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1. A 70-year-old woman has had increasing abdominal pain over the past 2 days. She has renal failure and has been receiving peritoneal dialysis for 18 months; her last treatment was 2 hours ago. She appears toxic. Her temperature is 39 C (102.2 F), and blood pressure is 140/90 mm Hg. Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness. Leukocyte count is 18,000/mm3. Which of the following is the most appropriate next step?
A ) X-ray films of the abdomen
B ) Comparison of abdominal fluid amylase with serum amylase activity
C ) Gram's stain of abdominal fluid
D ) Ultrasonography of the abdomen
E ) CT scan of the abdomen and pelvis
I think the answer is B or E. What do you think it is and why?
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why not CCC? it is spontaneous bact peritonitis ( next step paracent.+gram stain)
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Sorry.. yes I meant I think it is C or E.. my mistake. Why not E? Anyone else?
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because the presentation suggest clearly SBP ( history, peritoneal dialysis), clinical presentation ( fever, increase leuKO; etc etc).
From emedicine *
All patients suspected of having spontaneous bacterial peritonitis (SBP) must undergo peritoneal fluid analysis while in the ED. Antibiotics, if indicated, should be initiated as soon as possible.
* Peritoneal fluid PMN count greater than 500 cells/µL: These patients universally should be admitted and treated for SBP regardless of peritoneal fluid Gram stain result. Empiric therapy as discussed below should be initiated unless microbiologic studies further guide treatment.
* Peritoneal fluid PMN count less than 250 cells/µL: Management of this group depends upon the results of ascitic fluid cultures. All symptomatic patients should be admitted. Patients whose culture results are positive should be treated for SBP. A select subset of patients who are completely asymptomatic yet have positive culture results may be managed without treatment but must undergo a follow-up paracentesis within 24-48 hours.
* Peritoneal fluid PMN count of 250-500 cells/µL: All symptomatic patients in this group should be admitted and treated for SBP.
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Her pain started two days ago, before the peritoneal dialysis shouldn't we rule out ruture of viscus by an XRay
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agree with ccc
pain started 2 days back so abdominal organs rupture is unlikely to be the cause.
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''Plain films of the abdomen (eg, supine, upright, and lateral decubitus positions) are often the first imaging studies obtained in patients presenting with peritonitis ''
Emedicine.
There is a very little role of gram stain in the diagnosis. Cell count and culture are of value in this case.
Rupture can occur after two days of progessively increasing pain as in this case.
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I agree with digitalis1. Dx is SBP. But there is often negative result form gram stain so gram stain plays a little role in Dx of SBP. Culture is fine but not listed here as an option. So I am thinking if it is possible with "D"--Uts to detect the volume of ascites and prepare for paracentesis ? Welcome further input
