Peritonitis and Abdominal Sepsis Differential Diagnoses

Author: Brian James Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Julian Katz, MD more...

Updated: Mar 29, 2011

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Diagnostic Considerations

Thoracic processes with diaphragmatic irritation (eg, empyema), extraperitoneal processes (eg, pyelonephritis, cystitis, acute urinary retention), and abdominal wall processes (eg, infection, rectus hematoma) may mimic certain signs and symptoms of peritonitis. Always examine the patient for the presence of external hernias to rule out intestinal incarceration.

According to Adler and Gasbarra, the following should be considered in the differential diagnosis^[8]:

Chemical irritants (eg, bile, blood, gastric juice, barium, enema or douche contents)
Chronic peritoneal dialysis
Chylous peritonitis
Eosinophilic peritonitis
Familial Mediterranean fever
Fungal infections (eg, histoplasmosis, cryptococcosis, coccidioidomycosis)
Granulomatous peritonitis (eg, parasitic infestations, sarcoidosis, tumors, Crohn disease, starch granules)
Gynecologic disorders (Chlamydia peritonitis, salpingitis, endometriosis, teratoma, leiomyomatosis, dermoid cyst)
HIV-associated peritonitis (from opportunistic organisms)
Mesothelial hyperplasia and metaplasia
Neoplasms (eg, primary mesothelioma, secondary carcinomatosis, Pseudomyxoma peritonei)
Parasitic infections (eg, schistosomiasis, ascariasis, enterobiasis, amebiasis, strongyloidiasis)
Perforated viscus
Peritoneal encapsulation
Peritoneal loose bodies and peritoneal cysts
Peritoneal lymphangiectasis
Pyelonephritis
Sclerosing peritonitis
Splenosis
Vascular conditions (eg, mesenteric embolus, mesenteric nonocclusive ischemia, ischemic colitis, portal vein thrombosis, mesenteric vein thrombosis)
Vasculitis (eg, systemic lupus erythematosus, allergic vasculitis [Henoch-Schönlein purpura], Kohlmeier-Degos disease, polyarteritis nodosa)

Differential Diagnoses

Proceed to Workup

Contributor Information and Disclosures

Author

Brian James Daley, MD, MBA, FACS, FCCP, CNSC Professor, Associate Program Director, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Alex Jacocks, MD Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Disclosure: Nothing to disclose.

Chandler Long, MD Resident Physician, Department of Surgery, University of Tennessee Medical Center, Knoxville

Disclosure: Nothing to disclose.

Lena M Napolitano, MD, FACS, FCCP, FCCM Professor of Surgery, University of Michigan School of Medicine; Chief, Surgical Critical Care, Program Director, Surgical Critical Care Fellowship, Associate Chair, Department of Surgery, University of Michigan Health System

Lena M Napolitano, MD, FACS, FCCP, FCCM is a member of the following medical societies: Alpha Omega Alpha, American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, Association for Academic Surgery, Association of VA Surgeons, Association of Women Surgeons, California Professional Society on the Abuse of Children, Eastern Association for the Surgery of Trauma, Phi Beta Kappa, Shock Society, Society of Critical Care Medicine, and Society of University Surgeons

Disclosure: Pfizer, Wyeth, Schering Plough, Merck, Ortho-McNeil Honoraria Speaking and teaching

Ketul R Patel, MD Resident, Department of Internal Medicine, Providence Hospital

Ketul R Patel, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Ruben Peralta, MD, FACS Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic

Ruben Peralta, MD, FACS is a member of the following medical societies: American Association of Blood Banks, American College of Healthcare Executives, American College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, and Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Michael H Piper, MD, FACG, FACP Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates PLC

Michael H Piper, MD, FACG, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, and Michigan State Medical Society

Disclosure: Nothing to disclose.

Kenneth L Reed, DO Fellow in Gastroenterology, Providence Hospital, Michigan

Kenneth L Reed, DO is a member of the following medical societies: American College of Gastroenterology, American College of Osteopathic Internists, American Gastroenterological Association, American Osteopathic Association, American Society for Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America

Disclosure: Nothing to disclose.

Bradley J Warren, DO, FACG, FACOI Consulting Staff, Digestive Health Associates, PLC

Bradley J Warren, DO, FACG, FACOI is a member of the following medical societies: American College of Gastroenterology, American Osteopathic Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

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Barretti P, Montelli AC, Batalha JE, Caramori JC, Cunha Mde L. The role of virulence factors in the outcome of staphylococcal peritonitis in CAPD patients. BMC Infect Dis. Dec 22 2009;9:212. [Medline]. [Full Text].
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Diagnostic and therapeutic approach to peritonitis and peritoneal abscess.

A 48-year-old man underwent suprapubic laparotomy, right hemicolectomy, and gastroduodenal resection for right colon cancer invading the first portion of the duodenum. He developed abdominal pain and distention. Computed tomography (CT) scanning was used to confirm an anastomotic dehiscence. Figure A shows a contrast-enhanced scan of the abdomen and pelvis that reveals multiple fluid collections, perihepatic ascites, and mild periportal edema. A collection of fluid containing an air-fluid level is visible anterior to the left lobe of the liver. A second collection is anterior to the splenic flexure of the colon. In figure B, a third fluid collection is present in the inferior aspect of the lesser space and in the transverse mesocolon. Figure C shows the pelvis with a collection of free fluid in the rectovesical pouch.

A 78-year-old man was admitted with a history of prior surgery for small bowel obstruction and worsening abdominal pain, distended abdomen, nausea, and obstipation. In figure A, a marked amount of portal venous gas within the liver, mesenteric venous gas, and pneumatosis intestinalis are consistent with ischemic small intestine. The superior mesenteric artery appears patent. The liver has a nodular contour consistent with cirrhosis. In figures B and C, markedly distended loops of small intestine containing fluid and air-fluid levels are consistent with a small bowel obstruction. No focal fluid collections are identified.

A 35-year-old man with a history of Crohn disease presented with pain and swelling in the right abdomen. In figure A, a thickened loop of terminal ileum is evident adherent to the right anterior abdominal wall. In figure B, the right anterior abdominal wall is markedly thickened and edematous, with adjacent inflamed terminal ileum. In figure C, a right lower quadrant abdominal wall abscess and enteric fistula are observed and confirmed by the presence of enteral contrast in the abdominal wall.

Gram-negative Escherichia coli.

Table 1. Common Causes of Secondary Peritonitis

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.

Table 2. Microbial Flora of Secondary Peritonitis

Type	Organism	Percentage
Aerobic
Gram negative	Escherichia coli	60%
	Enterobacter/Klebsiella	26%
	Proteus	22%
	Pseudomonas	8%
Gram positive	Streptococci	28%
	Enterococci	17%
	Staphylococci	7%
Anaerobic	Bacteroides	72%
	Eubacteria	24%
	Clostridia	17%
	Peptostreptococci	14%
	Peptococci	11%
Fungi	Candida	2%

Table 3. Microbiology of Primary, Secondary, and Tertiary Peritonitis

Peritonitis (Type)	Etiologic Organisms		Antibiotic Therapy (Suggested)
Peritonitis (Type)	Class	Type of Organism	Antibiotic Therapy (Suggested)
Primary	Gram-negative	E coli (40%) K pneumoniae (7%) Pseudomonas species (5%) Proteus species (5%) Streptococcus species (15%) Staphylococcus species (3%) Anaerobic species (< 5%)	Third-generation cephalosporin
Secondary	Gram-negative	E coli Enterobacter species Klebsiella species Proteus species	Second-generation cephalosporin Third-generation cephalosporin Penicillins with anaerobic activity Quinolones with anaerobic activity Quinolone and metronidazole Aminoglycoside and metronidazole
	Gram-positive	Streptococcus species Enterococcus species
	Anaerobic	Bacteroides fragilis Other Bacteroides species Eubacterium species Clostridium species Anaerobic Streptococcus species
Tertiary	Gram-negative	Enterobacter species Pseudomonas species Enterococcus species	Second-generation cephalosporin Third-generation cephalosporin Penicillins with anaerobic activity Quinolones with anaerobic activity Quinolone and metronidazole Aminoglycoside and metronidazole Carbapenems Triazoles or amphotericin (considered in fungal etiology) (Alter therapy based on culture results.)
	Gram-positive	Staphylococcus species
	Fungal	Candida species

Table 4. Ascitic Fluid Analysis Summary^[4]

Routine	Optional	Unusual	Less Helpful
Cell count	Obtain culture in blood culture (BC) bottles.	Tuberculosis (TB) smear and culture	pH
Albumin	Glucose	Cytology	Lactate
Total protein	Lactate dehydrogenase (LDH)	Triglyceride	Cholesterol
	Amylase	Bilirubin	Fibronectin
	Gram stain		Alpha 1-antitrypsin
			Glycosaminoglycans

View Table List

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