Workup for Gastric Ulcer/Necrosis in Peritoneal Dialysis Patients
Immediately perform upper endoscopy (esophagogastroduodenoscopy) with biopsy to establish the diagnosis, assess severity, and rule out malignancy, as gastric ulcers in PD patients carry significant risk for perforation, bleeding, and may represent underlying malignancy. 1, 2
Initial Clinical Assessment
Symptom Evaluation
- Document specific symptoms: abdominal pain location and character, nausea, vomiting, anorexia, early satiety, and malaise 2
- Assess for peritonitis signs: cloudy dialysate, abdominal tenderness, fever, or rebound tenderness 3, 1
- Evaluate nutritional status: weight loss, declining serum albumin, and decreased protein intake, as PD patients already lose 5-15 g protein daily in dialysate 4
Physical Examination Findings
- Abdominal examination: tenderness, guarding, rigidity, or signs of perforation 5
- Volume status: assess for fluid overload or dehydration affecting dialysis adequacy 4
- Exit site inspection: rule out concurrent catheter-related infections 3
Diagnostic Workup
Immediate Imaging Studies
- Upright chest X-ray or abdominal X-ray: detect pneumoperitoneum if perforation is suspected (present in 90% of perforated ulcers) 5
- CT abdomen with oral contrast: if perforation suspected but X-ray negative, or to assess extent of disease 5
- Contrast study with water-soluble contrast (Gastrografin): can localize perforation site if present 5
Endoscopic Evaluation (Priority)
- Upper endoscopy with multiple biopsies: mandatory to differentiate benign ulcer from malignancy, especially in elderly PD patients 2
- Document ulcer characteristics: size, location (gastric vs duodenal), depth, and Borrmann classification if malignant 2
- Obtain at least 6-8 biopsies: from ulcer edges and base to rule out adenocarcinoma 2
Laboratory Assessment
- Complete blood count: assess for anemia from chronic bleeding 6
- Serum albumin and nutritional markers: PD patients with gastric ulcers are at high risk for severe malnutrition 4
- Helicobacter pylori testing: via biopsy, stool antigen, or urea breath test 1
- Dialysate analysis:
Specialized Testing
- Peritoneal equilibration test (PET): assess if gastric pathology has altered peritoneal membrane transport characteristics 4
- 24-hour dialysate and urine collection: measure adequacy (Kt/V), as gastric symptoms may indicate inadequate dialysis 4
- Serum gastrin level: if Zollinger-Ellison syndrome suspected in refractory ulcers 1
Critical Considerations
High-Risk Features Requiring Urgent Intervention
- Perforation: requires immediate surgical consultation; peritoneal dialysis with gastric aspiration may temporize in high-risk surgical candidates, but this is controversial and primarily historical 5
- Active bleeding: may require endoscopic hemostasis or surgery 6
- Malignancy: gastric cancer can present with peritoneal involvement in PD patients, detected by dialysate cytology 2
PD-Specific Complications
- Increased risk compared to hemodialysis: PD patients have higher rates of gastroesophageal reflux and gastric disorders due to increased intra-abdominal pressure from dialysate 7, 1
- Protein losses: gastric ulcers compound the 5-15 g/day protein loss inherent to PD, accelerating malnutrition 4
- Dialysis adequacy: severe gastric symptoms may indicate uremia from inadequate dialysis prescription 4
Common Pitfalls to Avoid
- Do not delay endoscopy: gastric ulcers in PD patients require tissue diagnosis to exclude malignancy, especially in elderly patients 2
- Do not assume symptoms are uremia-related: always investigate for structural GI pathology 1, 6
- Do not overlook dialysate cytology: if malignancy suspected, cytological examination of peritoneal fluid can detect peritoneal carcinomatosis 2
- Do not continue PD if perforation confirmed: this is an absolute indication for surgical intervention and temporary HD 5