Secondary peritonitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]

Overview

Secondary peritonitis has to be differentiated from spontaneous bacterial peritonitis which is also seen in cirrhotics.

Differential Diagnosis

Differentiating secondary peritonitis from spontaneous bacterial peritonitis
Characteristic Spontaneous bacterial peritonitis Secondary peritonitis
Presentaion
  • Similar presentation but insidious onset unlike rapid onset in SBP
Microorganism
  • Monomicrobial involvement is common
  • No identifiable source of intra-abdominal infection
  • Polymicrobial involvement is common
  • Identifiable source of intra-abdominal infection, with or without perforation (surgically treatable source)[1]
Diagnostic Criteria SBP is diagnosed in the presence of:[2]
  • Ascitic fluid PMN count of  ≥250/mm3
  • No evident intra-abdominal source of infection
  • Positive ascitic fluid bacterial culture
Diagnosed in the presence of
  • Positive ascitic fluid bacterial culture
  • Ascitic fluid PMN count of ≥250/mm3
  • Evidence of a source of infection (demonstrated at surgery or autopsy], either intra-abdominal or contiguous with the peritoneal cavity
Follow-up paracentesis
  • Ascitic fluid usually became sterile after one dose of antibiotic
  • Failure of the ascitic fluid to become culture-negative despite of initial antibiotic treatment, appears to be typical of secondary peritonitis due to continuous spillage of organisms into abdominal cavity which requires surgery.[3][4]
Disease Prominent clinical findings Lab tests Tratment
Primary peritonitis Spontaneous bacterial peritonitis
Tuberculous peritonitis
Continuous Ambulatory Peritoneal Dialysis (CAPD peritonitis)
Secondary peritonitis Acute bacterial secondary peritonitis
Biliary peritonitis
Tertiary peritonitis
Familial Mediterranean fever (periodic peritonitis, familial paroxysmal polyserositis)
  • Colchicine prevents but does not treat acute attacks.
Granulomatous peritonitis
  • Diagnosed by the demonstration of diagnostic Maltese cross pattern of starch particles.
Sclerosing encapsulating peritonitis
Intraperitoneal abscesses
  • Diagnosed best by CT scan of the abdomen.
  • Treatment consists of prompt and complete CT or US guided drainage of the abscess, control of the primary cause, and adjunctive use of effective antibiotics. Open drainage is reserved for abscesses for which percutaneous drainage is inappropriate or unsuccessful.
Peritoneal mesothelioma
peritoneal carcinomatosis

References

  1. Runyon BA, Hoefs JC (1984). "Ascitic fluid analysis in the differentiation of spontaneous bacterial peritonitis from gastrointestinal tract perforation into ascitic fluid". Hepatology. 4 (3): 447–50. PMID 6724512.
  2. Runyon BA, Hoefs JC (1986). "Spontaneous vs secondary bacterial peritonitis. Differentiation by response of ascitic fluid neutrophil count to antimicrobial therapy". Arch Intern Med. 146 (8): 1563–5. PMID 3729637.
  3. Runyon BA (1986). "Bacterial peritonitis secondary to a perinephric abscess. Case report and differentiation from spontaneous bacterial peritonitis". Am J Med. 80 (5): 997–8. PMID 3518442.
  4. Akriviadis EA, Runyon BA (1990). "Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis". Gastroenterology. 98 (1): 127–33. PMID 2293571.