Question: Hi .. My mother is undergoing haemodialysis(twice a week) for the last 8 months and was on PD for 4 years before that. (She had peritonitis and had her PD catheter removed. ) She is now having extreme gastro problem with indigestion, gas and continuous vomiting(vomits almost anything she eats). There were some abdominal fluid collections but now they have reduced considerably. Following are the results of the latest whole abdomen CT scan :
1) The study reveals a small well loculated collection seen along the left anterior abdominal wall with a peripheral rim enhancement measuring approx(17x30x36)mm in size with tethering of the small bowel and Dilation of the small bowel loops with mucosal edema with few tiny discrete mesentric lymph nodes.
2) A ground glass appearance is seen in the peri pacreatic region with few discrete tiny subcentric nodes. No abnormal collection seen.

Other details:
1) Her gall bladder was removed about 10 years back due to stones.
2) Her haemodialysis is done via her neck. Her fistula has failed thrice because of weakness.
3) Her latest blood report suggested low Bicarbonate (15 mEq/L - reference range= 22 - 29).
4) Current weight ~ 40 kg
5) She was also diagnosed with abdominal TB during the episode of Peritonitis and given medication for it but the entire dosage was not completed.

She is having extreme pain in her belly for the past few weeks and gas problem along with daily vomiting.
Kindly advice on treatment, dietary suggestion/restriction.

Hi, Thanks a lot for your reply.
Sorry for the delay in replying.

Her vomiting and gas trouble has comparatively reduced now since we changed her intake to only khichdi, resource dialysis, curd rice and 2-4 pieces of threptin biscuit. But stomach ache is still there, esp after eating.
(The stomach ache is usually accompanied by back pain also.)

I could not find the particulars relating to TB treatment but I have typed out the Discharge summaries when she was hospitalized in the recent past. I hope this helps in providing a better picture.

I missed out to mention that she also has been diagnosed with HCV(mentioned in the discharge summaries)

Please find 2 discharge summaries below.

Please help in anyway you can in diagnosing the possible problem. She will be admitted to the hospital again shortly but it will be great if in someway we could avoid it and improve her condition. She has to improve her health condition quickly so that another procedure is done to fix a fistula for HD.
Regards, XXXXXXX


DISCHARGE SUMMARY (1)
Date of Admission: 09-10-2010
Date of Discharge: 19-01-2011
Diagnosis: ESRD – CAPD Peritonitis – CAPD catheter removed initiated on MHD, HCV +
History and Course in Hospital:
This 56 years old lady is K/C/O Hypertension, CKD-5 ?CIN was on CCPD since Sep 2006, had peritonitis with TB-PCR +ve and mediastinal lymphadenopathy on ATT(HRZE) w.e.f. 04.06.2009 for 10 months, had poor functioning of CCPD hence converted to manual CAPD in Feb 2010. Since july 2010, had poor inflow and outflow which completely stopped since 1st Sept 2010. She was then onwards not on any modality of RRT & developed anorexia and generalized weekness, her daily urine output was 800ml. Her last serum creatinine prior to admission was 7.3mg/dl. She was admitted & planned for CAPD catheter repositioning which was attempted but was unsuccessful and catheter was removed on 13/10/2010. She was then initiated on HD via DLJC. After CAPD catheter removal she had residual intraperitoneal loculated multiseptate collection for which pigtail catheter was inserted on 04.11.2010 but there was minimal drain hence it was removed on 21.11.2010. CT abdomen was done which revealed multiple loculated collections with hyperdense contents, repeated usg abdomen were s/o thick multiseptate solidified collection. Surgery consultation was taken by Dr__________. He advised conservative management with regular follow up. She also has history of multiple AVF failures: in 2006 L Radiocephalic and Brachiocephalic(Primary failure) then a R Brachiocephalic was made in March 2010 which had a thrill but viens did not mature adequately. Exteriorisation of vein in R Brachicephalic fistula was done on 27/12/2010. She had repeated drop of haemoglobin and required 7 units of PRBC during hospital stay. UGIE revealed large hiatus hernia but no ulcer or varices and colonoscopy was normal. Presently patient is stable and discharged with following advice.
Investigations :
1)     USG abdomen (22-12-2010) : 5.9 x 5.5 x 7.2 cms heteroechoic mass with thick wall & hypoechoic centre, loculated.
2)     USG – abdomen (19-11-2010) : 10.5 x 5.2 x 10.9 = 315cc , multiseptate collection Lt iliac fossa extending to Lt adnexa inferiorly.
3)     USG – Abdomen (24-11-2010) : 6 x 9 x 5.6 cms collection in Lt iliac fossa with thick wall , XXXXXXX echoes and septae.
4)     USG Abdomen (15-01-2011): 2.5 x 1.9 x 1.8 = 4.8 ml thick walled (9 mm) loculated collection.
5)     CECT abdomen – (11-11-2010) multiple loculated collections in lesser sac (18x7cms), Rt parocolic, Lt anterolateral parietes, pelvis with hyperdense contents with s/o complicated collections ? infected ? hemorrhage
6)     UGIE – Large hiatus hernia
7)     Echo – Degenerative valve disease with moderate MR and AR with RWMA with moderate LV dysfunction.



Discharge Summary (2)
Date of Admission: 18/11/2009
Date of Discharge: 09/12/2009
Diagnosis:
1. CKD – ESRD, on APD from Sep 2006
2. Hypertension
3. Hypothyroidism
4. CAPD peritonitis – improved. Occult sepsis – improving
5. Mediastinal lymphadenopathy – on ATT from 04.06.2009
6. ATT induced Hepatitis
7. HCV infection
History and Course in Hospital:
ESRD on CCPD from September 2006 was admitted with pain in abdomen, fever, cloudy CAPD outflow, due to ascending colon perforation(enterobacter), which was healed with conservative therapy. Although CAPD cytology improved, she continued with fever and high TLC. She was extensively evaluated for the focus of sepsis (she refused BM study), and tried some antibiotics empirically. As she did not respond, CXR – s/o mediastinal lymphodenopathy, with CAPD – TB PCR was found positive, ATT (RHEZ) was started from 04/06/2009. Initially she responded but as fever relapsed, empirical liposomal Amphotericin B, 1.0gm was given from 24/06/2009, and then changed to oral voriconazole. She responded to this therapy. She is now admitted with myalgia, nausea and jaundice of 1 month duration. Clinical evaluation revealed icterus. Investigations revealed Anti0 HCV positive and raised liver enzymes(OT/PT – 775/334). She was managed with modification of ATT, followed by good response that her liver enzymes started to settle. With an isolated report of hyperglobulinemia, she underwent urine evaluation which revealed M band positivity on Urine protein electrophoresis. She is being investigated further with serum immunoglobulin levels, protein immunofixation. Bone marrow evaluation has ruled out any plasma cell dyscrasias as it is normal. Now she has been discharged in a stable condition.