Perforative Peritonitis caused by Appendicitis in a Patient on Peritoneal Dialysis

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1 CASE REPORT Perfortive Peritonitis cused y Appendicitis in Ptient on Peritonel Dilysis Msshi Mizuno 1,2, Ysuhiro Suzuki 1,2, Keisuke Nonk 2,YumiSei 2, Shoichi Mruym 2, Seiichi Mtsuo 2 nd Ysuhiko Ito 1,2 Astrct A 46-yer-old mn on peritonel dilysis (PD) ws hospitlized due to suspicious PD-relted peritonitis. Becuse the ptient s dominl pin ws unimproved y conventionl ntiiotics nd multiple cteri were identified in smer-smple of PD fluid, endogenous peritonitis ws suspected. Perforted ppendicitis ws finlly dignosed under explortory lprotomy. In this ptient, perforted ppendicitis ws difficult to dignose due to the ttenuted clinicl symptoms nd inconclusive results of dominl computed tomogrphy (CT), even though the positive predictive vlue of CT is >95% in non-pd ptients. Quickly deciding to perform explortory lprotomy in ptients suspected of hving endogenous peritonitis is thus importnt, even when the origin hs not een clrified. Key words: peritonel dilysis, peritonitis, perforted ppendicitis (Intern Med 52: , 213) (DOI: /internlmedicine ) Introduction In end-stge renl disese (ESRD) ptients on peritonel dilysis (PD), peritonitis remins n importnt compliction worldwide (1). In the Toki re of Jpn, we recently confirmed tht peritonitis represents n importnt ostcle to long-term PD therpy (2). The most frequent cuses of peritonitis re contmintion during the performnce of PD fluid ( PDF) exchnge nd PD ctheter exit-site infections (1, 3, 4). On the other hnd, endogenous peritonitis is less frequent nd its infectious routes vry. Gstrointestinl perfortion is one cuse of endogenous peritonitis, mjor indiction for emergency lprotomy nd generlly ccompnied y severe dominl symptoms, such s musculr gurding nd colicky pin. Perfortions cn e cused y peptic ulcers, diverticulitis, cholecystitis, ischemic colitis, ppendicitis, mlignncy, ingestion of foreign odies, such s fish or chicken ones, or, more rrely, moo sliver or indwelling ctheters (5-9). Typicl findings on computed tomogrphy (CT) include free ir in the peritonel cvity s n importnt indictor of gstrointestinl perfortion (8, 1, 11). As tool for the dignosis of perforted ppendicitis, dominl CT is well-estlished technique for use in ptients with cute dominl pin tht generlly shows >95% sensitivity nd specificity for dignosing nd differentiting ppendicitis in the erly stges of disese (12, 13). We herein present the cse of PD ptient with perforted ppendicitis resulting in endogenous peritonitis in which finl dignosis ws difficult to otin prior to lprotomy. In the present cse, the decision to perform explortory lprotomy could e mde quickly due to the detection of multiple cteri in the PD effluent. Cse Report A 46-yer-old mn who hd een on continuous multory PD (CAPD) for 2.5 yers due to ESRD secondry to dietes mellitus (DM) nephropthy experienced moderte non-loclized dominl discomfort one fternoon. By the lte fternoon, fter noticing cloudy PDF with moderte dominl pin ut no nuse or vomiting, the ptient cme to the emergency unit of our hospitl t night nd ws dmitted with dignosis of peritonitis. Prior to this hospitliz- Renl Replcement Therpy, Ngoy University Grdute School of Medicine, Jpn nd Division of Nephrology, Ngoy University Grdute School of Medicine, Jpn Received for puliction Octoer 25, 212; Accepted for puliction Ferury 1, 213 Correspondence to Dr. Msshi Mizuno, mmizu@med.ngoy-c.jp nd msshim1jp@yhoo.co.jp 1177

2 Intern Med 52: , 213 DOI: /internlmedicine c d Figure 1. Findings of dominl computed tomogrphy scns. ) CT performed on Dy., c), d) Contrst-enhnced CT performed on Dy 1 (second CT). The white rrows indicte the position of the ppendix. The lck rrows indicte the presence of free ir in the peritonel cvity. The white rrowheds indicte high density re suspected to e fecl stone. The ftty tissues round the ppendix were not ccompnied y high-density res, suggesting tht the inflmmtion might not hve expnded round the ppendix. tion, the ptient hd een on CAPD with 1.5% glucose solution (Dinel NPD4 1.5%; Bxter, Tokyo, Jpn) t 2 L three times/dy nd 2 L overnight. Multiple diverticul were identified in the colon prior to the induction of PD therpy; however, the ptient hd no history of diverticulitis. Likewise, he hd no previous history of peritonitis or lprotomy. The ptient hd een dignosed with DM (type II) over 11 yers erlier, nd his hemogloin A1c levels were controlled to etween 5.5 nd 5.8%. On dmission, physicl exmintion reveled moderte dominl pin nd mild tenderness unccompnied y the typicl initil limited pin loclized in the periumilicl region followed y migrtion of pin to the right lower qudrnt, musculr gurding or reound tenderness. The ptient s ody temperture ws 36.8, his lood pressure ws 15/ 65 mmhg nd his hert rte ws 85 ets/min with sinus rhythm. The clinicl lortory dt of the lood nd serum were s follows: peripherl white lood cell (WBC) count, 11,7 cells/mm 3 (polymorphoneutrophils, 88.%; lymphocytes, 8.2%); hemogloin, 9.6 g/dl; C-rective protein (CRP), 1.61 mg/dl; proclcitonin,.4 ng/ml (norml, -.5 ng/ml); mylse, 65 IU/L; lumin, 3.6 g/dl; glucose, 174 mg/dl. The WBC count ws 2,11 cells/mm 3 in the first cloudy PDF, nd the PDF did not smell of stool on dmission. Mild swelling of the ppendix with high density suspected to e fecl stone (rrowheds; Fig. 1d) without surrounding inflmmtion ws pprent on simple dominl computed tomogrphy (CT) nd contrst-enhnced dominl CT on dys nd 1 fter dmission (Fig. 1), nd smll mount of free ir ws oserved within the mount expected due to flow into the dominl cvity during PDF g chnges in generl PD ptients. The initil CT results were not prticulrly suggestive of cute perforted ppendicitis, even to the rdiologist. Although multiple diverticul were present, no findings suggestive of diverticulitis were seen on CT. On dmission, the ptient ws intrperitonelly treted with cefzolin sodium hydrte t dose of 1 g/dy nd ceftzidime hydrte t dose of 1 g/dy s conventionl therpy. However, his dominl pin remined unimproved 12 hours fter dmission, nd the WBC count in the PDF ws clerly incresed (to 27,3/mm 3 ; polymorphoneutrophils, 9.8%) (Fig. 2). At tht time, the serum CRP nd proclcitonin levels were incresed to 7.94 mg/dl nd 5.1 ng/ml, respectively. Grm-positive cocci nd Grm-negtive rods were oth detected on smer smples of the PDF performed on dmission (Fig. 3). These findings suggested tht the peritonitis might represent n endogenous peritonitis, such s gstrointestinl perfortion. The intrperitonel ntiiotic dministrtion ws therefore chnged to 1. g/time of vncomycin hydrochloride nd.5 g/dy of meropenem hydrte (MEPM) nd explortory lprotomy ws performed. Under lprotomy, the ppendix ws found to e inflmed with perfortion nd smll mount of purulent peritonel effusion nd two fecl stones in the peritonel cvity (Fig. 4). Finlly, perfortive peritonitis cused y cute ppendicitis with perfortion ws dignosed. Appendectomy nd peritonel lvge were performed intropertively, nd indwelling dringe tues were inserted into the dominl cvity for dringe. During the opertion, the PD ctheter ws lso removed, nd the renl replcement therpy ws chnged from PD to hemodilysis. Lter, cultures of lood otined on dmission nd PDF otined on dy 1 showed Klesiell pneumoni, Citrocter freundii, Enterococcus fecium nd Fusocterium nucletum. In ddition, Cndid glrt, Bcteroides thetiotomicron nd Prevotell spp. were detected in smples otined from the purulent peritonel effusion during surgery. 1178

3 Intern Med 52: , 213 DOI: /internlmedicine VCM 1g (ip) CEZ 1g/dy (ip.) CAZ 1g/dy (ip.) PD WBC (/mm 3 ) 3, 2, 1, ( ) 16, WBC (/mm 3 ) 12, 8, 4, ( )( 7 ) ( ) TP (g/dl) Al (g/dl) Blood ure nitrogen level (mg/dl) CAPD MEPM.5g/dy (ip.) (div.) HD Lprotomy ( ) Dy C-rective protein (mg/dl) 12 ( ) Serum cretinine level (mg/dl) Figure 2. Clinicl course of the ptient. Explortory lprotomy ws performed on Dy 1 (white rrow). CAPD: continuous multory peritonel dilysis, CAZ: ceftzidime hydrte, CEZ: cefzolin sodium hydrte, HD: hemodilysis, MEPM: meropenem hydrte, PD WBC: white lood cells in peritonel dilysis (PD) fluid, VCM: vncomycin hydrochloride, WBC: white lood cells, (i.p.): intrperitonel injection, (div.): drip infusion, TP: the serum totl protein level (g/dl), Al: the serum lumin level (g/dl) Figure 3. Grm-positive nd Grm-negtive cultures were isolted from the peritonel dilyste fluid in the present cse. Smer smples of centrifuged peritonel fluid otined from the ptient, stined using Grm stining. Multiple cteri were oserved in the smer smples of the peritonel dilyste fluid otined from the ptient. Blck rrows, Grm-positive cteri; white rrows, Grm-negtive cteri. Originl mgnifiction, 1,. These cteri were ctegorized s neroic Grm-negtive rods. Postopertively, the ptient quickly recovered from the peritonitis with MEPM nd ws dischrged on dy 29. The detiled course of the ptient is shown in Fig. 2. Discussion In the present cse, peritonitis resulted from cute perfortive ppendicitis. On dmission, the ptient did not disply ny severe dominl symptoms, such s nuse, vomiting, locl dominl pin, tenderness or reound tenderness. Although CT ws performed repetedly efore mking the decision to perform emergency surgery, perfortion of the ppendix ws not pprent. The ptient s initil symptoms nd rdiologicl findings were most likely msked y the frequent PDF chnges, which ttenuted the symptoms. The decision to perform emergency lprotomy ws mde nd lprotomy ws performed within 24 hours ecuse the ptient s clinicl symptoms remined unimproved nd multiple cteri were detected on smer smples of the PDF. However, the dignosis of perfortion of the ppendix could not e mde without performing lprotomy. 1179

4 Intern Med 52: , 213 DOI: /internlmedicine cm c 1cm Figure 4. Visuliztion of the perforted ppendix with focl inflmmtion nd fecl stones in the dominl cvity during lprotomy. The white rrows indicte perfortion of the ppendix under the opertion field () nd the resected ppendix otined vi ppendectomy (). Fecl stones were found in the dominl cvity intropertively (c). The scles re plced in the right ottom corners in () nd (c). Acute ppendicitis in non-esrd ptients is usully ccompnied y chrcteristic fetures, such s nuse, locliztion of severe dominl pin from the periumilicl to the right lower qudrnt re nd ilic foss, reound tenderness nd muscle rigid gurding, in terms of clinicl symptoms nd the results of physicl exmintions, nd perfortion occurs in <15% of totl ppendicitis cses (14). In contrst, ecuse gstrointestinl perfortion is often difficult to dignose efore lprotomy nd is delyed in ESRD ptients on PD (11), the prognosis cn e poor (1). The min resons for dignostic prolems in PD ptients re tht clinicl symptoms re ttenuted ecuse frequent PD g exchnges provide peritonel lvge nd dringe nd empiric ntiiotics re dministered intr-dominlly in ptients with PD-relted peritonitis (1, 11, 15). When multiple cteri nd/or neroic cteri re identified s the custive microorgnisms of peritonitis in PD ptients, complicted types of peritonitis, such s diverticulitis nd gstrointestinl perfortion, re suspected (16). However, it is difficult to mke finl dignosis of perforted peritonitis without performing explortory lprotomy. Some reports hve descried delys in the dignosis of 1 dys nd opertive mortlity rtes of 16-5% in PD ptients (1, 15, 17). Crmeci et l. reported mortlity rte for perforted ppendicitis of -33% (1). On the other hnd, the mortlity rte for perforted peritonitis is only -4% in non-pd ptients, nd the risk of n extended durtion efore lprotomy is reltively lower (18). However, even in non-pd ptients, the mortlity rtes re reportedly incresed with durtions of > 32 hours efore lprotomy (19). The intervl required to rech dignosis is very importnt. Eliminting the perfortion s soon s possile is thus impertive when gstrointestinl perfortion is suspected in PD ptients. In the present cse, nother ostcle to identifying endogenous peritonitis ws the presence of multiple diverticul. Although diverticulitis is one cuse of endogenous peritonitis, report y the Europen Renl Best Prctice Advisory Bord suggested tht only the ppernce of diverticulum is not contrindiction (2), nd our previous report showed tht the presence of diverticulum without ny prior history of diverticulitis is not risk fctor for endogenous peritonitis (21). In this cse, only the use of lprotomy mde it possile to chieve finl dignosis of perforted ppendicitis. In the present cse, even if ppendicitis hd extended into the perfortion, the definitive dignosis still would hve een difficult to otin without lprotomy. In PD ptients, gstrointestinl perfortion leding to endogenous peritonitis cn represent severe, emergency compliction. Gstrointestinl perfortion should thus e kept in mind s differentil dignosis in PD ptients presenting with peritonitis, especilly when multiple enteric cteri nd/or neroic cteri re identified, even if findings of CT, symptoms nd physicl exmintions re not sufficient to identify gstrointestinl perfortion. For these resons, otining cteril cultures nd smer smples of the PDF is very importnt to chieve dignosis nd determine the need for surgery. With endogenous peritonitis in PD ptients, mking quick dignosis is essentil in order to prevent life-thretening complictions, nd immeditely dministering pproprite therpeutic pproches, including explortory lprotomy, is essentil in order to optimize the prognosis of PD ptients if gstrointestinl perfortion is suspected, even when the origin hs yet to e confirmed. The uthors stte tht they hve no Conflict of Interest (COI). 118

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