Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

1162 Peritonitis

tests

Basic Tests: Blood

■increased WBC, with or without left shift in bacterial peritonitis; lym-

phocytosis in tuberculous peritonitis

Special Tests

Peritoneal Fluid (Bacterial Peritonitis):

■>100 WBC/mm3 with >50% PMNs, or >100 PMNs/mm3

■organisms on Gram’s stain: 70% of isolates are gram-positive, usually

from the skin flora

■Fitz-Hugh-Curtis: usually neutrocytic; highest reported total protein

of any cause of ascites

Laparoscopy:

■100% sensitive for diagnosis of tuberculous peritonitis

■laparoscopy shows characteristic “violin-string” or “bridal veil”

adhesions from abdominal to liver in Fitz-Hugh-Curtis syndrome

differential diagnosis

■peritonitis associated with AIDS: patients are predisposed to oppor-

tunistic infections that may involve the peritoneum:

➣viruses [i.e., CMV]

➣parasites [i.e., Pneumocystis carinii]

➣fungus [i.e., Histoplasma, Cryptococcus, and Coccidioides]

➣mycobacteria [i.e., Mycobacterium tuberculosis and Mycobac-

terium avium-intracellulare]

➣Non-Hodgkin’s lymphoma and Karposi sarcoma

management

What To Do First

■assess stability of patient and nature of underlying diseases

■perform diagnostic paracentesis

General Measures

■assess likelihood of bacterial peritonitis and need for empiric antibi-

otic therapy pending cultures

specific therapy

■presumed bacterial peritonitis: empiric IV or intraperitoneal

(in dialysis-related peritonitis) second- or third-generation

cephalosporin while awaiting culture result. Coverage for gram

positive cocci and anarobes should be considered in cases of