• Robert Ekart, Matjaž Horvat, Miran Koželj, Breda Pečovnik Balon, Sebastjan Bevc, and Radovan Hojs.
• Department of Dialysis; Clinic for Internal Medicine, University Medical Centre Maribor, Ljubljanska 5, Maribor, SI 2000, Slovenia. robert.ekart2@guest.arnes.si.
• J Med Case Rep. 2012 Sep 18; 6: 309.

IntroductionPresentations 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 PresentationWe 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.ConclusionA 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.

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