commenced parenteral nutrition (PN); 9 patients recovered, with albumin increasing over the 6-month follow-up. Mean hospital time was 62 days for the group receiving neither NG nor PN, compared with 124.3 for the PN/NG group ( p = 0.04). In patients that died of EPS, albumin continued to fall at 3 months post-diagnosis. Conclusion There is currently little guidance for nutritional management of EPS. From this study we recommend ( 1 ) a high level of clinical suspicion for EPS, especially if PD patients have weight loss; ( 2 ) PN may be better than NG feeding but further studies into dual enteral nutrition and PN are needed; ( 3 ) aggressive nutritional supplementation pre- and postoperatively; and ( 4 ) dietitians need to recognize the high risk of refeeding syndrome.

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Background:  To overcome high rates of non‐attendance, inappropriate referrals and long waiting times, an audit was undertaken of a dietetic outpatients clinic for gastroenterology patients in 2003 and then repeated in 2007. The aim of the first audit was to identify referral source, types of patient, attendance rates and if dietary advice had a positive outcome. This study aimed evaluated changes since 2003. Method:  The clinic diary was used to identify patients booked to attend in 2003 and 2007. Information was retrieved from the patient's record on source of referral, types of referral, waiting times, attendance rates and dietary goals achieved. The results were compared to determine if changes had improved service delivery. The data were analyzed in Microsoft Excel (2003) and the attendance rates were compared using chi‐squared statistics. Results:  There were 92 new patients in 2003 and 69 patients in 2007; data were obtained for n = 77 in 2003 and n = 55 in 2007. There was an increase in referrals from gastroenterologists (n = 31, 55%) in 2007 compared with 2003 (n = 23, 34%). Waiting times improved between the two audits with 44% being seen within 3 months in 2003 compared to 51% in 2007. Attendance rates improved by 30% when the two audits were compared and in both years 2003 and 2007 (p = 0.009), a positive outcome was recorded for the majority of patients who had completed their treatment episodes 78% and 63% respectively.  Types of patients referred to Gastroenterology clinic Type of referral 2003 2007 Irritable bowel syndrome4 (5)12 (21)Inflammatory bowel disease15 (19)7 (12)Bariatric surgery011 (20)Pancreatitis13 (16)9 (16)Gastric surgery7 (9)1 (2)General GI28 (36)13 (23)Non‐gastro10 (12)2 (3) Discussion:  The literature on the audit cycle in dietetic outpatients is limited. The baseline results in 2003 lead to the production of guidelines and the subsequent audit in 2007 demonstrated an improvement in clinical effectiveness. There was incomplete retrieval of records for the 2007 audit that led to missing data. Conclusion:  Guidelines for the clinic improved appropriateness of referrals and the focus of the clinic. The procedural changes have decreased non‐attendance and improved waiting times for patients. The changes implemented have improved service delivery for the patients and maximised the resources available for a specialist clinic by effectively utilising the skills of a Specialist gastroenterology dietitian.