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	Typical History	Localization of the abdominal pain	Symptoms and signs	Specific signs	Physical findings									Diagnostic tests and Lab findings	Choice of Imaging	Treatment	Other comments
							Appearance of the patient/ shape of the abdomen	Abdominal tenderness	Shifting dullness	Rigidity and Guard ing	Deep tenderness	Rebound tenderness	Cough tenderness	Bump tenderness	Bowel sounds
Common causes of peritonitis	Primary peritonitis	Spontaneous bacterial peritonitis					Motionless	✔	✔	✔		✔	✔		Absent (late)
	Inflammatory disorders and perforations causing Secondary peritonitis	Perforated gastro-duodenal ulcers				Loss of liver dullness due to free air accumulating under the diaphragm	Scaphoid, tense abdomen			✔					Diminished (late)		CT scan
		Acute cholangitis		Right upper quadrant	Jaundice,fever,confusion,shock												Ultrasound, CT, ERCP, MRCP, PTC	Biliary decompression + Broad spectrum antibiotics	Charcot triad ( RUQ pain, jaundice,fever) Reynold pentad ( RUQ pain, jaundice,fever, confusion,shock)
		Acute cholecystitis				Murphy sign		✔									Ultrasound
		Acute pancreatitis														Serum amylase/lipase	CT scan
		Acute appendicitis						✔									CT scan, ultrasound
		Small and large bowel perforations
		Acute diverticulitis						✔									CT scan
		Acute salpingitis
Visceral Abscess		Splenic abscess
		Hepatic abscess
Obstruction		Intestinal obstruction					Dissension of the abdomen								Hyper peristalsis (early) Visible peristalsis / quiet abdomen (late)		Flat and upright film, CT scan
		Biliary Colic
		Renal Colic
Paralytic ileus							Distension/ soft doughy fullness	✘							Minimally heard
Vascular disorders	Ischemic	Mesenteric ischemia					Soft duffy fullness	Severe pain out of proportion to examination									CT Angiogram, MRI
		Acute ischemic colitis															CT scan, Colonoscopy
	Hemorrhagic	Ruptured abdominal aortic aneurysm
		Intraabdominal or Retroperitoneal hemorrhage

References

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