CURRENT Essentials of Critical Care.pdf

150 Current Essentials of Critical Care■■■PeritonitisEssentials of Diagnosis• Spontaneous bacterial peritonitis (SBP); or secondary peritonitisfrom perforation of abdominal viscus• SBP defined as ascitic fluid with 250 neutrophils/mm 3 or positiveGram stain (rarely) or culture of ascitic fluid; 50% withfever, abdominal tenderness; 30% asymptomatic• SBP seen in 8–27% of patients with cirrhosis and ascites; likelydue to translocation of bacteria across gut lumen; E coli mostcommon, then K pneumoniae, streptococci, enterococci, anaerobes;mortality up to 50%• Secondary peritonitis patients have severe abdominal pain, nausea,vomiting, fever, abdominal tenderness, hypotension; secondaryto perforation of viscus; ascitic fluid with leukocytosis,Gram stain and cultures polymicrobial; abdominal radiographsor CT scan may show free intraperitoneal airDifferential Diagnosis• Appendicitis, intra-abdominal abscess• Sickle cell crisis• Diabetic ketoacidosis• Porphyria• Familial Mediterranean fever• Lead poisoning• Uremia• Systemic lupus erythematosus with serositisTreatment• SBP, use third-generation cephalosporin• Secondary peritonitis requires evaluation and surgical managementfor perforated viscus; antibiotic coverage must includeanaerobes and enteric gram-negative bacilli■ PearlSuspect secondary peritonitis if more than one microorganism onGram stain or culture of ascitic fluid.ReferenceMalangoni MA: Current concepts in peritonitis. Curr Gastroenterol Rep2003;5:295. [PMID: 12864959]