QuestionSBA
QuestionChoice
The history, combined with the ascitic tap results, point towards a diagnosis of spontaneous bacterial peritonitis. Ascitic fluid is likely to appear cloudy in spontaneous bacterial peritonitis, with a high neutrophil and protein count. Spontaneous bacterial peritonitis is most commonly seen in patients with end-stage liver disease
32913
a
Spontaneous bacterial peritonitis
QuestionChoice
Hepatocellular carcinoma may lead to feverish symptoms with abdominal pain. However, hepatocellular carcinoma is more likely to lead to a milky or bloody ascitic tap with mildly elevated red cell count and reduced glucose levels
32916
d
Hepatocellular carcinoma
QuestionChoice
Tuberculosis can lead to ascites, especially when granulomas spread to the peritoneum. However, tuberculosis is more likely to lead to a milky coloured ascitic tap along with raised protein levels. It is much rarer than spontaneous bacterial peritonitis
32915
c
Tuberculosis
QuestionChoice
Pancreatic carcinoma may lead to feverish symptoms, but they classically present without pain. Those that do have abdominal pain are more likely to experience epigastric rather than generalised pain. It is more likely to lead to a milky or bloody ascitic tap with mildly elevated red cell count and reduced glucose levels
32917
e
Pancreatic carcinoma
QuestionChoice
Liver cirrhosis is unlikely to be the sole cause of these symptoms; for example, cirrhotic patients will not become feverish without a secondary cause. Patients with liver cirrhosis are more likely to have clear or sometimes straw-coloured ascitic taps. They would also normally have a normal absolute neutrophil count
32914
b
Cirrhosis
QuestionComment
is there a mistake in neutrophil count reference range?
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subscriber
Myopathy Monoclonal
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# Summary

Peritonitis refers to the inflammation of the peritoneum, typically caused by perforation of a hollow viscus or an infection. The primary signs and symptoms include abdominal rigidity, rebound tenderness, fever, vomiting, tachycardia, and hypotension. Key investigations often involve imaging studies and peritoneal fluid analysis. Management strategies primarily focus on addressing the underlying cause and may involve surgical intervention, antibiotics, and supportive care. Peritonitis can be life-threatening if not treated early and carries a high mortality.

# Definition

Peritonitis is defined as inflammation of the peritoneum, which is the serous membrane lining the cavity of the abdomen and covering the abdominal organs.

# Epidemiology

Epidemiological data regarding peritonitis is somewhat variable, as it often presents secondary to other diseases or conditions. However, it is more commonly encountered in scenarios where there is a risk of abdominal infection or injury, such as abdominal surgeries, long-term peritoneal dialysis, or blunt abdominal trauma.

# Aetiology


-   **Perforation of a hollow viscus:** This can be from a perforated oesophagus (Boerhaave syndrome), a perforated duodenal or gastric ulcer, a perforated intestine (secondary to conditions such as appendicitis, diverticulitis, intestinal infarction, colorectal cancer, or inflammatory bowel disease). Perforation may also occur due to trauma, such as the ingestion of a foreign body. Perforation can lead to **diffuse** or faeculent peritonitis.
    
-   **Infection:** Infections leading to peritonitis include spontaneous bacterial peritonitis and peritoneal infection secondary to peritoneal dialysis. Uncomplicated appendicities can cause **local** peritonitis due to inflammation of the surrounding peritoneum.
    

Remember, sterile fluids can also leak into and irritate the peritoneum. This can occur with leakage of blood (e.g. in blunt abdominal trauma), bile (e.g. in liver biopsy), and pancreatic fluids (e.g. in acute pancreatitis).

# Signs and Symptoms

- Severe abdominal pain. Patients will often be lying completely still so as to not trigger/exacerbate pain
- Systemic signs of illness such as fever, haemodynamic instability, tachycardia
- Nausea and vomiting
-   **Abdominal rigidity/Involuntary abdominal guarding:** Involuntary tensing of the abdominal wall muscles in response to pressure on the abdomen (to protect inflamed abdominal organs).
-   **Rebound tenderness:** Pressing on the abdomen elicits **less** pain than releasing the hand (as the peritoneum bounces back into place).
-   Percussion tenderness

# Differential Diagnosis

-   **Gastroenteritis:** Presents with nausea, vomiting, abdominal cramping, and diarrhea.
-   **Pancreatitis:** Characterized by severe upper abdominal pain, often radiating to the back, nausea, vomiting, and fever.
-   **Cholecystitis:** Signs and symptoms include right upper quadrant abdominal pain, nausea, vomiting, and fever.
-   **Appendicitis:** Symptoms include right lower quadrant pain, nausea, vomiting, and low-grade fever.
-   **Diverticulitis:** Usually presents with left lower quadrant pain, fever, and changes in bowel movements.

# Investigations

- Patients presenting with peritonitis can be very systemically unwell and the SEPSIS 6 should be initiated in these situation.
-   **Laboratory tests:** Blood tests to assess for elevated white blood cell count and markers of inflammation (e.g. C-reactive protein), kidney function, and liver function.
-   **Imaging:** Abdominal x-ray, ultrasound, or CT scan to identify fluid collections or perforations (looking for free gas - pneumoperitoneum, rigler’s sign and football sign).
-   **Peritoneal fluid analysis:** If feasible, an analysis of peritoneal fluid obtained by paracentesis can help identify the causative organism and guide treatment.

# Management

Management of peritonitis is guided by the underlying cause but may include:

-   **Surgical intervention:** For conditions such as a perforated viscus, appendicitis, or diverticulitis, surgical intervention is often required to control the source of infection or inflammation.
-   **Antibiotics:** Empirical antibiotic therapy should be initiated as soon as possible and then tailored according to culture results.
-   **Supportive care:** Fluid resuscitation, pain management, and monitoring of vital signs are crucial in the management of peritonitis.

# References

[NHS UK - Peritonitis](https://www.nhs.uk/conditions/peritonitis/)
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Peritonitis
Topic
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Gastroenterology
6583
Spontaneous bacterial peritonitis commonly occurs in patients with liver cirrhosis and is characterised by cloudy ascitic fluid and elevated white blood cell counts.
A 54-year-old woman presents to A&E with abdominal pain. The pain is generalised across the abdomen, which appears distended. She feels feverish and has been experiencing diarrhoea and vomiting. She has known liver cirrhosis.


An ascitic tap is performed:


 - Appearance cloudy


||||
|---------------------------------|:-------------------------:|-------|
|RBC|80|none|
|WBC|550 /mm<sup>3</sup>|< 300|
|Albumin|5.2 g/L|< 40|
|Glucose|4.5 mmol/L|3.5 - 5.5|
|Amylase|350 U/L|< 100|


What is the most likely diagnosis?
a