Abstract: FR-PO572
Anterior Cutaneous Nerve Entrapment in a Patient on Peritoneal Dialysis
Session Information
- Dialysis and Vascular Trainee Case Reports
November 08, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 703 Dialysis: Peritoneal Dialysis
Authors
- Remz, Matthew Aaron, Parkland Memorial Hospital, Dallas, Texas, United States
- Shastri, Shani, UT Southwestern, Dallas, Texas, United States
Introduction
Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly underdiagnosed cause of abdominal pain and has been implicated in 15-30% of cases of chronic abdominal pain. It is caused by the entrapment of the cutaneous branches of the intercostal nerves at the lateral border of the rectus abdominis muscle that supply the abdominal wall. ACNES should always be considered in the differential in patients with chronic unilateral abdominal pain.
Case Description
55-year-old man with history of end stage renal disease secondary to hypertension on peritoneal dialysis (PD) for ∼ 4 months and diabetes developed 5/10, intermittent sudden onset shooting and burning right sided abdominal pain. It was not associated with nausea, vomiting, fever or changes in bowel habit. PD fluid analysis revealed clear effluent with total nucleated white cells ≤20 and negative culture. Liver function tests were normal except for mild elevation in lipase at 133 with normal amylase. Noncontrast CT of abdomen and pelvis was unrevealing except for persistent defect in the left rectus abdominis muscle with overlying surgical scar. As Liraglutide can cause elevation in lipase in the absence of pancreatitis, it was discontinued with decrease in lipase to 81. However, his pain persisted and Pregabalin was prescribed with some efficacy. He was seen by neurologist where careful history and physical examination yielded the diagnosis of ACNES. Persistent defect in the left rectus abdominis muscle with overlying surgical scar noted on abdominal CT was thought to be the likley culprit of ACNES. He was treated with a compounded lidocaine gel with resolution of his pain and discontinuation of pregabalin.
Discussion
ACNES is commonly overlooked or confused with visceral pain, often leading to extensive diagnostic testing with negative results before an accurate diagnosis is established. Diagnosis of ACNES is based on the presence of well-localized abdominal pain often along the lateral aspect of the rectus abdominis muscle sheath, increase in tenderness to palpation during muscle tensing on examination (Carnett’s sign) and response to trigger point injection of a local anesthetic. Although ACNES can be quite painful and disabling, it is typically nonprogressive with no long-term sequelae. Mainstay of treatment is reassurance, activity modification, physical therapy, and pain relief with analgesics or trigger point injections.