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Clinical Consult

Charlotte Szromba, Department Editor

Abdominal Mysteries: Pain, Peritonitis,


Pancreatitis, Pseudocyst
Maureen Craig

Sergio Infante

Clinical Consult

Copyright 2011 American Nephrology Nurses Association

When a patient on peritoneal


dialysis (PD) presents with
abdominal pain, what etiologies should be considered?
The differential diagnosis
for the presenting symptom
of abdominal pain is quite
broad for the patient on PD.
Infectious peritonitis is always suspected, but it may not be the root or the
only cause of the abdominal pain.

Q:
A:

Case Study
Patient Presentation
A 28-year-old Asian female with a
history of chronic kidney disease
(CKD) Stage 5 on PD presents to the
emergency department at a university
medical center with worsening
Maureen Craig, MSN, RN, CNN, is a Clinical
Nurse Specialist Nephrology, University of
California Davis Medical Center, Patient Care
Services, Sacramento, CA, and a member of ANNAs
Sacramento Valley Chapter. She may be contacted
via e-mail at macraig@ucdavis.edu
Sergio Infante, MD, is an Assistant Professor of
Medicine, Department of Nephrology, Loma Linda
University Medical Center, Loma Linda, CA.
Statement of Disclosure: The authors reported no
actual or potential conflict of interest in relation to
this continuing nursing education article.

The Clinical Consult department is designed


to provide answers to questions concerning clinical problems and to report innovative clinical
practices. Readers are invited to submit questions to be answered by a guest consultant.
Questions should provide background information and state specific information requested.
Answers will be referenced. Manuscripts that
address clinical problems or present innovative
ideas are also invited. These should be between
400 and 600 words and contain one to three references. Address correspondence to: Charlotte
Szromba, Clinical Consult Department Editor,
through the ANNA National Office; East Holly
Avenue/Box 56; Pitman NJ 08071-0056; (856)
256-2320. The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of
the American Nephrology Nurses Association.

Nephrology Nursing Journal

Continuing Nursing
Education

Craig, M., & Infante, S. (2011). Abdominal mysteries: Pain, peritonitis, pancreatitis,
pseudocyst. Nephrology Nursing Journal, 38(2), 173-186.
The differential etiology of abdominal pain in patients on peritoneal dialysis (PD) is
broad, and these patients may experience the same symptoms as those of the general population. This article provides an overview of the various types of abdominal pain in patients
on PD, as well as their possible etiologies, symptoms, and treatment regimens.

Goal
To provide an overview of abdominal pain in patients on peritoneal dialysis.
Objectives
1. Discuss the treatment of a patient on peritoneal dialysis who presents with acute
abdominal pain.
2. Identify the potential etiologies of abdominal pain in patients on peritoneal dialysis.
3. Explain the symptoms and considerations for the etiologies of abdominal pain in
patients on peritoneal dialysis.

abdominal pain and vomiting. The


patient describes pain on a pain scale
as 10/10, similar to prior pancreatitis
episodes and unlike prior peritonitis
episodes. She has a history of peritonitis and multiple episodes of pancreatitis. Her most recent pancreatitis
episode was managed at an outside
hospital about two weeks earlier with
a peak serum lipase of 2489 U/L. She
was discharged from the hospital 8
days ago with improved but not
absent symptoms of nausea, vomiting,
and abdominal pain. She reports
avoiding fatty foods during the last
week, but her symptoms have again
worsened. She had a soft stool one
day ago, and denies diarrhea, melena,
and hematochezia. Her vomitus is bilious and nonbloody. The patient

denies any fever or chills, and her PD


effluent remains clear. The esophagogastroduodenoscopy and colonoscopy performed at her previous hospitalization showed a small hiatal hernia and normal colonoscopy. She is
away from her home now, visiting her
sister in town, who is a potential kidney donor. They are awaiting medical
clearance prior to proceeding with
kidney transplantation.

Past Patient History


The patient has CKD Stage 5 and
reports some urine output. She started
on hemodialysis 10 months ago and
converted to PD after two months of
therapy. Her PD routine is four
exchanges per day, two liters per
exchange, typically a mix of 1.5% and

This offering for 1.3 contact hours is provided by the American Nephrology Nurses
Association (ANNA).
ANNA is accredited as a provider of continuing nursing education (CNE) by the American
Nurses Credentialing Centers Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
Accreditation status does not imply endorsement by ANNA or ANCC of any commercial product.
This CNE article meets the Nephrology Nursing Certification Commissions (NNCCs) continuing nursing education requirements for certification and recertification.

March-April 2011

Vol. 38, No. 2

173

Abdominal Mysteries: Pain, Peritonitis, Pancreatitis, Pseudocyst

2.5% dextrose PD solution. The etiology of her renal failure is unclear, and
she has a congenital solitary kidney.
She presented with proteinuria and
hypertension during her pregnancy,
and her blood pressure never
returned to baseline after delivery two
years ago. The patient has a history of
peritonitis 2 and 7 months ago; both
resolved with 2 to 3 weeks of vancomycin treatment. She has had multiple episodes of acute pancreatitis, the
most recent occurring 1 week ago.
Additionally, the patient had gout 1.5
years ago; measles, mumps, chicken
pox in the past; and a recent positive
PPD for tuberculosis. Her allergies
include hydrocodone/acetaminophen
with a rash reaction, and latex with a
hives reaction when exposed.
The patients family history is significant for a father who died of a
stroke at age 45 and her mother who
is alive on dialysis at 55 years of age.
The patient is married, and living
with her husband and daughter. She
denies tobacco, alcohol, or drug use.

Physical Examination
The patients physical examination is noted to reveal a blood pressure of 180/114, mild chest tightness,
blurry vision, burning of the eyes, and
a headache. She is a thin female, who
is tired but alert. The patient has a PD
catheter in the left lower quadrant,
and the exit site is clean with no evidence of infection or local irritation.
She has mild to moderate distention
of her abdomen, nontender to palpation except at the low right inguinal
area and later in the mid-epigastric
region. She has normal bowel sounds.

Diagnostic Tests
Ultrasound (US) of the abdomen
showed no gall stones or gallbladder
thickening, negative Murphys sign,
no free fluid, normal liver, and absent
left kidney.
Laboratory results include a serum
Hct of 25.6%, white blood count
(WBC) of 8.1 K/mm3, albumin 1.7
g/dL, AST 13 U/L, ALT 12 U/L,
bilirubin total 1 mg/dL, lipase 52 U/L,
and amylase of 6 U/L. Urinalysis
showed WBCs 1 per high power field,

174

Figure 1
Tenckhoff Catheter within a Pancreatic Pseudocyst that Extended
into the Pelvis

Note: Patient's estimated peritoneal surface area was 1560 cm2. Pseudocyst estimated
surface area = 1153 cm2.

red blood counts (RBCs) 2 per high


power field, negative nitrate, and negative leukocyte esterase.

The Hospital Course:


Abdominal Saga Begins
The patient was made nothing by
mouth (NPO) and given D5 normal
saline intravenously (IV) for hydration. Computerized tomography (CT)
(see Figure 1) of the abdomen
revealed a large 22x13x8.3 cm
pseudocyst in the left abdomen
extending into the pelvis, with tubular-shaped fluid collection at inferior
aspect, and the PD catheter tip in
inferior portion of pseudocyst.
PD effluent samples were sent for
cell count and culture. The patient
was empirically started on intraperitoneal (IP) vancomycin and ceftazidime. IP heparin was used due to
fibrin in the peritoneal effluent fluid.
She also initiated a course of oral fluconazole for fungal prophylaxis. Her
routine outpatient medications were
started.
PD fluid analysis confirmed peritonitis with a rising WBC count, and
by the third day, a 3+ acid fast bacilli
(AFB) was found, but final speciation
and sensitivities of the organism
remained unanswered. Because of
her history of a Bacille CalmetteGurin (BCG) inoculation as a child
and having several positive PPD

screens, one recently, a peritoneal


Mycobacterium tuberculosis infection
was in the differential diagnosis.
The peritoneal effluent WBC was
initially 890/mm3 and rose while on
IP antibiotics to a peak of 3050/mm3
over 6 days. The peritoneal effluent
WBC subsequently fell but never
went below 100/mm3. The low
responsiveness to IP antibiotics suggested that the cavity she was using
for dialysis was perhaps loculated
away from much of her viscera. She
was switched to IV antibiotics and
then back to IP, since there was better
reduction in the WBC count in the
peritoneal effluent. Clinicians entertained the idea of the presence of an
abscess in the pseudocyst or that the
pseudocyst might need to be endoscopically or surgically drained or
biopsied via peritoneoscopy. The
patient continued to report feeling
better on the IP antibiotics, but continued to complain about nausea,
vomiting, and abdominal pain in the
lower quadrants with no rebound tenderness or guarding. She received
pain medication for pain management.

Consultation with Infectious


Disease
During the hospital stay, the
Department of Infectious Diseases
was consulted and concluded in the

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differential that the patient was dealing with a resistant peritoneal organism, or the load of the organism was
too high for standard IP antibiotic
treatment. The consult from the
Department of Infectious Diseases
suggested to rest the peritoneum,
switch to hemodialysis, send peritoneal effluent for reculture, and
entertain a medication cause of pancreatitis. A tagged WBC scan was
negative for active focus of infection
or inflammation.
In light of the acid-fast bacilli
(AFB) in the peritoneal fluid, the
patient was started on moxifloxacin,
pyrazinamide, rifampin, ethambutol,
and continued on fluconazole. Early
results from microbiology confirmed
a rapidly growing AFB, so the patient
was started on clarithromycin per
consult recommendation from the
Department of Infectious Diseases.
Clinicians from the Department of
Infectious Diseases later recommended an adjustment in antibiotics to
include azithromycin. The patient
was eventually stabilized on moxifloxacin, rifampin, and azithromycin,
which continued through the hospitalization and was expected to continue for 6 to 12 months.
AFB rapidly growing in the peritoneal fluid would indicate it was not
Mycobacterium tuberculosis. However,
considering her recent and remote
history of positive PPD, the Department of Infectious Diseases continued
to recommend rifampin. The patient
noted that she had previously been
started on isoniazid (INH) at an outside hospital but had an allergic reaction, resulting in pancreatitis; hence,
this drug was not restarted.

Complications

Clinical Sequelae

The patient continued to have


pain throughout her hospital stay.
Abdominal pain was at times in the
epigastric region and occasionally in
the lower abdominal area. Pain was
thought to be secondary to peritonitis,
post-operative pain from PD catheter
removal, hematoma/seroma development, and constipation/ileus. Constipation was visualized on abdominal
CT scan throughout the colon and
extending into the small bowel, com-

Due to the low responsiveness of


the PD fluid WBC to the IP antibiotics,
the patient was converted to hemodialysis 16 days after admission, and the
PD catheter was removed shortly afterward. This was consistent with evidence indicating a PD fluid WBC nonresponsive to antibiotic therapy by day
three is predictive of treatment failure
defined as PD catheter loss or patient
death (Chow et al., 2006).

Nephrology Nursing Journal

The following day after the PD


catheter was removed, the patient
developed a hematoma/seroma on the
lower left abdominal wall. This was
very painful for the patient. Heparin
for deep vein thrombosis (DVT) prophylaxis was stopped. She was taken
back to surgery, and the hematoma
was evacuated and closed with a drain
left in place. The patient had a reaccumulation of the hematoma/seroma
and again went to the operating room
for evacuation. The patients hematocrit dropped, and she received two
units of packed red blood cells. Her
abdomen remained painful, and she
had ongoing nausea and vomiting
controlled with IV fentanyl and
antiemetics around the clock. CT
scan revealed a fluid collection in the
left lower abdomen over the adnexa
and a bowel full of stool consistent
with the constipation the patient was
experiencing and possibly related to
opioid medication used for pain control. Serial CT scans demonstrated
the fluid collection in the abdomen
reducing in size over time. Review of
the CT did not determine suspicions
that the abdominal hematoma had a
communication with the original
abdominal fluid collection thought to
be secondary to retained peritoneal
dialysate.
The patient was stabilized on oral
moxifloxacin, rifampin, azithromycin, antihypertensive medications,
and antiemetic and pain medications
as needed. She was subsequently discharged.

Pain Management
Can Be a Pain

March-April 2011

Vol. 38, No. 2

plicating the picture of abdominal


pain, tenderness, and ongoing nausea. She had an allergy to
hydrocodone. The nephrologist was
concerned about the accumulation of
morphine in the presence of CKD
Stage 5. The patient was placed on
oxycodone/acetaminophen, fentanyl,
and ketamine for pain management.
Anxiety and depression about her
medical condition and the status of
her kidney transplant were possibly
contributing to her overall pain medication needs.

Nausea and Vomiting Leads


To Readmission
The patient returned to the ER for
a second and third visit presenting
with nausea and vomiting, and unable
to keep her antibiotic or pain medications down. The second admission
occurred two days after discharge, and
the patient was diagnosed with
clostridium difficile colitis. An abdominal CT showed pancolitis, a minimal
decrease of a pelvic abscess, and
enlargement of a subcutaneous hematoma. The second of two stool cultures
was positive for Clostridium difficile.
The patient was stabilized, and
metronidazole (Flagyl) was started to
treat the C. difficile colitis. Upon discharge, the patient was instructed to
take antiemetics around the clock and
not as needed, as previously prescribed. On the third consecutive
admission three days after the prior
discharge, the patient presented with
nausea, vomiting, diarrhea, abdominal pain, and facial swelling, again
unable to keep her medications down.
Gastrointestinal symptoms resolved with management of her nausea
with metoclopramide (Reglan) and
promethazine (Phenergan), and
resuming the Flagyl in a liquid form to
ease swallowing to continue the treatment of C. difficile. Facial swelling was
the result of a nonocclusive thrombus
formed around her hemodialysis
catheter that repeat scanning determined was not progressing. Facial
swelling resolved during the hospital
stay. The patient was again discharged
on oral medications.

175

Abdominal Mysteries: Pain, Peritonitis, Pancreatitis, Pseudocyst

Hypertensive Crisis
Complication
The patient presented on the first
hospitalization with BP 180/114
mmHg and a two-year history of
hypertension. She continued to have
episodes of hypertension potentially
exacerbated by her pain. The patient
was stable toward the end of her first
hospitalization with metoprolol, diltiazem, and clonidine. She had elevated blood pressure during each subsequent admission. Five days after discharge from her third hospitalization,
she was en route to the ER with complaints of abdominal pain with nausea
and vomiting preventing medication
intake when she experienced a tonicclonic seizure. She had two more
seizures witnessed in the ER and had
a blood pressure of 200/130 mm Hg.
An MRI of the brain was consistent
with seizures secondary to posterior
reversible encephalopathy syndrome
secondary to hypertensive emergency. She was placed on phenytoin
(Dilantin), and a repeat MRI
showed the condition resolving.
Antibiotics were held in anticipation
that they may have lowered the
seizure threshold. When the Dilantin
level was therapeutic, the antibiotics
were restarted. The main concern
with the patients hypertensive emergency was due to her not taking clonidine (Catapres) due to her nausea
and vomiting, and thus, causing a
rebound hypertension. She was
placed on a clonidine patch prior to
discharge.

Subsequent Follow Up
During the fourth hospitalization,
CT of the abdomen showed no
abnormalities, and compared to prior
examinations, there was significant
improvement in the diffuse colonic
wall thickening. There was marked
interval improvement in the left lateral abdominal wall fluid collection as
well as in the mid-pelvic fluid collection that was identified previously on
CT scan of the abdomen. Four
months after the specimen was collected, the organism in the PD fluid
was identified at an outside laboratory as a scotochromogenic Mycobacter-

176

ium with susceptibilities to all antibacterial agents tested. The patient completed the 6-month course of moxifloxacin, rifampin, and azithromycin.
She was cleared to again pursue kidney transplantation. The infectious
disease consult recommendation
included a prophylaxis with trimethoprim/sulfamethoxazole at the time of
transplantation.

Discussion
Some Questions to Ponder
What was the etiology of this
patients abdominal pain? The
patient had four consecutive hospitalizations over a 2-month period. She
returned each time to the emergency
department with nausea and vomiting
usually accompanied by abdominal
pain. The potential etiologies of her
abdominal pain included hiatal hernia,
a non-tuberculosis mycobacteria
(NTM) infectious peritonitis, pancreatitis, C. difficile colitis, a post- operative wound with a reoccurring seroma/hematoma, and constipation/ileus
related to pain medication. Her multiple etiologies for abdominal pain
made treatment challenging; since an
etiology for the abdominal pain was
determined, treatment focused on resolution for that etiology (antibiotics for
infections, drainage of the seroma/
hematoma, and adjustments to medications to improve elimination of
bowel contents).
The original abdominal pain presentation was deemed by the patient to
be pancreatitis like, even though
she was found to not have pancreatitis by enzyme level but did have peritonitis. This initial pain presentation
may have occurred because the
patient was dialyzing in the pancreatic pseudocyst that communicated
with the pancreas, and therefore,
when the fluid became infected, it was
interpreted by the patient as pancreatitis like pain.
The WBC count in the PD fluid
remaining above 100/mm3 combined
with a prolonged time to organism
identification and antibiotic susceptibility complicated the patients man-

agement. The PD catheter material


could have been seeded with the bacterial organism, so PD catheter
removal was the expected choice
when the PD fluid WBC did not
respond to the antibiotics as expected.
Why did the patient become
infected with the strotochromogenic Mycobacterium? The organism cultured from the patients PD
effluent was eventually identified as a
strotochromogenic Mycobacterium.
This is an environmental Mycobacterium in soil and tap water, and is more
likely to cause opportunistic disease
in an immunocompromised patient.
Patients with CKD Stage 5 are typically immunocompromised; however, the exact mechanism through
which this patient contracted this
organism or why this organism grew
in this patient is unclear. Case reports
in the literature identify NTM peritonitis as an unusual complication of
PD (Li et al., 2010). NTM peritonitis
should be in the differential when a
bacterial peritonitis does not respond
to IP antibiotics. Recovery can be
expected if appropriate antibiotics are
used and the catheter removed if indicated (Lee, Chen, & Wu, 2008).
One report looked at 39 patients
reported in the literature on PD with
an NTM infection, and reviewed the
treatment and outcomes for these
patients (Singh & Saha, 2008). This
study concluded there is growing consensus that treatment of NTM in
patients on PD should be considered
in the differential of exit site infections
or peritonitis if routine cultures are
repeatedly negative or if the patient
does not respond to first-line therapy.
Antibiotics should be guided by susceptibility results. Treatment duration
has not been defined, but several
months of antibiotics may be
required. If peritonitis develops, the
catheter should be removed (Singh &
Saha, 2008).
Why did the patient have prior
episodes of pancreatitis? Studies in
the literature suggest that the incidence of pancreatitis may be up to
three times higher in patients using
PD compared to those on hemodialysis

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(Lankisch, Weber-Dany, Maisonneuve,


& Lowenfels, 2008). The basis for this
increased incidence is not clear.
Abnormalities, however, such as
hypertriglyceridema, hypercalcemia,
and irritation of the pancreas from the
retroperitoneal diffusion of the
dialysate, may play a role. Serum
amylase levels may be increased, but
dialysate amylase levels may be more
valuable in providing diagnostic
information. Pancreatitis in the PD
population causes increased morbidity and mortality, so early diagnosis
and vigilant management are important to improve patient outcomes
(Mehrota & Kathuria, 2008).
How could this patient have
dialyzed in this pancreatic
pseudocyst? Historically, this patients PD experience was complicated
with the PD catheter migrating into
what was eventually determined to be
a pancreatic pseudocyst, which possibly resulted from a previous pancreatitis. Reviewing the PD equilibration
test, this relatively small patient was
adequately dialyzed with a Kt/V urea
of 1.9 prior to admission. Further calculations showed that the surface area
of the cyst was 1153 cm2. Her estimated peritoneal surface area is 1560
cm2. The size of the pseudocyst was
large enough to accomodate the volume of her PD exchanges and to
maintain an adequate Kt/V urea. The
presence of inflammation may have
enhanced solute transport (Infante,
Depner, Morfin, & Pappoe, 2009).
Patients with large body surface
area do not stay on dialysis as long as
smaller patients mostly because of
inadequate clearances (Prowant,
Moore, Satalowich, & Twardowski,
2010). This relatively small patient (5
feet, 2 inches, and whose weight was
56.3 kg) was able to maintain an adequate Kt/V urea via her pseudocyst
membrane with an estimated surface
area of 1153 cm2.

Assessment of Abdominal
Pain in the Patient on PD
Acute abdominal pain is one of
the most frequent complications for a
patient undergoing PD. The differential diagnosis for abdominal pain in

Nephrology Nursing Journal

these patients is broad and should be


approached based on the patients
presentation and history. Pain receptors in the abdomen respond to
mechanical and chemical stimuli.
Stretch is the principal mechanical
stimulus involved in visceral nociception, although swelling, distention,
contraction, traction, compression,
and torsion are also perceived.
Mucosal receptors respond primarily
to chemical stimuli, in contrast to
other visceral nociceptors that
respond to chemical or mechanical
stimuli. A variety of chemical stimuli
are capable of triggering these receptors,
including
substance
P,
bradykinin, serotonin, histamine, and
prostaglandins, which are released in
response to inflammation or oxygen
deprivation caused by ischemia.
Opioids are the most effective pain
medication for this classification of
pain (Miranda, 2011), which feels like
a deep ache with cramping. Visceral
abdominal pain may radiate to other
locations in the back and chest
(Miranda, 2011).
The clinician assessing a patient
on PD with abdominal pain should
consider the location and description
of the abdominal pain in addition to
associated symptoms and patient history to guide assessment and to create
the treatment plan. The clinician
should gather pertinent information
from the patients presentation and
history, including changes in temperature, blood pressure, heart rate,
breath sounds, bowel sounds,
appetite, weight, urine, stool, or medications taken. Abdominal pain is
often associated with symptoms that
include nausea, vomiting, diarrhea,
constipation, bloating, hematochezia,
melena, and/or jaundice (Penner &
Majumdar, 2009). The history should
include a gynecological history in
women. Physical examination should
include palpation of the abdomen for
masses or tenderness, inspection of
the PD catheter exit site, palpation of
the PD catheter tunnel, rectal examination for occult blood, and pelvic
examination for women with lower
abdominal pain. Information is provided in Table 1 to differentiate the

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etiology of the abdominal pain based


on pain location and characteristics.

Diagnostic Assessment
Laboratory assessment should
always include PD fluid for cell count
with differential, culture, and sensitivity to look for peritonitis. Additional
laboratory assessment when indicated
should include serum CBC with differential, electrolytes, glucose, aminotransferases, alkaline phosophatase,
bilirubin, lipase, urinalysis (if producing urine), a pregnancy test for
women of child bearing age, and
blood and urine cultures. Further
work-up recommendations (such as
abdominal X-ray, US, or CT) based
on pain location and characteristics
are shown in Table 1.

Causes of Abdominal Pain


In Patients on PD
Peritonitis
The most common cause of
abdominal pain in the patient on PD
is peritonitis. Peritonitis is most commonly caused by bacterial infections
from a skin or bowel source, but may
occur secondary to a fungal pseudomonas or mycobacterial infection. In
addition to abdominal pain, turbid
dialysate effluent, rebound tenderness, and occasionally fever, nausea,
and vomiting may be present. The
incidence of peritonitis in recent years
has decreased to 0.5 episodes per
patient year or about one episode
every 24 to 26 patient months. This
decrease is due to improved technology and connection techniques
(Ponferrada, Prowant, & Satalowich,
2008). Aseptic peritonitis occurs infrequently and can be caused by a reaction of the peritoneum to medications
or intraabdominal foreign material
(such as PD catheter). Turbid
dialysate and a relatively low WBC
count are characteristic of this condition (Ponferrada et al., 2008).
Clinical course of peritonitis.
When a patient on PD presents with
infectious peritonitis, clinical improvement and a reduced peritoneal
fluid WBC should occur within 72

177

Abdominal Mysteries: Pain, Peritonitis, Pancreatitis, Pseudocyst

Table 1
Abdominal Pain in the Patient on PD by Location
Potential Etiology

Accompanying Symptoms and Considerations


Epigastric Region Abdominal Pain

Diabetic gastroparesis
and delayed gastric
emptying

Patient may present with dyspepsia, upper abdominal fullness, early satiety, bloating, nausea, and
vomiting. Delayed gastric emptying of solids and liquids has been detected in 50% of both symptomatic
and asymptomatic patients undergoing PD, including those patients without diabetes (Barri & Golper,
2010).
A scintigraphic gastric emptying study is useful to reach diagnosis.

Gastro-esophageal reflux
disease, hiatal hernia,
and/or Mallory-Weiss
syndrome

The patient may present with a pain pattern synchronized with eating. Symptoms worsen with increased
pressure on the gastro esophageal sphincter and include post-prandial and/or substernal fullness,
dysphagia, nausea and vomiting, and hematemesis in a Mallory-Weiss tear. Reflux symptoms may be
worsened by increased intra-abdominal pressure from PD fluid, although changes are usually not
measurable in the lower esophageal sphincter pressures (Holley & Schmidt, 2010). Patients on CAPD
who were symptomatic were observed to have a significantly higher number of reflux episodes and an
increased time in which the lower esophageal pH was less than 4 as determined by 24-hour gastric and
esophageal pH monitoring (Kim, Kwon, & Lee, 1998).
Gastroscopy is useful to visualize the tissue for inflammation, trauma, and/or bleeding.

Gastritis and peptic ulcer


disease

The patient presents with burning, gnawing stomach pain. Symptoms occur 2 to 5 hours after eating and
are typically worst between 11:00 p.m. and 2:00 a.m. Patients will report relief with alkali or antisecretory
agents (Fishman & Aronson, 2010). Although the incidence of peptic ulcer disease is not increased in
patients on dialysis, an enhanced frequency of underlying mucosal inflammation in the upper GI system
may be observed (Barri & Golper, 2010).
Gastroscopy is useful to visualize the tissue for inflammation, trauma, and/or bleeding.

Myocardial ischemia or
infarction

The patient may have referred cardiac pain to the epigastric area. This pain is typically accompanied by
shortness of breath. Patients with CKD Stage 5 are at increased risk for cardiovascular disease.
Cardiovascular disease accounts for 50% of deaths in the CKD Stage 5 population (United States Renal
Data System, 2010). Presenting patient may have recurrent hypotension that prevents attaining dry
weight and heart failure that is unresponsive to changes in dry weight.
An EKG, echocardiogram, and cardiac troponin-I can aid diagnosis.

Ruptured aortic
aneurysm

The patient may present with a pulsatile abdominal mass, usually combined with unstable blood
pressure. Typically, patient pain is very acute and radiates to the back. This is a life-threatening condition;
consider an abdominal ultrasound if the patient is hemodynamically stable; otherwise, the patient should
go directly to surgery (Fishman & Aronson, 2010).

Pancreatitis

The patient may have a history of gallbladder disease or recent alcohol ingestion (previous 1 to 3 days).
The patient may present with rapid onset (10 to 20 minutes) diffuse pain or band-like radiation of pain to
the back, with nausea, vomiting, and anorexia. Pain may last for many days. The patient may be restless
and agitated. The patient may have relief when bending forward. The most common cause of pancreatitis
in the U.S. is a gallstone blocking pancreatic outflow (Go & Everhart, 1994). Patients on PD have an
increased risk for developing acute pancreatitis. Possible causative factors related to PD therapy include
exposure to PD solutions or dialysis-related irritants, the incidence of peritonitis, or the presence of
hypertriglyceridema.
Abdominal ultrasound and CT scan aid diagnosis. A serum lipase level is preferred to an amylase level
because elevations in amylase in patients with CKD Stage 5 are most often due to impaired renal
clearance. Lipase levels may be elevated in patients on hemodialysis thought to be secondary to the
heparin exposure. Icodextrin, in one study, decreased measured amylase activity by as much as 90%
(Soundararajan & Golper, 2009).

GI and pancreatic cancer

The patient can present with pain worsening with eating and radiating straight through to the back. The
patient may prefer the fetal position. The patient is usually experiencing weight loss. Tumors in the
pancreatic tail present with more pain. Tumors in the head of the pancreas present with steatorrhea,
weight loss, and often jaundice (Fernandez-del Castillo, 2010).
Gastroscopy is useful to determine pathology and can include biopsies.

continued on next page

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Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology

Accompanying Symptoms and Considerations


Right Upper Quadrant Abdominal Pain

Pancreatitis

(See above.)

Cholecystitis

Cholecystitis symptoms often occur one hour after fatty food ingestion. Pain may be deep and gnawing
or severe and sharp. Pain may radiate to right shoulder. Pain may last 4 to 8 hours and may be
accompanied by a fever. Pain with jaundice but without a fever may be ascending cholangitis (Fishman
& Aronson, 2010). The clinical management of patients with CKD Stage 5 with cholecystitis is similar to
those without renal failure.
Ultrasound may show dilated biliary tree. Endoscopic retrograde cholangiopancreatography (ERCP)
allows visualization to diagnose and sometimes to treat (removal of stones or blockage) disorders of the
bile and pancreatic ducts.

Hepatitis

Pain may be accompanied by malaise, nausea, vomiting, anorexia, and/or fever. Hepatitis may be viral
or alcohol related. Historically, the most common cause of viral hepatitis in patients on hemodialysis was
the hepatitis B virus (HBV). Implementation of standard precautions, screening of patients and staff,
vaccinations of all susceptible patients and staff, and the use of dedicated rooms and machines has led
to the decline in spread of HBV in dialysis units. Hepatitis C virus and hepatitis G virus are both more
prevalent in patients on dialysis (Natov & Pereira, 2010).
Hepatitis serologies are useful in determining a patients exposure to a virus; however, patients on dialysis
are often immunocompromised, and serum reactivity can be challenging to interpret. Aminotransferases
tend to be below normal in patients on dialysis without liver disease present. Upper limit of normal in
these patients is AST 24 IU/L, and ALT 17 IU/L (Soundararajan & Golper, 2009). Gammaglutanyltranspeptidase (GGT) increases with hepatobiliary disease. Alkaline phosphatase may be increased
related to renal osteodystrophy.

Pulmonary or pleural
pathology

Pain may be related to volume overload secondary to heart failure or a pleuroperitoneal leak giving rise
to a pleural effusion (hydrothorax). Finding the effusion is only right-sided should prompt a search for a
pleuroperitoneal communication in the patient on PD (Holley & Schmidt, 2010).
Left Upper Quadrant Abdominal Pain

Splenic abscess or
infarction

A splenic abscess is usually associated with a fever and may be associated with splenic infarction.
Splenic infarction may be the result of an embolic insult from atrial fibrillation (Fishman & Aronson, 2010).
Patients with polycystic kidney disease can present with cysts in the spleen.

Gastritis and peptic ulcer


disease

(See above.)

Pancreatitis

Pancreatitis infrequently presents on the left. (See pancreatitis above.)

Hepatobiliary disease

(See cholecystitis and hepatitis above.)


Periumbilical Region Abdominal Pain

Early appendicitis

(See appendicitis below.)

Diverticular disease

(See below.)

Mesenteric ischemia or
infarction

Mesenteric infarction may be a life-threatening condition. Pain appears to be out of proportion to physical
findings and may be accompanied by diarrhea. Risk factors include a personal or family history of a
hypercoagulable state or venous thrombosis, congestive heart failure, recent myocardial infarction,
hypotension, hypovolemia, sepsis, cardiac surgery, or a requirement for dialysis. Patients on dialysis are
frequently older, have extensive peripheral vascular disease, and may experience prolonged periods of
hypotension, thereby increasing the risk for ischemia of the mesenteric vasculature (Barri & Golper,
2010).
Mesenteric angiography is the most effective diagnostic tool.

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179

Abdominal Mysteries: Pain, Peritonitis, Pancreatitis, Pseudocyst

Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology

Accompanying Symptoms and Considerations


Periumbilical Region Abdominal Pain (continued)

Intestinal obstruction

Pain may be accompanied by bloating following meals, vomiting, weight loss, abdominal distention tender
to palpation, and constipation. Intestinal obstruction may be partial or complete and result from
incarcerated hernias, surgical adhesions, intussusceptions, volvulus, inflammatory bowel disease,
colonic carcinoma, and constipation leading to fecal impaction (Fishman & Aronson, 2010; Penner &
Majumdar, 2009).
Constipation is a common complication of the patient on PD who often uses phosphate binders,
analgesics, and iron. Additionally, the patient on PD may have a motility disorder and a sedentary lifestyle.
Constipation causes nearly half of all cases of PD catheter outflow failure (Schmidt & Holley, 2010b).
Prolonged constipation should be treated promptly because it may lead to a secondary peritonitis.
Computerized tomography (CT) has been replacing the small bowel radiographic series as the adjunctive
study of choice since it can simultaneously provide information about the presence, level, severity, and
cause of intestinal obstruction.

Ruptured aortic aneurysm

(See above.)

Gastroenteritis

(See below.)
Right Lower Quadrant Abdominal Pain

Appendicitis

Pain and rebound tenderness may migrate from the periumbilical area to the right iliac fossa as the
appendiceal inflammation involves the peritoneal surface. Pain may be accompanied by fever, anorexia,
nausea, and vomiting (Fishman & Aronson, 2010).
A serum WBC and an abdominal CT with contrast are useful to confirm clinical suspicion.

Diverticulitis

(See below.) In Asian countries, diverticulitis commonly presents uniquely with pain on the right side.
Right-sided pain can lead to misdiagnosis of appendicitis (Fishman & Aronson, 2010).

Salphingitis

(See pelvic inflammatory disease below.) Symptoms and causes are the same but may be more onesided in the event the focus of the inflammation is on one fallopian tube.

Ectopic pregnancy

Pain is accompanied by missed or late menstrual period (6 to 8 weeks) and vaginal bleeding (Fishman
& Aronson, 2010). Pregnancies are uncommon in the patient on dialysis but do occur. There are no
findings to indicate an increased risk for ectopic pregnancy in the patient on PD; however, both conditions
are associated with infertility.
A transvaginal ultrasound combined with a serum or urine human chorionic gonadotropin level will aid
diagnosis (Fishman & Aronson, 2010).

Hernia

Hernias present with a bulge that can become more prominent when coughing, straining, or standing up.
Hernias are rarely painful, and pain is suggestive of strangulated or incarcerated bowel. Hernias occur more
often in patients on PD secondary to the increased abdominal pressure from the PD fluid/treatment. Surgical
incisions in the abdominal wall to place the PD catheter also increase the risk for an abdominal hernia.
Dialysate fluid leaks can occur from acquired or congenital defects in the abdominal and thoracic wall. This
may demonstrate as a hydrothorax, hernia, or genital/abdominal wall edema (Ponferrada et al., 2008).
Peritoneal scintigraphy and CT peritoneography are useful tests to detect peritoneal defects.

Nephrolithiasis

The colicky pain of nephrolithiasis is most often located in the back, but can present in the abdomen and
may be accompanied by nausea, vomiting, hematuria, pyuria, oliguria, and/or hydronephrosis (Fishman
& Aronson, 2010). If the patient on PD has had a history of nephrolithiasis, he or she would be at
increased risk for a repeat occurrence.
A non-contrast helical CT scan can detect both stones and urinary tract obstruction, and is the gold
standard for diagnosing nephrolithiasis (Fishman & Aronson, 2010).

Inflammatory bowel
disease

Crohns disease and ulcerative colitis are the primary examples of inflammatory bowel disease and
involve ulcerations of the intestine from the distal ileum to the anus. Pain is accompanied by vomiting,
diarrhea, rectal bleeding, and weight loss. Among current asymptomatic patients on dialysis, for example,
routine colonoscopy reveals no enhanced incidence of mucosal lesions (Barri & Golper, 2010).
Diagnosis is generally achieved by colonoscopy with biopsy of pathological lesions.

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Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology

Accompanying Symptoms and Considerations


Mid-Lower Region Abdominal Pain

Pelvic inflammatory
disease (PID)

Lower abdominal pain with menses, coitus, or jarring movement is the classic symptom of PID. Pain may
be accompanied by fever (50%), uterine bleeding (33%), and/or vaginal discharge (Fishman & Aronson,
2010). PID is associated with sexually transmitted diseases or invasive gynecological procedures. There
are no findings to indicate the patient on PD has increased risk for PID.
Diagnosis is aided by a urinalysis and microscopic evaluation of vaginal discharge.

Ectopic pregnancy

(See above.)

Endometriosis

Pain associated with endometriosis is typically worse during menses. Pain typically occurs with
abnormal menstrual bleeding and infertility (Fishman & Aronson, 2010). The female patient on PD may
experience benign hemoperitoneum secondary to ovulation, retrograde menstruation, or
endometriosis; however, there are no findings to indicate an increased incidence for endometriosis in
the patient population on PD.
Laparoscopy is the preferred technique for diagnosing endometriosis.

Leiomyomas

Pain may be accompanied by urinary frequency, difficulty emptying the bladder, constipation, and
dyspareunia. Degeneration, torsion, or infarction of the fibroid is associated with pain, nausea, vomiting,
and vaginal bleeding (Fishman & Aronson, 2010). The female patient on PD may experience
leiomyomas; however, there are no findings to indicate an increased incidence in the patient on PD.
Abdominal ultrasound will aid diagnosis.

Urinary tract infection

Pain may be suprapubic and accompanied by pelvic pressure, dysuria, hematuria, diarrhea, nausea,
vomiting, lethargy, incontinence, urinary frequency, foul-smelling or cloudy urine, and fever.
Diagnosis is aided by a urine culture and urinalysis.
Left Lower Quadrant Abdominal Pain

Diverticulitis

Patient may present with nausea, vomiting, diarrhea, or constipation. Left lower quadrant pain is most
common in Western countries, while right-sided disease with right lower quadrant pain is the most
common finding in Asian countries (Fishman & Aronson, 2010). Diverticula may progress with the
formation of an abscess, fistula, obstruction, perforation, and/or peritonitis, all of which are very serious
findings for the patient on PD. Incidence for patients on PD is increased if patient has a diagnosis of poly
cystic kidney disease (Barri & Golper, 2010).
Abdominal CT scan with contrast will assist in confirming clinical suspicions.

Constipation

(See above.)

Nephrolithiasis

(See above.)

Salpingitis

(See pelvic inflammatory disease above.) Symptoms and causes are the same but may be more onesided in the event the focus of the inflammation is on one fallopian tube.

Ectopic pregnancy

(See above.)

Hernia

(See above.)

Irritable bowel syndrome

Irritable bowel syndrome is a diagnosis of exclusion and presents with abdominal pain or discomfort in
association with frequent diarrhea or constipation. No change of incidence is noted in the PD population.

Inflammatory bowel
disease

(See above)

Infectious bowel disease of (See gastroenteritis below.) Patients on dialysis are particularly susceptible to Clostridium difficile colitis,
since they commonly receive antibiotics. Pain may be accompanied by watery diarrhea, fever, and ileus.
distal intestinal tract
One study noted the dismal long-term prognosis was 60 of 70 patients with C. difficlie died over a followup period of five years (Schmidt & Holley, 2010a).
Cytotoxin assay and endoscopic examination may be needed to support clinical suspicions.

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181

Abdominal Mysteries: Pain, Peritonitis, Pancreatitis, Pseudocyst

Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology

Accompanying Symptoms and Considerations


Left Lower Quadrant Abdominal Pain (continued)

GI cancer

Pain may be accompanied by blood loss and changes in bowel habits. Presentations of colonic neoplasia
are highly variable, so risk factors for colon cancer (particularly age and family history) should be
considered in patients with lower abdominal pain. Patients on PD have a higher incidence of
nonmalignant gastrointestinal abnormalities leading to a positive stool guaiac test (Barri & Golper, 2010).
For early detection of a colorectal malignancy, the patient on dialysis should receive annual screening
with stool guaiac testing, followed by colonoscopy if indicated.
Multifocal, Global, or Diffuse Abdominal Pain

Mesenteric ischemia and


infarction

(See above.)

Pancreatitis

(See above.)

Intestinal obstruction

(See above.)

Irritable bowel syndrome

(See above.)

Ruptured aneurysm

(See above.)

Lactose intolerance

Pain is accompanied by stomach cramps, nausea, bloating, acid reflux, and flatulence. Incidence is most
common in African and Asian populations, and is independent of the presence of PD.
The lactose breath hydrogen test is a noninvasive test that measures lactose nonabsorption.

Inflammatory bowel
disease

(See above)

Gastroenteritis

Pain with vomiting and diarrhea caused by a viral or bacterial ingestion. Family may present with the
same symptom history if toxin-mediated food poisoning (Penner & Majumdar, 2009).
A careful history is used to determine the etiology of symptoms. Diagnostic work-up should continue if
the patient presents with diarrhea-associated hypovolemia, small volume stools containing blood and
mucus, bloody diarrhea, temperature equal to or greater than 38.5C, passage of more than six unformed
stools per 24 hours or a duration of illness greater than 48 hours, severe abdominal pain, recent use of
antibiotics, diarrhea in the elderly (70 years of age or older), or the patient is immunocompromised
(Penner & Majumdar, 2009).
Abdominal Pain Directly Related to PD Treatments

Peritonitis

Pain is characteristically diffuse with rebound tenderness. Patient will be very still to decrease pain from
movement. Patients on PD are at increased risk for peritonitis secondary to a break in aseptic technique
in appropriately performing the PD treatment itself. This typically results in a bacterial peritonitis from a
skin or bowel source; however, the patient on PD can also experience a fungal, pseudomonal,
mycobacterial, or aseptic peritonitis (Ponferrada et al., 2008).
The PD fluid cell count should be measured and tracked over time; a WBC greater than 100/microliter
with greater than 50% polymorphonuclear cells is diagnostic of peritonitis. The PD fluid should be cultured
to determine the organism and susceptibility to treatment (Ponferrada et al., 2008).

PD infusion or drain pain

Pain predominately occurs at the time of PD fluid drain or fill. This complaint is thought to be caused by
the acidic pH (5.2 to 5.5) of conventional PD solution and is often improved when alternative solutions
are used that have added bicarbonate. Contributing factors may include poor catheter position, dialysis
solution temperature, rapidity of the dialysis solution inflow, and the hypertonicity of the dialysis solution
containing an elevated glucose concentration (Holley & Schmidt, 2010).

Catheter position

Severe pain in the rectum or perineum can be the result of an improperly placed catheter that is abutting
against sensitive abdominal structure (Ponferrada et al., 2008).

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Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology

Accompanying Symptoms and Considerations


Abdominal Pain Directly Related to PD Treatments (continued)

Dialysis solution leaks

Fluid may leak due to high pressure in the abdomen. The leak may occur into the abdominal wall, through
the abdominal wall as a hernia, or into the pleural space through a diaphragmatic leak. When a leak
occurs and causes pressure in an adjacent space, the tissue can be swollen, tender, or painful (Holley &
Schmidt, 2010).
(See hernia above.)

Exit site/tunnel
complications

Pain is local to the exit site and/or tunnel. A tender exit site or tunnel should be treated and watched
carefully because either of these conditions may lead to peritonitis if the infection tracts down the tunnel
into the peritoneal space. Culture the exit site and any fluid or pus expressed from the tunnel. If the exit
site does not appear healthy, exit site care should be performed 2 to 3 times a day.

Constipation

(See intestinal obstruction section above.)

Hemoperitoneum

This condition may occur painlessly. Very small amounts of blood will make the dialysis effluent appear
pink tinged. Pink or bloody effluent suggests bleeding inside the abdomen. The female patient on PD may
experience benign hemoperitoneum secondary to ovulation, retrograde menstruation, or endometriosis.
Catheter manipulation can result in some bleeding and typically resolves with time. If bleeding continues,
any anticoagulation therapy should be stopped, and the source should be investigated and could include
ruptured cysts from polycystic kidney disease or other retroperitoneal pathology (Bleyer & Burkart, 2010).
A cell count of the dialysis effluent can help quantify the volume of blood loss. Abdominal imaging can be
useful to find the source of the bleeding.
Abdominal Pain in Special Populations

Elderly patients

Elderly patients may present with little to no symptoms and underwhelming laboratory findings that do
not demonstrate the etiology of the abdominal pain. A thorough history is critical in developing clinical
suspicion. Mortality related to under-diagnosis of the acute abdomen in the elderly is high (Fishman &
Aronson, 2010).

Hemophilia

Patients with hemophilia presenting with abdominal pain should be screened for hematomas in the bowel
wall with appendicitis-like pain (Fishman & Aronson, 2010).

Sickle cell disease

Patients with sickle cell disease presenting with abdominal pain (usually right upper quadrant) should be
evaluated for injury to the bowel related to ischemia (Fishman & Aronson, 2010).

hours after treatment initiation. When


faced with an elevated peritoneal fluid
WBC and the absence of positive cultures, the clinician must think beyond
the most common causes of peritonitis. If a drop in WBC does not occur
with initial treatment, then further and
aggressive work-up is indicated for
alternative causes of the peritonitis,
including fungal or mycobacterial
sources. The clinician should keep in
mind that by day three, a WBC
greater than 1090/mm3 in the PD
fluid increases the mortality exponentially (Chow et al., 2006).
When the patient has relapsing or
refractory peritonitis, the clinician
should drain the peritoneum, remove
the PD catheter, and focus on preserv-

Nephrology Nursing Journal

ing the peritoneum rather than saving


the peritoneal catheter (Li et al., 2010).
Diagnosing peritonitis caused
by Mycobacterium. Difficulties in
identifying and determining susceptibilities of Mycobacterium in a timely
manner lead to delays in targeted
treatment. One case report describes
using real-time polymerase chain
reaction (PCR) methods to identify
the M. tuberculosis DNA instead of
waiting for a traditional positive AFB
smear (Dervisoglu, Sayan, Sengul, &
Yilmaz, 2006). This approach can lead
to isolating the Mycobacterium more
quickly, allowing the clinician to initiate appropriate treatment.
Currently, there are 71 recognized
species of Mycobacterium. The relative

March-April 2011

Vol. 38, No. 2

virulence of mycobacteria encountered in clinical situations varies from


the pathogenic species, such as M.
tuberculosis, to the typically nonpathogenic species of Mycobacterium
(Shinnick & Good, 1994).
Mycobacteria thought to be nonpathogenic may still present in the
immunocompromised patient. A case
report for a peritonitis caused by
Mycobacterium simiae in a patient with
human immunodeficiency virus (HIV)
on PD demonstrated the difficulty of
diagnosing and treating peritonitis with
an NTM. Peritonitis caused by
mycobacteria should be considered in
all patients with recurrent peritonitis
that fails to resolve with conventional
therapy. Additionally, NTM isolated in

183

Abdominal Mysteries: Pain, Peritonitis, Pancreatitis, Pseudocyst

the PD fluid should be confirmed on


more than one specimen, given the
possibility of an environmental contamination (Keenan, Jeyaratnam, &
Sheerin, 2005).
Treatment of peritonitis. When
treating a patient with peritonitis secondary to mycobacteria, the peritoneal fluid concentration of the
antibiotics must reach a therapeutic
level. When measured, the peritoneal
fluid concentrations of standarddosed, orally administered isoniazid
and pyrazinamide were maintained
above the minimum inhibitory concentrations (MICs); however, peritoneal fluid concentration of rifampin
was below the therapeutic range most
of the time. Orally administered
rifampin did not reach MICs for
Mycobacterium tuberculosis in the peritoneal fluid (Ahn et al., 2003).
Treatment for NTM, depending
on the organism and its susceptibility
pattern, generally requires prolonged
(6 to 12 months) multi-drug antimicrobial therapy and PD catheter
removal. The mycobacterial agents
require dosing adjustments for clearance and careful monitoring for toxicity (Rho, Bia, & Brewster, 2007).
Although NTM is not a common
cause of peritonitis in the patient on
PD, its presence is an indication to
remove the PD catheter and to transfer the patient to hemodialysis. A
Japanese study looked at risk factors
and causes for removal of the PD
catheter and found 47% of the
catheters were removed secondary to
infections including Staphylococcus,
Candida, Pseudomonas, and NTM
(Nodaira et al., 2008).
The patient on PD with peritonitis
secondary to an NTM needs to be
adequately treated to resolve the peritonitis. This includes culturing the PD
fluid, often more than one time; treating the infection with antibiotics to
which the organism is susceptible
(although susceptibility information
may take a long time to result, meaning the clinician will use the clinical
response of the patient in combination with treating the organism with
broad antibiotic coverage); usually
removing the PD catheter; and sup-

184

porting the patient through the rigors


of a prolonged course of antibiotics
(Keenan et al., 2005; Lee et al., 2008;
Rho et al., 2007; Singh & Saha, 2008).

Pancreatitis
The most common cause of acute
pancreatitis in the U.S. is gallstones
blocking pancreatic flow. Patients can
also experience acute pancreatitis
after alcohol ingestion (1 to 3 days).
Patients on dialysis, especially PD,
have an increased risk for developing
acute pancreatitis. Acute pancreatitis
in patients undergoing PD is more
frequent and seems to be more severe
than in those receiving hemodialysis
treatments. Some causative factors
related to PD therapy include PD
solutions or dialysis-related irritants,
the incidence of peritonitis, or hypertriglyceridema (Lankisch et al., 2008).

Pseudocyst
Pancreatic pseudocysts develop
after an acute attack of pancreatitis in
approximately 10% of cases
(Cameron, 1983; O Malley, Cannon,
& Postier, 1985). Pseudocysts are
lined by fibrous tissue and granulation tissue. The lack of an epithelial
lining distinguishes pseudocysts from
true cystic lesions of the pancreas.
The pseudocyst can be filled with
necrotic material and fluid, and may
communicate with the pancreatic
ductal system and contain high concentrations of digestive enzymes
(Khalid & McGrath, 2010).
When assessing an encapsulated,
fluid-filled peripancreatic lesion in a
patient with acute pancreatitis, diagnosis of a pancreatic pseudocyst
should occur cautiously since there is
no single test that can definitively rule
out a pancreatic cystic neoplasm.
Ideally, there is a baseline abdominal
imaging study that demonstrates the

absence of the lesion, chronologically


followed by a clinical history that documents pancreatitis, again followed
chronologically by abdominal CT
demonstrating the presence of the
pancreatic lesion and associated
inflammatory changes. Management
of the pancreatic pseudocyst can
occur conservatively by watching the
lesion for resolution, or with drainage
accomplished surgically with or without percutaneious catheter or endoscopically with or without stenting
(Howell, Shah, & Lawrence, 2009).

Nursing Implications
When a patient undergoing PD
presents with abdominal pain, the differential etiology is broad. Patients on
PD may experience similar types of
abdominal pain as the general population. The clinician, however, should
always check the PD fluid for cell
count and culture, and sensitivity.
Abdominal pain may be PD-related
peritonitis, or it could be multi-factorial, as was the case in this scenario presented. Patients on PD have an
increased risk for some abdominal
pathologies, and additionally, are
immunocompromised because of
CKD Stage 5. Careful assessment of
the patient upon presentation will
guide the work-up for abdominal pain
and lead the clinician to the causative
factor(s) and appropriate interventions.
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Ahn, C., Oh, K.H., Kim, K., Lee, K.Y.,
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(2003). Effect of peritoneal dialysis
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Nephrology Nursing Journal Editorial Board Statements of Disclosure


In accordance with ANCC-COA governing rules Nephrology Nursing Journal Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for this offering are published below.
Paula Dutka, MSN, RN, CNN, disclosed that she is a consultant and research coordinator, is on the speakers
bureau, and has sat on the advisory board for Genentech.
Patricia B. McCarley, MSN, RN, NP, disclosed that she is on the Consultant Presenter Bureau for Amgen,
Genzyme, and OrthoBiotech. She is also on the Advisory Board for Amgen, Genzyme, and Roche and is the
recipient of unrestricted educational grants from OrthoBiotech and Roche.

Nephrology Nursing Journal

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Vol. 38, No. 2

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Journal of Surgery, 150, 680-682.

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Vol. 38, No. 2

Penner, R., & Majumdar, S. (2009).


Diagnostic approach to abdominal pain in
adults. Retrieved from http://www.
uptodate.com/contents/diagnosticapproach-to-abdominal-pain-in-adults
Ponferrada, L., Prowant, B., & Satalowich,
R. (2008). Peritoneal dialysis complications. In C. Counts (Ed.) Core curriculum for nephrology nursing (pp. 824851). Pitman, NJ: American
Nephrology Nurses Association.
Prowant, B., Moore, H., Satalowich, R., &
Twardowski, Z. (2010). Peritoneal dialysis survival in relation to patient
body size and peritoneal transport
characteristics. Nephrology Nursing
Journal, 37(6), 641-647.
Rho, M., Bia, M., & Brewster, U. (2007).
Nontuberculous mycobacterial peritonitis in peritoneal dialysis patients.
Seminars in Dialysis, 20, 271-276.
Schmidt, R., & Holley, J. (2010a). Non-access
related infections in chronic dialysis
patients. Retrieved from http://www.
uptodate.com/contents/non-accessrelated-infections-in-chronic-dialysispatients
Schmidt, R., & Holley, J. (2010b). Noninfectious complications of peritoneal
dialysis catheters. Retrieved from
http://www.uptodate.com/contents/
noninfectious-complications-ofperitoneal-dialysis-catheters
Shinnick, T., & Good, R. (1994). Mycobacterial taxonomy. European Journal
of Clinical Microbiology and Infectious
Diseases, 13(11), 884-901.
Singh, H., & Saha, T. (2008). Exit-site infection due to nontubercular Mycobacteria in an immune-compromised
peritoneal dialysis patient. Nephrology
Dialysis Transplantation, 37(10), 401409.
Soundararajan, R., & Golper, T. (2009).
Serum enzymes in patients with renal failure. Retrieved from http://www.
uptodate.com/contents/serumenzymes-in-patients-with-renal-failure
United States Renal Data System. (2010).
USRDS 2009 annual data report. U.S.
Department of Health and Human
Services. The National Institutes of
Health, National Institute of Diabetes
and Digestive and Kidney Diseases.
Baltimore: Author.

Additional Reading
Holley, J. (2010). Cancer screening in patients
with end stage renal disease. Retrieved
from http://www.uptodate.com/contents/cancer-screening-in-patientswith-end-stage-renal-disease

185

ANNJ1112

Abdominal Mysteries: Pain, Peritonitis, Pancreatitis, Pseudocyst

ANSWER/EVALUATION FORM

Abdominal Mysteries: Pain, Peritonitis, Pancreatitis, Pseudocyst


Maureen Craig, MSN, RN, CNN; Sergio Infante, MD
1.3 Contact Hours
Expires: April 30, 2013
ANNA Member Price: $15
Regular Price: $25
Posttest Instructions
Complete the evaluation.
Send this page to the ANNA National
Office; East Holly Avenue Box 56;
Pitman, NJ 08071-0056; or fax this
form to (856) 589-7463.
Enclose a check or money order
payable to ANNA. Fees listed in
payment section.
A certificate for the contact hours will
be awarded by ANNA.
Please allow 2-3 weeks for processing.
You may submit multiple answer forms
in one mailing; however, because of
various processing procedures for
each answer form, you may not receive
all of your certificates returned in one
mailing.

Complete the Following:


Name: ____________________________________________________________
Address: __________________________________________________________
__________________________________________________________________
Telephone: ______________________ Email: _____________________________
CNN: ___ Yes ___ No

CDN: ___ Yes ___ No

CCHT: ___ Yes ___ No

Payment:
ANNA Member: ____ Yes ____ No
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upon successful completion of the posttest.
Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at
www.annanurse.org/journal
1. What would be different in your practice if you applied what you have learned
from this activity? (Response Required)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

To provide an overview of abdominal pain in


patients on peritoneal dialysis.
Please note that this continuing nursing education activity does not
contain multiple-choice questions. This posttest substitutes the multiple-choice questions with an open-ended question. Simply answer
the open-ended question(s) directly above the evaluation portion of
the Answer/Evaluation Form and return the form, with payment, to
the National Office as usual.

Strongly
disagree

Evaluation
2. By completing this offering, I was able to meet the stated objectives
a. Discuss the treatment of a patient on peritoneal dialysis who presents with acute
abdominal pain.
b. Identify the potential etiologies of abdominal pain in patients on peritoneal dialysis.
c. Explain the symptoms and considerations for the etiologies of abdominal pain in patients on
peritoneal dialysis.
3. The content was current and relevant.
4. This was an effective method to learn this content.
5. Time required to complete reading assignment: _________ minutes.
6. I am more confident in my abilities since completing this material.

Strongly
agree

1
1

2
2

3
3

4
4

5
5

1
1
1

2
2
2

3
3
3

4
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5
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I verify that I have completed this activity ________________________________________________________________________________


(Signature)

186

Nephrology Nursing Journal

March-April 2011

Vol. 38, No. 2

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