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Gangrenous appendicitis presenting as acute abdominal pain in a patient on automated peritoneal dialysis: a case report
© Ekart et al.; licensee BioMed Central Ltd. 2012
Received: 22 February 2012
Accepted: 11 August 2012
Published: 18 September 2012
Presentations of abdominal pain in patients on peritoneal dialysis deserve maximal attention and careful differential diagnosis on admittance to medical care. In this case report a gangrenous appendicitis in a patient on automated peritoneal dialysis is presented.
We report the case of a 38-year-old Caucasian man with end-stage renal disease who was on automated peritoneal dialysis and developed acute abdominal pain and cloudy peritoneal dialysate. Negative microbiological cultures of the peritoneal dialysis fluid and an abdominal ultrasonography misleadingly led to a diagnosis of culture negative peritonitis. It was decided to remove the peritoneal catheter but the clinical situation of the patient did not improve. An explorative laparotomy was then carried out; diffuse peritonitis and gangrenous appendicitis were found. An appendectomy was performed. Myocardial infarction and sepsis developed, and the outcome was fatal.
A peritoneal dialysis patient with abdominal pain that persists for more than 48 hours after the usual antibiotic protocol for peritoneal dialysis-related peritonitis should immediately alert the physician to the possibility of peritonitis caused by intra-abdominal pathology. Not only peritoneal catheter removal is indicated in patients whose clinical features worsen or fail to resolve with the established intra-peritoneal antibiotic therapy but, after 72 hours, an early laparoscopy should be done and in a case of correct indication (intra-abdominal pathology) an early explorative laparotomy.
Acute abdominal pain could be a very serious complication in patients receiving continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). The peritonitis caused by exogenous infection related to the peritoneal catheter is a common reason for abdominal pain in these patients. Consequently, to identify whether a patient on CAPD or APD has underlying intra-abdominal pathology by means of a laparoscopy remains a diagnostic challenge for nephrologists and abdominal surgeons. A misled diagnosis may result in delayed urgent surgery and contribute to the high rate of deaths in such patients.
We present the case of a patient on APD with gangrenous appendicitis. Diagnosis was delayed and the patients`s outcome was catastrophic. According to our experience with peritoneal dialysis (PD) patients with a clinical picture of acute abdominal pain, it is necessary to think about all differential diagnostic possibilities and not only about the usual peritonitis. It is also crucial to exclude intra-abdominal pathology in those patients who do not respond promptly to intra-peritoneal antibiotics.
In the medical literature 16 cases of appendicitis in adult patients on PD have been reported to date [1–11]. Most patients survived. Only one patient, a 46-year-old man, has died ; the reason was septic shock. Our case is the second with a fatal outcome but the first in which the patient suffered from acute myocardial infarction that influenced the postoperative clinical course and final outcome.
The presented case shows that a clinical presentation of abdominal pain in patients on PD deserves maximal attention and careful differential diagnosis on admittance to hospital. To find intra-abdominal pathology in these patients can be very difficult because the common cause of acute abdominal pain in PD patients is peritonitis caused by exogenous infection related to the peritoneal catheter. In our patient the delay in diagnosis of appendicitis was 10 days and it was consistent with the delays of between 2 and 27 days reported by others [1, 2].
There are many reasons for a delay in diagnosis. The patients presented with symptoms of abdominal pain complained about diffuse pain and failed to localize the pain to a specific quadrant and thus raised the suspicion of appendicitis, perforation, diverticulitis and so on . The treatment with intra-peritoneal antibiotics is indicated in PD peritonitis. Unfortunately, in PD patients with intra-abdominal pathology intra-peritoneal antibiotics probably dilute the bacterial load, retard abscess formation and also protract the course of the clinical picture . The cultures of peritoneal fluid in patients with intra-abdominal pathology, especially before perforation, are often negative, and it can take several days to reveal multiple enteric Gram-negative organisms. In 13 out of 16 reported cases, the Gram stain of the peritoneal fluid was negative. In the positive cultures of peritoneal fluid mostly Bacteroides species and Escherichia coli were isolated. In our case, the patient did not complain of localized abdominal pain; the two cultures of peritoneal fluid were also negative, the second probably because of the intra-peritoneal antibiotic treatment. We also speculated that the delay in diagnosis was due to masked abdominal signs and direct local instillation of antibiotics in peritoneal fluid on the inflammatory appendix. The patient complained about pain in his arms, troponin T was elevated, and ECG changes were found. This coronary incident also had some influence on the postoperative complications, sepsis and fatal outcome.
Before the surgical procedure, two abdominal USs were performed. Unfortunately, no computed tomography (CT) scan of the abdomen was performed. The sensitivity of abdominal US and CT as diagnostic tools in appendicitis in PD patients is rather doubtful. Carmeci et al., Yang et al. and Yehia et al. reported that abdominal CT scanning is not a sensitive diagnostic tool in the evaluation of these patients [1, 3]. Mihout et al. consider that the CT scan represents a diagnostic test of choice . Yehia et al. reported that a laparotomy was typically delayed because of negative findings on CT . Carmeci et al. concluded in their series of six patients that the negative imaging added to the delay in diagnosis and treatment of serious intra-abdominal infections . The non-localizing physical examination and negative or non-specific results of an abdominal CT scan do not rule out serious intra-abdominal disease . On the basis of these different conclusions about the CT scan it can be said that a negative CT scan does not rule out an abdominal complication and should lead to further investigations by means of other procedures such as an explorative laparoscopy.
According to available data on PD patients, we can conclude that cloudy peritoneal effluent together with abdominal pain is not necessarily PD-related peritonitis. Furthermore, abdominal pain that persists for more than 48 hours after the usual antibiotic protocol for PD-related peritonitis should immediately alert the physician to the possibility of peritonitis caused by intra-abdominal pathology.
To avoid the unsuccessful treatment of a PD patient with acute abdominal pain as described in this case, an intra-hospital agreement of the treatment strategy between nephrologists and abdominal surgeons was reached. In PD patients whose clinical features worsen or fail to resolve with the established intra-peritoneal antibiotic therapy not only peritoneal catheter removal is indicated but a laparoscopy should be done after 72 hours, and in the case of correct indication (intra-abdominal pathology) an early explorative laparotomy.
Written informed consent was obtained from the patient´s next-of-kin for the publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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