An unexpected cause of abdominal pain in a peritoneal dialysis patient

Abstract

Sirs, In the recent issue of the journal, pelvic inflammatory disease in a pediatric peritoneal dialysis patient was presented by Ozcakar et al. as an unexpected cause of abdominal pain during continuous ambulatory peritoneal dialysis (CAPD). Although peritonitis is a main cause of abdominal pain in CAPD patients, other primary abdominal events occasionally develop and surgery is frequently considered in such cases. We herein report a CAPD patient who presented with abrupt abdominal pain and was finally diagnosed with intussusception of the jejunum associated with a juvenile polyp. This is, to the best of our knowledge, the first report of a case of intussusception as a complication in a CAPD patient. A 16-year-old boy was admitted to our hospital because of severe abrupt abdominal pain and recurrent vomiting. He had been undergoing CAPD since he was 13 years of age because of a chemotherapyinduced nephropathy for acute lymphocytic leukemia which had developed when he was 3 years of age. He was oliguric and needed five cycles of peritoneal dialysis a day to keep his blood pressure normal. On admission, he had severe pain and tenderness in his epigastric region. Laboratory studies showed the following: WBC 7,500/μl, hematocrit 36.1%, platelets 208,000/μl, serum total protein 7.1 g/dl, albumin 4.1 g/dl, blood urea nitrogen 62 mg/dl, creatinine 12.8 mg/dl, sodium 144 mEq/l, potassium 4.0 mEq/l, chloride 97 mEq/l, amylase 114 IU/l (normal range: 35–133 IU/l), and C-reactive protein 0.1 mg/dl. The dialysate was clear and not bloody. On abdominal Xray examination, neither air-fluid level nor free air was noted. However, a segmental dilation of the small intestine with edematous thickening of the intestinal wall was noted on computed tomography and on ultrasonography, suggesting a possibility of adhesionrelated strangulation of the intestine. A laparotomy was performed on the following day and the operative findings, however, showed an intussusception of the jejunum that was about 20 cm in length at the portion of 80 cm from the ligament of Treitz. After closed reduction of the intussusception, because a polyp was tangible at the lead point of the intussusception from outside of the intestinal wall, the bowel was removed about 40 cm in length including the polyp. The polyp was identified as a juvenile polyp in the jejunum that was about 2 cm in length. After the operation, his symptoms disappeared and he could carry on peritoneal dialysis after a short period of transition to hemodialysis. Although the association of his intussusception with the implementation of CAPD is unclear, this case indicates that intussusception should also be included as one of the unexpected causes of abdominal pain in patients undergoing peritoneal dialysis.