Spontaneous bacterial peritonitis physical examination
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Examination reveals signs of acute abdomen and in advanced cases, shows signs of shock and septicemia.
Appearance of the patient
- Patients with peritonitis are usually ill-appearing.
- Initially they appear alerted, restless and irritable.
- They may later become apathetic and delirious.
- They are often noticed lying quietly supine, on the bed with the knees flexed and with frequent limited intercostal respirations because any motion intensifies the abdominal pain.
- Hyperthermia (temperatures as high as 42° C) is a sign of infection and hypothermia (temperatures as low as 35° C) indicates septic shock.
- Hypothermia is a grave sign,seen late in the course of the disease in patients with on-going intra-abdominal sepsis or septic shock.
- Hypertension can be seen if associated with any heart condition or renal disease.
- The blood pressure is maintained within normal limits early in the disease process but as peritonitis progresses, the blood pressure decreases due to volume loss diarrhea or severe ascites.
- Tachycardia with weak, thready peripheral pulses represents decreased effective circulating blood volume, indicating a stage of shock later in the disease.
- May be normal or increased in rate due to infection.
- It may be low in volume due to dehydration.
- Tachypnea due to infection and increased demand.
- Skin over abdomen is tense due to ascites.
- Skin changes such as spider nevus, palmar erythema, large abdominal wall collateral veins are suggestive of parenchymal liver disease and portal hypertension
- Jaundice may be seen in cases of liver cirrhosis.
- Periorbital puffiness may be noticed in cases of renal failure.
- Usually tense and distended due to ascites
- Marked abdominal tenderness to palpation is present.
- Shifting dullness on percussion is noted in patients with ascites, but may be painful due to infection.
- Bowel sounds vary along the course of peritonitis, are initially hypoactive, and may disappear later.
- Absence of bowel sounds may be the only manifestation of peritonitis in some patients, and a high index of suspicion is necessary
- The absence of any of these findings does not exclude peritonitis.
- When present, peripheral edema in patients with liver disease is usually found in the lower extremities and occasionally may involve the abdominal wall.
- Patients with nephrotic syndrome or cardiac failure may have total body edema (anasarca).