A Patient with Severe Pancreatitis Successfully Treated by. Takaya Tanaka, Kenji Suzuki, Nobuaki Matsuo, Fumihiro Nozu,

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1 A Patient with Severe Pancreatitis Successfully Treated by Continuous Peritoneal Dialysis Takaya Tanaka, Kenji Suzuki, Nobuaki Matsuo, Fumihiro Nozu, Kazunobu Yamagami and Naoshi Takeyama Emergency Care Unit, Kansai Medical University, Moriguchi, Osaka 570 Japan (Received for publication November 9, 1987) Key words : Pancreatitis, Peritoneal dialysis Summary This report describes a case of aged patient with severe acute pancreatitis successfully treated with peritoneal dialysis. Since no improvements were observed, showing amylase levels at 4, 800 IU/1 in the blood, 7, 700 IU/1 in the urine, and 6, 468 IU/1 in the ascites, respectively, though continuous intravenous administration of proteninase inhibitors was conducted, continuous peritoneal dialysis was performed for 10 days with the peritoneal perfusion fluid mixed with proteinase inhibitors and antibiotics, resulting in the improvements of parameters and disappearance of subjective symptoms. Thus, our present case demonstrates that peritoneal dialysis is very effective for intractable acute pancreatitis. Introduction Acute necrotic pancreatitis is often fatal, with the mortality rate being 80% or greater by conservative treatment 3' 5' 6), and the results of various surgical treatments have not been satisfactory', 3). Severe acute pancreatitis is often accompanied by multiple organ failure and shock, and peritoneal dialysis is considered to be effective in such cases. This report describes a patient with severe acute pancreatitis in whom continuous peritoneal dialysis was very effective. Case Report The patient, a 74-year-old woman with a history of pulmonary tuberculosis but no particular family history, suddenly felt severe pain in the upper abdomen and yielded coffee-ground vomit 2 days before admission. She was conservatively treated at a hospital by fluid infusion and administration of proteinase inhibitors under a diagnosis of acute pancreatitis, but she was referred to us due to deterioration of symptoms and the appearance of oliguria.

2 On admission, the patient showed a moderatge body build, normal nutritional condition, blood pressure of 180/104 mmhg, regular pulse at 84 beats/min, and respiratory rate of 28/min. The entire abdomen was slightly swollen and tender, and muscular protection and Blumberg sing were noted. Laboratory data on admission included : RBC 415 x 104, WBC 11, 300, Hb g/dl, Hct 34%, platelets 26 x 104, GOT 62 IU/L, GPT 32 IU/L, Alp 259 IU/L, T-bil 1. 5 mg/dl, D-bil 2. 5 mg/dl, LDH 715 IU/L, TP 5. 7 g/dl, Alb 3. 2 g/dl, BUN 54 mg/dl, Cr 2. 7 mg/ dl, s-amy 4, 800 IU/L, u-amy 7, 700 IU/L, blood glucose 138 mg/dl, Na 134 meq/l, K 5. 3 meq/l, Cl 98 meq/l, Ca 3. 8 meq/l, PT 70% or above, APTT 26 sec. No other relevant findings were obtained. Fig. 1 shows an abdominal radiogram. Abdominal ultrasonography on admission revealed a large volume of peritoneal fluid and enlargement of the pancreas but no marked changes in the liver or the spleen. Since oliguria was considered to be due to dehydration by ascites, massive fluid transfusion was carried out. Continuous peritoneal dialysis was instituted in addition to intravenous administration of proteinase inhibitors, because proteinase inhibitor therapy alone failed to alleviate the symptoms at the previous hospital. A_ catheter was inserted through a 2cm median incision in the lowere abdomen, and the peritoneum was lavaged with a dialysis fluid supplemented with proteinase inhibitors and antibiotics. The ascites was yellowish brown, and the ascitic Amy, T-bil and D-bil levels being 6, 468 IU/L, mg/dl, and 9 mg/dl, respectively, on the 1st hospital day reduced to 2, 571 IU/L, 3 mg/dl and 4 mg/dl on the 3rd hospital day. Perfusion was suspended on the 5th hospital day because of adequate reductions in the serum and urinary amylase levels but resumed on the 8th hospital day due to elevations in the urinary and ascitic amylase levels (6, 091 IU/L). It was continued until the 10th hospital day. The BUN and Cre levels

3 Fig. 3 Abdominal CT taken on the otn nospitai clay snowing only mild enlargement of the pancreas. The patient had an uneventful clinical course.

4 also returned to the normal ranges by fluid infusion and peritoneal dialysis. Slight transient liver dysfunction was noted, but subsided before discharge on the 46th hospital day (Fig. 2). Only slight enlargement of the pancreas was noted on CT taken on the 5th hospital day (Fig. 3). Discussion Surgical treatment of severe pancreatitis has limitations, and its conservative treatment is difficult because of the frequent complications such as shock, renal insufficiency and DIC. Peritoneal dialysis as a treatment of pancreatitis was first reportd by Wall"), who noted marked symptomatic improvements in 2 of 3 patients. The clinical usefulness of this treatment was demonstratedby subsequent fundamental studies in which survival rates of 50%l0) and 86%", significantly higher than those of the control groups, were achieved. Among a number of clinical studies that followed, Ranson et al. 9) reported that none who underwent peritoneal dialysis died in contrast to death in 45% of those who were not given this treatment, and Balldin et al. 2) observed survival of 58 (80%) of the 69 patients treated by this procedure. According to Stone et al. 12), symptomatic improvements were noted in 29 of the 34 patients treated by peritoneal dialysis but in 13 of the 36 who did not receive this treatment. This aim of peritoneal perfusion for the patients with severe acute pancreatitis is elimination of agents such as amylase, lipase, trypsinogen, phospholipase A, kinin and bradykinin, which are considered to be responsible for shock, renal insufficiency, DIC, respiratory insufficiency and hypocalcemia. In our patient, amylase was efficiently reduced. The treatment was considered to become even more effective by the addition of proteinase inhibitors to the lavage fluid. Although there is no agreement on the optimal time for peritoneal dialysis, the survival rate was reported to be higher as it was performed earlier'', 8, 11). Therefore, early initiation of the treatment is recommended in the patients showing deteriorating symptoms and examination results. Although peritoneal perfusion reduces mortality rate of severe acute pancreatitis, it cannot be applied to all patients. As Jacobs et al. 4) showed that the mortality rate was 71% without operation but was 36% with operation, the time of surgery is an important prognostic factor in this disease. Prompt decision must be made whether conservative therapy is sufficient, peritoneal perfusion should be decided, or surgical treatment is necessary. Closing Remarks We successfully treated an aged patient with severe acute pancreatitis showing oliguria by peritoneal dialysis.

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