78
Journal of the association of physicians of india • MAY 2014 • VOL. 62
Correspondences
Abdominal Pain in Diabetes – DKA is not the Only
Cause
Shubha Laxmi Margekar1, Satyam Singh Jayant1, Om Prakash Jatav2, Maneesh Jain3,
Amit Chouksey 4
Assistant Professor, 2Professor
1
and Head, 3Senior Resident,
Department of Medicine,
G.R. Medical College, Gwalior,
Madhya Pradesh; 4Senior
Resident, Department of
Medicine, G.T.B Hospital, Delhi
Received: 17.09.2012;
Revised: 01.01.2013;
Re-revised: 02.02.2013;
Accepted: 02.03.2013
450  © JAPI • MAY 2014 • VOL. 62
Sir,
A bdominal pain in case of diabetes is
usually interpreted as a presentation
of diabetic ketoacidosis (DKA), but
sometimes is may not be the only
cause of pain in abdomen and can be
misguiding to the physician’s too. As
other causes of abdominal pain like intra
abdominal abscess (renal abscess) being
so uncommon, can be missed and if not
entertained timely can lead to prolonged
hospital stay and fatal outcome. So, high
index of suspicion is required in such
patients which we have tried to focus
by this case.
Diabetes is one of the worlds leading
chronic disease and DKA is one of the
acute complication of diabetes that can
lead to increase morbidity and mortality
if not treated promptly and effectively. 1
Most common presenting symptoms of
DKA is vomiting and pain abdomen. 2
30-50% cases of DKA are precipitated
by infections, in which urinary tract
infection (UTI), pneumonia and intra
abdominal sepsis accounts for majority
of cases. 1 Renal abscess is an uncommon
disease entity, it accounts for 0.2%
of all intra abdominal abscess and
the common predisposing factors are
diabetes mellitus, renal calculi, ureteral
obstruction and vesicoureteral reflux,
longer duration of symptoms of UTI,
immunosuppression and renal failure. 3,4
We report a case of known diabetic,
45 yrs old female who presented in
emergency department with complaint
of pain abdomen, high grade fever
and breathlessness since 5 days. On
admission, she was anxious, febrile and
dehydrated. Her pulse was 120/min, BP
was 130/80 mmHg and respiratory rate
was 24/min.
Per abdomen examination revealed
tenderness in the epigastric and
right lumbar region with no palpable
organomegaly. Rest of the systemic
examination was unremarkable. On
investigation, urgent bed side urine
examination by dipstick revealed
urine glucose 4+ and ketone 4+, RBS
by glucometer revealed high blood
sugar. Blood and urine samples were
sent for investigations. Blood analysis
r e ve a l e d H b - 1 0 . 8 g m % , T L C 9 2 0 0 /
cumm,Neutrophils-78%,Lymphocytes-
19%,Platelet-2 lacs/cumm,blood urea
42 mg/dl, Serum creatinine-1.2 mg/dl,
Serum Uric acid -2.02 mg/dl, Serum
Na +-127.52 meq/l, Serum K +-4.29 meq/l,
Serum Ca ++-9.01 mg%, Serum bilirubin
- 0.62 mg/dl, SGOT-32 iu/l, SGPT-12
iu/l, pH-7.29, Urine-routine/microscopy
showed - 8-10 pus cells/hpf and 4-5
epithelial cells/hpf, ECG and X-ray chest
were normal.
Patient was diagnosed as a case of
DKA and was treated with intravenous
fluid, insulin as per guidelines and
empirical antibiotics. Over a period of
48 hours, blood sugar reduced to 256
mg/dl, urine sugar and urine ketone
r e d u c e d t o 2 + . Pa t i e n t s c o n d i t i o n
improved but abdominal pain increased
in severity and tenderness persisted
and more localised to right lumbar
region. In view of persisting abdominal
pain and tenderness, USG abdomen
was performed to rule out any other
possibilities (acute appendicitis, acute
pancreatitis, ruptured viscus or intra
ab domi nal ab scess). USG ab d omen
revealed a renal abscess in lower pole
Journal of the association of physicians of india • MAY 2014 • VOL. 62 79
Fig. 1 : USG abdomen showing a hypoechoic lesion of size
2.5 × 2.5 cm in lower pole of right kidney suggestive
of abscess
of right kidney measuring 2.5 × 2.5 cm in size which
was not aspirable (Figure 1). E-coli was grown in
urine culture and blood culture was sterile. Patient
was switched over to sensitive antibiotics after
urine culture sensitivity report. Follow up USG
abdomen after 7 days and 21 days showed gradual
reduction in size of abscess to 2 × 2.2 cm and 1.1 ×
1.2 cm respectively. Abdominal pain decreased in
intensity after 10 days and patient was switched to
oral antibiotics and pain subsided completely after 3
weeks. Patient was discharged after 4 weeks on oral
antibiotics and advised to follow up after 7 days.
Discussion
Infections of kidney and perinephric space
are uncommon renal pathology but can cause
considerable morbidity and mortality. 5 Its common
presenting symptoms are fever and flank pain but it
is difficult to diagnose because of its nonspecific and
varied presentation. 4 As in our case patient did not
have classical flank pain at the time of presentation.
In this case total leucocyte count (TLC) was normal
with neutrophilia, where as in previous reports raised
TLC was common. 4 This probably suggests that TLC
may not be raised in immunosuppressed condition like
diabetes mellitus but neutrophilia indirectly points
towards septicaemia. According to various studies
© JAPI • MAY 2014 • VOL. 62
E-coli and proteus are the most common organisms
responsible for renal abscess. 4,5 This was true in
our case also. In 40-75% cases of DKA, abdominal
pain sometimes mimics acute abdomen (like acute
pancreatitis, ruptured viscus, and acute appendicitis)
which usually resolves with correction of metabolic
disturbance.1,2 But in our case, pain abdomen persisted
even after correction of hyperglycaemia and metabolic
acidosis, which made us to further investigate the
patient for other aetiology of abdominal pain. USG
abdomen is reliable and easily available diagnostic
tool for intra abdominal pathology like renal abscess.3
Successful management of renal abscess depends on
early diagnosis and appropriate antibiotics for at
least 4 weeks in case of small (< 3cm) and medium
(3-5 cm) sized renal abscess depending upon the
causative organisms, failing which can lead to serious
complication. 3,5 In this case also patient’s hospital stay
was of 4 weeks on antibiotics to which she responded
well. Diagnosis of renal abscess should be considered
in patients of pain abdomen that fails to improve
even after appropriate therapy and correction of
ketoacidosis in case of DKA, as the cause of death
in patient of DKA relates to the underlying medical
illness that precipitate the metabolic decompensation.2
This case also highlights that renal abscess can be one
of the precipitating cause of DKA in case of diabetes
and should be looked for in DKA patients.
References
1. Umpierrez GE, Murphy MB, Kitabchi AE. Diabetic ketoacidosis and
hyperglycemic hyperosmolar syndrome. Diabetes Spectr 2002;15:28-
36.
2. Umpierrez G, Freire AX. Abdominal pain in patients with
hyperglycemic crises. J Crit Care 2002;17: 63– 67.
3. NP Jaik, K Sajuitha, Milly Mathew, Uma Sekar, Sarah Kuruvilla, G
Abraham. Renal abscess. J Assoc Physicians India 2006;54:241-3.
4. Lt Col RS Rai, Col SC Karan, Brig A Kayastha, SM. Renal and perinephric
abscesses revisited. Medical Journal Armed Forces India 2007;63:223-
225.
5. Seung Hwan Lee, Hyun Jin Jung, Sang Yol Mah, and Byung Ha
Chung. Renal abscesses measuring 5 cm or less: Outcome of medical
treatment without therapeutic drainage. Yonsei Med J 2010;51:569-
573.
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