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Sergio Infante
Clinical Consult
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.
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.
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
173
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.
March-April 2011
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
Pain Management
Can Be a Pain
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175
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-
March-April 2011
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
March-April 2011
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.
177
Table 1
Abdominal Pain in the Patient on PD by Location
Potential Etiology
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.
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).
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.
178
March-April 2011
Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology
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.
(See above.)
Pancreatitis
Hepatobiliary disease
Early appendicitis
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
Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology
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.
(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.
180
March-April 2011
Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology
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.
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 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.
March-April 2011
181
Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology
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
(See above.)
Pancreatitis
(See above.)
Intestinal obstruction
(See above.)
(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).
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).
182
March-April 2011
Table 1 (continued)
Abdominal Pain in the Patient on PD by Location
Potential Etiology
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
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).
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).
March-April 2011
183
184
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
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.
References
Ahn, C., Oh, K.H., Kim, K., Lee, K.Y.,
Lee, J.G., Oh, M.D., ... Shin, S.G.
(2003). Effect of peritoneal dialysis
on plasma and peritoneal fluid concentrations of isoniazid, pyrazinamide and rifampin. Peritoneal
Dialysis International, 23 ,362-367.
March-April 2011
March-April 2011
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
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