Spontaneous bacterial peritonitis physical examination
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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] Guillermo Rodriguez Nava, M.D. [3] Shivani Chaparala M.B.B.S [4]
Overview
The clinical exam is unpredictable, so there should be a low threshold to consider SBP in any patient with cirrhosis. If a patient presents with a full, bulging abdomen, percussion of the flanks can provide valuable information to diagnose ascites. The presence of shifting dullness has 83% sensibility and 56% specificity to diagnose ascites. A patient without flank dullness has less than 10% chance of having ascites.[1] Peritoneal signs are uncommonly encountered on examination.
Physical Examination
Appearance of the patient
- The patient may appear toxic and in distress because of pain in the abdomen.
- Patients with peritonitis are usually ill-appearing.
- Initially they appear alert, 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.
Vital Signs
Temperature
- 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.
Blood Pressure
- 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 lossdiarrhea or severe ascites.
Pulse
- 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.
Respiration
- Tachypnea due to infection and increased demand.
Skin
- 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
Eyes
- Jaundice may be seen in cases of liver cirrhosis.
- Periorbital puffiness may be noticed in cases of renal failure.
Neck
- Jugular venous distension may be seen in cases of heart failure causing ascites.
Heart
- Signs of heart failure may be seen like S3.
Lungs
- Signs of any infection, or signs of volume overload in lungs due to heart failure.
Neurologic
Following may be noticed when spontaneous bacterial peritonitis complicates or due to underlying liver or renal failure.
Abdomen
- Usually tense and distended due to ascites
- Marked abdominal tenderness to palpation is present.
- Direct and referred rebound tenderness may be present and signifies the irritation of the parietal peritoneum.
- Muscular rigidity of the abdominal wall produced by voluntary guarding and reflex muscular spasm may also be present.
- Hyper-resonance on percussion if present,indicates the gaseous dissention of the intestine.
- 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.
Extremities
- 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).
References
- ↑ Cattau EL, Benjamin SB, Knuff TE, Castell DO (1982). "The accuracy of the physical examination in the diagnosis of suspected ascites". JAMA. 247 (8): 1164–6. PMID 7057606.