Ekart et al. Journal of Medical Case Reports 2012, 6:309 http://www.jmedicalcasereports.com/content/6/1/309 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Gangrenous appendicitis presenting as acute abdominal pain in a patient on automated peritoneal dialysis: a case report Robert Ekart1*, Matjaž Horvat2, Miran Koželj2, Breda Pečovnik Balon1, Sebastjan Bevc3 and Radovan Hojs3 Abstract Introduction: Presentations of abdominal pain in patients on peritoneal dialysis deserve maximal attention and careful differential diagnosis on admittance to medical care. In this case report a gangrenous appendicitis in a patient on automated peritoneal dialysis is presented. Case presentation: We report the case of a 38-year-old Caucasian man with end-stage renal disease who was on automated peritoneal dialysis and developed acute abdominal pain and cloudy peritoneal dialysate. Negative microbiological cultures of the peritoneal dialysis fluid and an abdominal ultrasonography misleadingly led to a diagnosis of culture negative peritonitis. It was decided to remove the peritoneal catheter but the clinical situation of the patient did not improve. An explorative laparotomy was then carried out; diffuse peritonitis and gangrenous appendicitis were found. An appendectomy was performed. Myocardial infarction and sepsis developed, and the outcome was fatal. Conclusion: A peritoneal dialysis patient with abdominal pain that persists for more than 48 hours after the usual antibiotic protocol for peritoneal dialysis-related peritonitis should immediately alert the physician to the possibility of peritonitis caused by intra-abdominal pathology. Not only peritoneal catheter removal is indicated in patients whose clinical features worsen or fail to resolve with the established intra-peritoneal antibiotic therapy but, after 72 hours, an early laparoscopy should be done and in a case of correct indication (intra-abdominal pathology) an early explorative laparotomy. Keywords: Abdominal pain, Appendicitis, Myocardial infarction, Peritoneal dialysis Introduction Acute abdominal pain could be a very serious complica- tion in patients receiving continuous ambulatory peri- toneal dialysis (CAPD) and automated peritoneal dialysis (APD). The peritonitis caused by exogenous infection related to the peritoneal catheter is a common reason for abdominal pain in these patients. Consequently, to identify whether a patient on CAPD or APD has under- lying intra-abdominal pathology by means of a laparos- copy remains a diagnostic challenge for nephrologists and abdominal surgeons. A misled diagnosis may result in delayed urgent surgery and contribute to the high rate of deaths in such patients. * Correspondence: robert.ekart2@guest.arnes.si 1Department of Dialysis; Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska 5, Maribor SI 2000, Slovenia Full list of author information is available at the end of the article We present the case of a patient on APD with gan- grenous appendicitis. Diagnosis was delayed and the patient`s outcome was catastrophic. According to our experience with peritoneal dialysis (PD) patients with a clinical picture of acute abdominal pain, it is necessary to think about all differential diagnostic possibilities and not only about the usual peritonitis. It is also crucial to exclude intra-abdominal pathology in those patients who do not respond promptly to intra-peritoneal antibiotics. Case presentation We present the case of a 38-year-old man with end-stage renal disease secondary to diabetes mellitus type 1 on CAPD for 18 months and on APD for 40 months. The patient, who had no previously reported episode of PD- related bacterial peritonitis, was admitted to our depart- ment with a 2-day history of emesis, cloudy peritoneal © 2012 Ekart et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.