Severe Necrotizing Pancreatitis and Pseudocyst Development in a Patient on Peritoneal Dialysis

Abstract

In recent years renal dialysis, especially peritoneal dialysis (PD), has become increasingly considered a risk factor for acute pancreatitis (AP). The mechanism of pathogenesis of AP in PD is unclear, however PD appears to have at least a 3-fold higher risk of AP when compared with hemodialysis (HD). Most reported cases of AP in PD are mild or moderate in severity. In this case we report on the development of severe necrotizing pancreatitis and subsequent pseudocyst development with steatorrhea in a patient on PD. Case Report: A 42 y/o black woman with end-stage renal disease from focal segmental glomerulosclerosis, on PD for 22 months, presented to our institution with 2 weeks of abdominal pain, nausea and vomiting. She had no jaundice or fever, and reported no history of alcohol use. She was not taking medications associated with pancreatitis. On admission her lipase was >4000 and liver enzymes were normal. Her WBC count was 23K but rapidly climbed to >50K by the following day. Blood and peritoneal fluid cultures and Gram stains were negative, however she had over 13000 WBC's in the peritoneal fluid. She had no prior episodes of peritonitis, and was not hypercalcemic or hyperlipidemic. She was placed into the ICU and started on empiric imipenem. PD was ceased and she was changed to HD. CT scan showed necrosis of approximately 30% of the pancreas. She had no apparent complications while in the hospital and was discharged after 12 days. 2 weeks later, she was noted to have steatorrhea, intermittent bouts of pain, and epigastric fullness. She was placed on pancreatic enzyme replacement with resolution of her steatorrhea. MRI/MRCP showed a 6–8 cm cystic lesion in the body of the pancreas. CT guided drainage could not be performed because of an inadequate percutaneous window. She is currently being considered for endoscopic cystgastrostomy. Discussion: This case demonstrates an important, newly recognized risk factor (PD) for AP, and is one of the first reported cases of severe necrotizing pancreatitis with pseudocyst formation and residual exocrine insufficiency associated with PD. Gastroenterologists and nephrologists should recognize PD as an emerging risk factor for AP, including severe cases. Although a complete workup needs to be performed to rule out anatomical causes for AP, these patients may require conversion from PD to HD.