Spontaneous bacterial peritonitis differential diagnosis

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

Overview

Spontaneous bacterial peritonitis must be differentiated from other diseases that cause fever and abdominal pain, such as peritonitis, pyelonephritis, and appendicitis.

Differentiating Spontaneous bacterial peritonitis from other Diseases

Spontaneous bacterial peritonitis presents as fever and pain in the abdomen. These symptoms may also be seen in other abdominal conditions such as:

• Peritonitis - this presents as abdominal pain with guarding which is seldom seen in spontaneous bacterial peritonitis.
• Pyelonephritis - this presents as pain in the costovertebral angle.
• Appendicitis - this presents with a typical history of radiation of pain from umbilicus to McBurney's point compared to diffuse pain in spontaneous bacterial peritonitis.
• PCT level was higher in advanced Liver cirrhosis patients with SBP than CNNA which indicated it may represent as a simple biomarker for differentiating SBP from CNNA. PCT may be a prognostic predictor to guide the empirical antimicrobial therapy in order to decrease the in-hospital mortality and the frequency of complications.

Classification of acute abdomen based on the etiology		Presentation	Symptoms						Signs							Lab findings	Preferred diagnostic test	Additional findings
			Fever	Jaundice	Nausea/ Vomiting	Diarrhea	Constipation	Abdominal Pain Location	General Appearance	Bowel Sounds	Abdominal tenderness		Shifting dullness	Rigidity	Rebound tenderness
											Superficial	Deep
Common causes of peritonitis	Primary peritonitis	Spontaneous bacterial peritonitis	✔	✘	✔/✘	✘	✘	diffuse	lies supine motionless tense abdomen due to ascites	diminished	✔	✘	✔	✘	✘	Ascitic fluid PMN>250cells/mm3 Single organism on culture of the ascitic fluid	ascitic fluid PMN count	Altered mental status usually seen.
	Inflammatory disorders and perforations causing Secondary peritonitis	Perforated gastro-duodenal ulcers	✔	✘	✔/✘	✘	✘	right upper quadrant	Scaphoid, tense abdomen	✘	✔	✘	✘	✔	✔	Fulfillment of 2/3 runyon's criteria: glucose < 50mg/dl total protein > 1g/dl LDH ascites > normal LDH serum	upright chest x-ray, CT scan
		Acute cholangitis	✔	✔	✘	✘	✘	Right upper quadrant	Toxic look	normal	✘	✘	✘	✘	✘		Ultrasound, CT, ERCP, MRCP, PTC	Charcot triad ( RUQ pain, jaundice,fever) Reynold pentad ( RUQ pain, jaundice,fever, confusion,shock)
		Acute cholecystitis	✔		✔	✘	✘	Right upper quadrant or epigastrium may radiate to the right shoulder or back			✔ right upper abdomen	✘	✘	✘	✘		Ultrasound	Murphy's sign (pain on inspiration causing a cessation of breathing) may be present
		Acute pancreatitis	✔		✔			midepigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side with a band-like radiation to the back			✔epigastrium	✘	✘	✘	✘	Serum amylase/lipase	CT scan
		Acute appendicitis	✔			✘	✘	vague periumbilical initially that eventually localises to right lower quadrant			✔right lower quadrant						CT scan, ultrasound
		Acute diverticulitis	✔	✘	✔	✔/✘	✔/✘	Left lower quadrant pain			✔left lower quadrant						CT scan	leukocytosis
		Acute salpingitis	✔
Hollow Viscous Obstruction		small Intestinal obstruction			✔			periumbilical and crampy, with paroxysms of pain occurring every 4-5minutes.Pain progresses from crampy to constant and more severe indicating impending strangulation	Dissension of the abdomen								Flat and upright film, CT scan
		Volvulus			✔		✔ in sigmoid volvulus	steady pain, with a superimposed colicky component
		Biliary Colic			✔			right upper quadrant									CT scan	hepatomegaly and a palpable gallbladder(courvoisier sign) pancreatic head tumor
		Renal Colic						colicky and radiates to the flank or groin										Hematuria
Vascular disorders	Ischemic	Mesenteric ischemia			✔			severe periumbilical pain out of proportion to physical examination findings	Soft duffy fullness		Severe pain out of proportion to examination					increased lactic acid and leukocytosis	Abdominal x-ray, CT Angiogram, MRI
		Acute ischemic colitis															CT scan, Colonoscopy
	Hemorrhagic	Ruptured abdominal aortic aneurysm																cullen sign(bruising around the umbilicus)
		Intraabdominal or Retroperitoneal hemorrhage																Grey turner sign(bruising in the flank)
Gynecologic Causes	Ovarian Cyst Complications	Torsion			✔			lower abdominal pain
		Rupture						focal,unilateral lower abdominal pain accompanied by light vaginal bleeding
	Ruptured Ectopic Pregnancy							lower quadrant									transvaginal ultrasonography and serial testing of hCG	Amenorrhea and vaginal bleeding.

References

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