Department of nephrology 2006년 8월 7일 R3 신준범 Case conference Department of nephrology 2006년 8월 7일 R3 신준범

Patient information Chief complaint 미만성 복부통증 (발병일 : 내원 7 일전) 11313163 김O임(F/58) Chief complaint 미만성 복부통증 (발병일 : 내원 7 일전) Present illness 58세 여자, 20년전 당뇨병으로 진단, 이후 신장내과 외래 추적관찰 도중 ’02년 2월부터 ESRD로 CAPD 시작, ’04년 5월부터는 APD 시행하며 지냄. 1주전부터 상기 주소 있으면서 watery diarrhea ( > 10회/day) 있었고 내원 2일전부터는 평소 연락하던 복막투석간호사와 상의하에 1.5% glucose 복막액으로 하루 4회 CAPD로 전환하였음. 내원 1일전부터는 하루 1~2회 정도의 hematochezia도 동반되었으며 복막액 color가 turbid해진 소견이 있어 신장내과 외래 경유 입원.

Past medical history DM(+) for 20 years on intermittent medication 2. HTN(+) for 7 years on medication (manidipine 10mg qd, valsartan 80mg qd, aspirin 100mg qd) Pul. TB(-), Hepatitis(-) 3. CHF(+) : digoxin 0.0625mg qd Family history Unremarkable Personal history Alcohol (-), Smoking (-)

Review of systems General : generalized weakness (+), fatigue(+) fever/chilling sense(-/-) Resp. : cough(-), sputum(-), dyspnea(-) Cardiac : anginal chest pain(-), orthopnea(-), palpitations(-) G-I : anorexia(+), nausea(+), vomiting(-) abdominal pain(+), diarrhea(+) (watery, >10회/day) M-S : generalized myalgia(-), trauma(-), joint pain(-) Endo. : weight change(-), temperature tolerance(-) Nerv. : syncope(-), seizure(-), memory disturbance(-) ** Complaint of turbid peritosol color

Physical examination (V/S 120/80 mmHg-64회/min-20회/min-36.5 ℃) Alert consciousness Chronically ill-looking, edematous appearance Neck vein engorgement Isocoric pupil with PLR (+/+) No yellowish sclera, pale conjunctiva Coarse breathing sound without crackles or wheezing Regular heart beat without murmur Soft & obese abdomen Normoactive bowel sound Diffuse abdominal tenderness and rebound tenderness No CVA tenderness or rebound tenderness Pretibial pitting edema

Initial lab data CBC/DC 7,220/mm3 – 7.9g/dL – 25.1% - 363,000/mm3 (Seg. 86.8%) PT (%) INR : 13.7 sec (92%) 1.05 aPTT : 45 C 33 Blood chemistry Total bil./Direct bil. 0.44/0.12 mg/dL Total cholesterol 128 mg/dL Protein/Albumin 3.7/0.7 g/dL AST/ALT 14/8 IU/L LD/CK 596/134 IU/L BUN/Creatinine 43/9.0 mg/dL (←31/8.6 mg/dL) Na/K/Cl 133/3.8/94 mmol/L

Serum iron/TIBC 49/117 μg/dL Ferritin 264 ng/mL ESR 46 mm/hr CRP 26.3 mg/dL Peritosol study WBC 2,060/μL(seg. 5%, mono. 92%), RBC 1,040/μL 8. Peritosol culture : S. aureus (+)

Impression Plan CAPD peritonitis ESRD on CAPD T2DM HTN IP antibiotics Pain control and supportive care

HD 1일~2일 Sx > Melena : 1회당 100~150 mL, 3회, 가장 마지막 stool에는 bloody color의 hematochezia 섞여서 나오는 양상 보임. L-tube irrigation : old blood clot (+), active bleeding (-) EGD : L-tube induced esophageal ulcer, mild duodenitis. Colonoscopy : Multiple shallow ulcers and mucosal swelling, RS junction and sigmoid area. Abdominal CT : Ischemic enterocolitis, small bowel and colon. Submucosal edema of gastric antrum.

Gastroscopy (07/13)

Colonoscopy (07/13)

Impression Plan CAPD peritonitis ESRD on CAPD T2DM HTN Ischemic enterocolitis Plan IP antibiotics Pain control and supportive care NPO and TPN

HD 8일~10일 Sx > Melena : 1회당 100~150 mL, 6~7회/day, hematochezia 섞여서 나오는 양상 지속중. Hemoglobin : 6.5~8.0 g/d, 입원기간중 총 2 pint의 Packed RBC transfusion 시행함. EGD : Herpectic esophagitis, R/O CMV esophagitis, Acute gastric mucosal lesion, Duodenitis. -> endoscopic biopsy 시행함. 3. Sigmoidoscopy : Ischemic colitis, R/O Herpetic colitis, R/O CMV colitis.

Gastroscopy (07/20)

Sigmoidoscopy (07/20)

Impression Plan CAPD peritonitis ESRD on CAPD T2DM HTN Herpes simplex esophagitis Acute gastric mucosal lesion Duodenitis Ischemic enterocolitis Plan IP antibiotics Pain control and supportive care NPO and TPN PPI IV antiviral agent : Acyclovir 150 mg IV qd

Gastroscopy (07/28)

Sigmoidoscopy (07/28)

HD 18일~20일 Sx > Melena (-), hematochezia (-), 1회당 100~150 mL정도의 loose stool 4~5회/day, soft diet 가능한 상태로 호전됨. Hemoglobin : 7.5~8.0 g/dL 유지중 EGD : Moderate erythematous gastritis. 3. Sigmoidoscopy : Ischemic colitis, healing stage. 4. Peritosol study : WBC 8/μL, RBC 48/μL

Final diagnosis CAPD peritonitis ESRD on CAPD T2DM HTN Herpes simplex esophagitis Acute gastric mucosal lesion Duodenitis Ischemic enterocolitis R/O Herpes simplex colitis