Huang J W, Peng Y S, Wu M S, Tsai T J
Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC.
Am J Kidney Dis. 1999 Apr;33(4):e6. doi: 10.1016/s0272-6386(99)70247-7.
Peritonitis due to viscus perforation in peritoneal dialysis (PD) patients can be catastrophic. We describe the first reported case of perforated peptic ulcer (PPU) in a PD patient. This 78-year-old man presented with a 1-day history of mild abdominal pain. He had been receiving nocturnal intermittent PD for 2 years and had ischemic heart disease and cirrhosis of the liver. Pneumoperitoneum and peritonitis were documented, but the symptoms were mild. The "board-like abdomen" sign was not noted. Air inflation and contrast radiography indicated a perforation in the upper gastrointestinal tract, and laparotomy disclosed a perforation in the prepyloric great curvature. Unfortunately, the patient died during surgery. This case illustrates that the "board-like abdomen" sign may be absent in PD patients with PPU because of dilution of gastric acid by the dialysate. Free air in the abdomen, although suggestive of PPU, is also not uncommon in PD patients without viscus perforation. Because PD has to be discontinued after laparotomy and exploratory laparotomy may be fatal in high-risk patients, other diagnostic methods should be used to confirm viscus perforation before surgery. PPU, which can be proved by air inflation and contrast radiography, should be suspected in PD patients with pneumoperitoneum and peritonitis.
腹膜透析（PD）患者因脏器穿孔导致的腹膜炎可能是灾难性的。我们描述了首例报道的PD患者发生的消化性溃疡穿孔（PPU）病例。这名78岁男性患者有1天的轻度腹痛病史。他接受夜间间歇性腹膜透析已2年，患有缺血性心脏病和肝硬化。记录到有气腹和腹膜炎，但症状较轻。未发现“板状腹”体征。充气造影和对比造影显示上消化道穿孔，剖腹探查发现胃幽门前大弯处穿孔。不幸的是，患者在手术过程中死亡。该病例表明，PPU的PD患者可能因透析液稀释胃酸而无“板状腹”体征。腹部游离气体虽然提示PPU，但在无脏器穿孔的PD患者中也并不少见。由于剖腹手术后必须停止腹膜透析，而剖腹探查对高危患者可能是致命的，因此在手术前应采用其他诊断方法来确诊脏器穿孔。对于有气腹和腹膜炎的PD患者，应怀疑有可通过充气造影和对比造影证实的PPU。
