Appendicitis Perforata in CAPD Patients -Report of Two Cases

Abstract

Two patients on CAPD had peritonitis due to perforated appendicitis. Both presented with diffuse painful peritonitis with nausea, fever and prostration. There was blood leukocytosis with a shift to the left. The peritonitis did not respond to antibiotic therapy. The diagnosis was made after 8 and 18 days respectively by exploratory laparotomy. Both patients had a gangrenous perforated appendix surrounded by abscess. Both patients had uncomplicated recovery after appendectomy, drainage, removal of the Tenckhoff catheter with discontinuation of CAPD and change to hemodialysis. Our experience suggests that a perforated appendix might be recognized early in a patient with apparent fecal peritonitis in whom other more common causes (e.g. diverticulosis/ diverticulitis) have been ruled out, or when he presents with severe symptoms and a low peritoneal white cell count. Perforated appendicitis leading to fecal peritonitis is a rare complication of continuous ambulatory peritoneal dialysis (CAPD). Among 85 patients treated with CAPD since 1978 for a total of 1062 patient months, we observed two such cases. Although CAPD now is established as a kidney replacement treatment and appendicitis is a common condition, we know of no other report of perforated appendicitis during CAPD. Therefore we describe our experience with two such patients, treated with CAPD for 14 and 5 months, respectively. The diagnostic and therapeutic implications are discussed in the context of other forms of fecal peritonitis, mainly due to colonic perforation, secondary to diverticular disease. This report emphasizes the need for a high level of suspicion that the peritonitis may be related to bowel disease, especially when it does not respond quickly to standard treatment.