How is secondary peritonitis (SP) differentiated from SBP in patients with cirrhosis?

Updated: Jul 23, 2019
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Answer

As many as 15% of patients who have cirrhosis with ascites who were initially presumed to have SBP have SP. In many of these patients, clinical signs and symptoms alone are not sensitive or specific enough to reliably differentiate between the 2 entities. A thorough history, evaluation of the peritoneal fluid, and additional diagnostic tests are needed to do so; a high index of suspicion is required.

Table 1. Common Causes of Secondary Peritonitis (Open Table in a new window)

Source Regions

Causes

Esophagus

Boerhaave syndrome

Malignancy

Trauma (mostly penetrating)

Iatrogenic*

Stomach

Peptic ulcer perforation

Malignancy (eg, adenocarcinoma, lymphoma, gastrointestinal stromal tumor)

Trauma (mostly penetrating)

Iatrogenic*

Duodenum

Peptic ulcer perforation

Trauma (blunt and penetrating)

Iatrogenic*

Biliary tract

Cholecystitis

Stone perforation from gallbladder (ie, gallstone ileus) or common duct

Malignancy

Choledochal cyst (rare)

Trauma (mostly penetrating)

Iatrogenic*

Pancreas

Pancreatitis (eg, alcohol, drugs, gallstones)

Trauma (blunt and penetrating)

Iatrogenic*

Small bowel

Ischemic bowel

Incarcerated hernia (internal and external)

Closed loop obstruction

Crohn disease

Malignancy (rare)

Meckel diverticulum

Trauma (mostly penetrating)

Large bowel and appendix

Ischemic bowel

Diverticulitis

Malignancy

Ulcerative colitis and Crohn disease

Appendicitis

Colonic volvulus

Trauma (mostly penetrating)

Iatrogenic

Uterus, salpinx, and ovaries

Pelvic inflammatory disease (eg, salpingo-oophoritis, tubo-ovarian abscess, ovarian cyst)

Malignancy (rare)

Trauma (uncommon)

*Iatrogenic trauma to the upper GI tract, including the pancreas and biliary tract and colon, often results from endoscopic procedures; anastomotic dehiscence and inadvertent bowel injury (eg, mechanical, thermal) are common causes of leak in the postoperative period.


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