Abdominal Pain in Peritoneal Dialysis: Peritonitis or Pancreatitis? A Report of Three Cases

Abstract

Pancreatitis in peritoneal dialysis (PD) patients is a complex clinical challenge, often masked by symptoms that overlap with other conditions such as peritonitis. This article presents three clinical cases that illustrate the difficulty of diagnosing and managing pancreatitis in this setting.
The first case concerns a 40-year-old patient who presented with severe acute pancreatitis after two years of PD. The diagnosis, initially mistaken for peritonitis due to the presence of hematic drained dialysat, was rectified by a marked rise in pancreatic enzymes and a CT scan confirming pancreatic necrosis. Despite rapid treatment, including CT-guided drainage, the patient died of septic shock.
The second case involved a 64-year-old patient with chronic pancreatitis predisposed by familial hypertriglyceridemia. Although this patient survived several episodes of pancreatitis, the management of her condition required constant monitoring and ongoing adjustment of her PD therapy.
The third case describes a 58-year-old patient whose acute lithiasis-induced pancreatitis rapidly progressed to pancreatic necrosis, leading to fatal septic shock, despite CT-guided drainage.
These cases highlight the importance of increased vigilance in monitoring patients with PD, in whom pancreatitis can develop insidiously. Diagnosis must be based on rigorous clinical assessment, relevant biological markers such as lipase, and appropriate imaging to avoid potentially fatal delays in treatment. Early multidisciplinary management is essential to improve the prognosis of this serious complication, which is often underestimated in the peritoneal dialysis population.

INTRODUCTION

Pancreatitis is an inflammatory process of the pancreas and takes different forms in terms of severity, ranging from moderate to severe forms requiring special intensive care.

Diagnosis of pancreatitis is based on clinical, biological, and radiological factors. Abdominal computed tomography (CT) scans are used to classify pancreatitis according to severity. Hypertriglyceridemia, the presence of gallstones, and alcoholism are the main causes¹. The occurrence of pancreatitis in peritoneal dialysis (PD) patients can be serious and life-threatening, and its management is complicated, especially when it recurs. Abdominal pain is the most frequent clinical manifestation of pancreatitis, which can be confused with medical peritonitis¹². Hence, early diagnosis and appropriate treatment are important. Here, we report the observation of three PD patients who presented with pancreatitis.

CLINICAL CASES

Clinical case 1

This was a 40-year-old male patient, not known to be an alcoholic, on continuous ambulatory peritoneal dialysis (CAPD) for 2 years with a history of familial Mediterranean fever.

Two years after the start of exchanges, he presented with generalized abdominal pain with vomiting and a fever of 38.2 °C.

Clinical examination revealed a blood pressure of 123/62 mmHg with sinus tachycardia at 127 beats per minute, diffuse abdominal tenderness, and systemic inflammatory response syndrome (SIRS) with a score of 3.

Biologically, we found an infectious syndrome with hyperleukocytosis at 14,800 elements/mm3, predominantly neutrophilic polynuclear, with an increase in C-reactive protein (CRP) to 550 mg/L and an increase in procalcitonin (PCT) to 8 ng/ml. In view of this picture, the diagnosis of peritonitis was evoked. The dialysate effluent was hematic (Figure 1), with a dialysate white blood cell (WBC) count of 59 cells/mm3 and a negative culture. The diagnosis of peritonitis was ruled out. Biological and radiological tests were carried out to rule out other diagnoses, such as an abdominal surgical emergency.

Figure 1.Dialysate fluid on patient admission (case 1)

The diagnosis of acute pancreatitis was based on a plasma lipase level of 13 times normal (13 x N) and a plasma amylase level of 7 times normal (7 x N). The abdominal CT scan showed stage D acute pancreatitis.

In order to determine the cause of this pancreatitis, a complementary workup was requested, and it came back without any particularities, i.e., no hypercalcemia, no hypertriglyceridemia, and no vesicular lithiasis on the abdominal ultrasound and CT scans. The immunological workup for autoimmune pancreatitis included serum IgG4.

The patient was placed on dietary restriction and parenteral nutrition with maintenance of CAPD (3 exchanges/day). The immediate evolution was favorable, with a decrease in pancreatitis-specific markers, under symptomatic treatment with imipenem-based antibiotics.

Two weeks later, his clinical condition worsened, and he developed severe sepsis. The abdominal CT scan (Figure 2) showed a progression to stage E pancreatitis, with increasing necrotic flow, requiring urgent scanno-guided drainage. Sadly, the patient died within 24 hours from septic shock secondary to the pancreatitis.

Figure 2.Abdominal CT scan showing necrotic flow (case 1)

Clinical case 2

This was a 64-year-old female patient, type II diabetic and hypertensive for 15 years, with familial hypertriglyceridemia and dyslipidemia, put on automated peritoneal dialysis (APD) for 6 years for IgA nephropathy.

Three months after the start of exchanges, she presented with transfixing epigastric abdominal pain, with hematic dialysate fluid.

On clinical examination, the patient was hemodynamically stable, apyretic, and tachycardic at 100 beats per minute, and her abdomen was tender but not contracted.

Biological tests revealed lipasemia at 3.5 times normal. The abdominal CT scan showed stage B pancreatitis, and the workup showed hypertriglyceridemia at 11 g/L.

However, the patient presented six episodes of pancreatitis during her follow-up, which were resolved by symptomatic treatment and dietary restriction. The diagnosis of chronic pancreatitis of metabolic origin was retained. The patient is still on PD, at the moment of this report; with good purification and adequacy.

Clinical case 3

This male patient was 58 years old, suffering from chronic end-stage renal failure due to tubulointerstitial nephritis, and he had been on APD for 8 months. One month after the start of exchanges, the patient presented with transfixing epigastralgia-like abdominal pain radiating to the right hypochondrium without fever.

He was neurologically and hemodynamically stable, with a blood pressure of 130/90 mmHg, a heart rate of 80 beats per minute, and a fever of 38.5 °C, with a SIRS score of 2.

Biologically, we found an inflammatory syndrome with predominantly neutrophilic hyperleukocytosis at 12,600 elements/mm3 and a C-reactive protein (CRP) level of 23 mg/l. The dialysate effluent was turbid, with a dialysate WBC of 68 elements/mm3.

The diagnosis of acute lithiasis pancreatitis was made in the presence of 6 times normal hyperlipasemia and Balthazar stage D acute pancreatitis with a multi-lithiasis gallbladder on the ultrasound and abdominal CT scans. The immediate evolution was favorable, with a decrease in pancreatitis-specific markers, under dietary restriction and symptomatic treatment.

A few days later, the patient’s clinical condition worsened, with the appearance of subicterus, cholestasis, hepatic cytolysis, elevated CRP, and lipasemia at 3,299 elements/mm3 (20 x N). The abdominal CT scan showed a progression to stage E pancreatitis, with a progression of necrotic flow and a 14 mm collection, requiring urgent scanno-guided drainage (Figure 3). Unfortunately, the patient died 2 weeks later from septic shock secondary to pancreatitis.

Figure 3.Drained fluid from pancreas (case 3)

DISCUSSION

Table I summarizes our three observations. Acute pancreatitis (AP) is an inflammatory disease of

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