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Peritonitis, Acute

- Immediate evaluation - Perform paracentesis, blood, and urine cultures before administration of antibiotics (1,5)[B]. - Ascitic fluid studies should minimally include culture (use aerobic and anaerobic blood culture bottles), Gram stain, cell count with differential, and albumin (1)[B]; if assessing for secondary peritonitis also include LDH, total protein and glucose.

para>30% of patients are asymptomatic (1)[C].

Geriatric Considerations

Signs and symptoms are frequently absent, particularly in pediatric and elderly patients (1)[B].

PHYSICAL EXAM

  • Tachycardia, fever, tachypnea, altered mental status
  • Abdominal distention, ascites, abdominal wall guarding and rigidity, rebound tenderness, hypoactive/absent bowel sounds

DIFFERENTIAL DIAGNOSIS

  • Liver disease: acute hepatitis, decompensated cirrhosis
  • Luminal disease: abscess formation, ileus, volvulus, intussusception, mesenteric adenitis, pancreatitis, cholecystitis, malignancy, peritoneal carcinomatosis
  • Extraluminal disease: ruptured ectopic pregnancy, tubo-ovarian abscess, PID, severe UTI, and/or pyelonephritis
  • Systemic disease: tuberculosis, pneumonia, MI, porphyria, SLE

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

ALERT

Early diagnosis is essential to reduce mortality. Paracentesis should be performed in any patient with new ascites, including suspected SBP (5)[B].

  • Immediate evaluationPerform paracentesis, blood, and urine cultures before administration of antibiotics (1,5)[B].Ascitic fluid studies should minimally include culture (use aerobic and anaerobic blood culture bottles), Gram stain, cell count with differential, and albumin (1)[B]; if assessing for secondary peritonitis also include LDH, total protein and glucose.

ALERT

Lab interpretation: Ascitic fluid culture is negative in up to 50% of patients with SBP (1)[A].

  • SBP: bacterascites and ascitic fluid PMN >250 cells/mm3
  • Culture-negative neutrocytic ascites: negative ascites culture, ascitic fluid PMN >250 cells/mm3
  • Nonneutrocytic bacterascites: positive ascites culture, ascitic fluid PMN <250 cells/mm3
  • Secondary peritonitis: PMN >250 cells/mm3 on ascitic fluid analysis, with any of the following criteria:Polymicrobial culture or two of the following: ascitic fluid total protein >1 g/dL, glucose <50 mg/dL, or LDH >225 mU/mL. Sensitivity for perforation 96%, sensitivity for nonperforation secondary peritonitis 50% (5)[B]Secondary peritonitis with perforation is likely with alkaline phosphatase >240 U/l or CEA >5 ng/mL, sensitivity 92% (5)[B].

ALERT

Imaging: Criteria or clinical suspicion for secondary peritonitis necessitates emergent CT scan. CT diagnostic for secondary peritonitis in 85% (5)[B].

  • Ultrasound or CT scan with enteral and IV contrast shows intra-abdominal mass, ascites, abscess, or extravasation of contrast in secondary peritonitis
  • Abdominal or chest x-ray may show free air in peritoneal cavity, large/small bowel dilatation, intestinal wall edema in secondary peritonitis.

Follow-Up Tests & Special Considerations

  • If asymptomatic bacterascites, recent antibiotic exposure, nosocomial atypical organism, or no clinical improvement, repeat paracentesis in 48 hours to resolution, defined as decrease in PMNs of 25% or negative cultures (1)[C].
  • In hemorrhagic ascites, PMN count can be corrected by subtracting 1 PMN per 250 RBCs (3)[A].

TREATMENT

GENERAL MEASURES

  • For SBP, control the effects of cirrhosis/ascites with salt restriction, spironolactone +/ ’ furosemide, albumin infusion after large volume paracentesis, and/or lactulose for encephalopathy (5)[A].
  • Avoid nephrotoxic medications (e.g., NSAIDs) or other renal insults (5)[C].

MEDICATION

  • SBP empiric first-line treatmentCommunity-acquired SBP w/o recent ²-lactam antibiotic use: 3rd-generation cephalosporins, preferably cefotaxime, 2 g IV q8h for 5 days (5)[A]SBP in absence of previous quinolone use/prophylaxis, vomiting, shock, hepatic encephalopathy, or serum creatinine >3 mg/dL: ofloxacin 400 mg PO can be substituted for cefotaxime (5)[B].Nosocomial SBP or recent ²-lactam antibiotic: Empiric therapy based on local susceptibility of patients with cirrhosis for resistant bacteria (e.g., ESBL Enterobacteriaceae, MRSA) (6)[B]Symptomatic bacterascites with PMN count <250 cells/mm3: cefotaxime 2 g IV q8h while awaiting sensitivities (5)[B]Second-line antibiotic regimens include fluoroquinolones (levofloxacin), piperacillin/tazobactam, or vancomycin (5)[C].SBP with renal or hepatic impairment (serum creatinine >1 mg/dL, BUN >30 mg/dL, or total bilirubin >4 mg/dL): Add albumin 1.5 g/kg within 6 hours and 1 g/kg on day 3 (1)[A],(5)[B].
  • Secondary bacterial peritonitisEmpiric broad spectrum antibiotic coverage for polymicrobial infection; IV cefoxatime or other 3rd- to 4th-generation cephalosporin plus metronidazole is one option for an initial regimen.In peritoneal dialysis associated infection, intraperitoneal route superior to IV (6)[A]
  • Tertiary bacterial peritonitisIf no unrepaired perforations or leaks, conservative medical management. This includes antibiotics (guided by prior susceptibilities if available) and early enteral nutrition to prevent atrophy and maintain immunocompetence (2)[B].In recurrent or persistent peritoneal dialysis associated infection, removal of the PD catheter is warranted (6)[A].

SURGERY/OTHER PROCEDURES

  • SBP
  • Secondary bacterial peritonitisEmergent surgical management, including source control with open laparotomy to repair any perforated viscus and eradicate infected material, is first-line treatment (2)[A],(5)[B].
  • Tertiary bacterial peritonitisIf no unrepaired perforations or leaks, additional surgery for severe abdominal infection is correlated with deterioration and significant mortality (2).

ALERT

Mortality of SBP approaches 80% if the patient receives unnecessary exploratory laparotomy; conversely, mortality of secondary bacterial peritonitis approaches 100% if not treated surgically (1,3).

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Acute peritonitis typically warrants inpatient admission.
  • In patients with cardiogenic or septic shock, invasive monitoring with early goal-directed fluid therapy
  • Patients who present with peritonitis can be severely hypovolemic. In these cases, volume resuscitation is critical. In patients with significant renal or hepatic dysfunction, albumin decreases mortality (1)[A],(5)[B].
  • Cirrhotic patients often take ²-blockers as part of their outpatient regimen, but during an episode of SBP ²-blockers increase mortality, hepatorenal syndrome, and hospital stay in SBP patients (5)[B]
  • Nasogastric tube placement can prevent aspiration in patients with vomiting or GI bleeding.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Normalization of vital signs with resolution of leukocytosis indicates improvement.

  • SBP: If follow-up paracentesis is performed after 48 hours to evaluate resolution, PMN decrease >25% is expected.
  • Development of leukopenia indicates immune exhaustion and poor prognosis.

DIET

  • NPO, total parental nutrition as necessary
  • Resume enteral feeding after return of bowel function
  • Sodium restriction can reduce future ascites (3)[A].

PROGNOSIS

  • SBPFor inpatients with first episode of SBP, mortality ranges from 10% to 50% (3).Prognosis is improved if antibiotics are started early, prior to onset of shock or renal failure.Strongest negative prognostic indicator is renal insufficiency.Other poor prognostic factors include nosocomial acquisition, old age, high Child-Pugh-Turcotte or MELD score, malnutrition, malignancy, peripheral leukopenia, and antibiotic resistance (3).Patients with prior SBP have 1-year recurrence rate of 40 " 70% and 1-year mortality of 31 " 93% (1,3).
  • Secondary bacterial peritonitis:In-hospital mortality of treated patients is 67% (4).Mortality approaches 100% if not treated surgically, especially if secondary to perforation (2,4).Prognosis is worse in perforated etiologies.

COMPLICATIONS

  • Renal failure, liver failure, encephalopathy, coagulopathy
  • Secondary infection, iatrogenic infection, abscess, fistula formation, abdominal compartment syndrome
  • Sepsis/septic shock, cardiovascular collapse, adrenal insufficiency, respiratory failure, ARDS

REFERENCES

11 Alaniz C, Regal RE. Spontaneous bacterial peritonitis: a review of treatment options. P T. 2009;34(4):204 " 210.22 Panhofer P, Izay B, Riedl M, et al. Age, microbiology and prognostic scores help to differentiate between secondary and tertiary peritonitis. Langenbecks Arch Surg. 2009;394(2):265 " 271.33 Wiest R, Krag A, Gerbes A. Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut. 2012;61(2):297 " 310.44 Soriano G, Castellote J, Alvarez C, et al. Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol. 2010;52(1):39 " 44.55 Runyon B; AASLD. Introduction to the revised American Association for the Study of Liver Diseases practice guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57(4):1651 " 1653.66 Ballinger A, Palmer SC, Wiggins KJ, et al. Treatment for peritoneal dialysis-associated peritonitis. Cochrane Database Syst Rev. 2014;(4):CD005284.

ADDITIONAL READING

  • Bajaj JS, O 'Leary JG, Wong F, et al. Bacterial infections in end-stage liver disease: current challenges and future directions. Gut. 2012;61(8):1219 " 1225.
  • Cheong HS, Kang CI, Lee JA, et al. Clinical significance and outcome of nosocomial acquisition of spontaneous bacterial peritonitis in patients with liver cirrhosis. Clin Infect Dis. 2009;48(9):1230 " 1236.
  • Deshpande A, Pasupuleti V, Thota P, et al. Acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. J Gastroenterol Hepatol. 2013;28(2):235 " 242.
  • Ghassemi S, Garcia-Tsao G. Prevention and treatment of infections in patients with cirrhosis. Best Pract Res Clin Gastroenterol. 2007;21(1):77 " 93.
  • Jain P. Spontaneous bacterial peritonitis: few additional points. World J Gastroenterol. 2009;15(45):5754 " 5755.
  • Koulaouzidis A, Bhat S, Karagiannidis A, et al. Spontaneous bacterial peritonitis. Postgrad Med J. 2007;83(980):379 " 383.
  • Koulaouzidis A, Bhat S, Saeed AA. Spontaneous bacterial peritonitis. World J Gastroenterol. 2009;15(9):1042 " 1049.
  • Mandorfer M, Bota S, Schwabl P, et al. Nonselective ² blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology. 2014;146(7):1680.e1 " 1690.e1.

SEE ALSO

Appendicitis, Acute; Cirrhosis of the Liver; Diverticular Disease; Peptic Ulcer Disease

CODES

ICD10

  • K65.0 Generalized (acute) peritonitis
  • K65.2 Spontaneous bacterial peritonitis
  • K65.8 Other peritonitis
  • K65.9 Peritonitis, unspecified
  • K65.1 Peritoneal abscess

ICD9

  • 567.21 Peritonitis (acute) generalized
  • 567.23 Spontaneous bacterial peritonitis
  • 567.89 Other specified peritonitis
  • 567.9 Unspecified peritonitis
  • 567.22 Peritoneal abscess
  • 567.29 Other suppurative peritonitis

SNOMED

  • 67602004 Acute peritonitis
  • 11836002 Primary bacterial peritonitis (disorder)
  • 31860008 Acute bacterial peritonitis
  • 213293008 Aseptic peritonitis (disorder)

CLINICAL PEARLS

  • Maintain a high index of suspicion for SBP in cirrhotic patients with ascites. SBP occurs in preexisting ascites and carries a high mortality, especially if presenting with GI bleed.
  • Early diagnosis and treatment reduces mortality.
  • Paracentesis is necessary to diagnose SBP.
  • Emergent CT scan should be performed if there is suspicion of secondary bacterial peritonitis.
  • Distinguishing SBP from secondary bacterial peritonitis is essential, as SBP treatment consists of antibiotic therapy whereas secondary bacterial peritonitis necessitates emergent surgical intervention.
  • Renal function is an important prognostic indicator for SBP. Albumin administration decreases the incidence of renal failure and mortality in patients with renal or hepatic impairment or large-volume paracentesis.