Peritonitis associated with peritoneal dialysis as a reason for delay in the diagnosis of gastric ulcer perforation: a case report

Abstract

This report presents a case of a perforated gastric ulcer in a patient on peritoneal dialysis (PD), illustrating the diagnostic challenges of abdominal pain in this population. PD patients are highly susceptible to dialysis-associated peritonitis, which is often the initial, presumed diagnosis for abdominal pain. This can lead to a critical delay in recognizing other serious intra-abdominal pathologies, such as peptic ulcer perforation, which these patients are predisposed to due to factors like uremia and medication use. A 74-year-old female on PD presented with abdominal pain. Initial studies supported a diagnosis of PD-associated peritonitis, and conservative management began. When symptoms persisted despite normalized fluid studies, a surgical consultation was requested. Imaging revealed a perforated gastric ulcer. She underwent ulcer resection, ulcerorrhaphy, and an omental patch. Her postoperative course was complicated by pneumonia, requiring transfer for further management. Patients on PD have an increased risk for gastric ulcers due to elevated gastrin levels, H. pylori, and gastric mucosa-damaging medications. While peritonitis is a common and primary concern, it can mask other acute abdominal conditions. Diagnosis relies on clinical assessment, peritoneal fluid analysis, and imaging (X-ray and CT scan). The choice between open or laparoscopic surgery depends on the patient's clinical condition and comorbidities. This case emphasizes the need for a broad differential diagnosis and high clinical suspicion to ensure timely intervention for life-threatening conditions beyond typical dialysis-related complications.