Critical Cases - Spontaneous Bacterial Peritonitis!


  • Had sudden onset RLQ pain starting about 1.5 hours prior to arrival
  • Associated nausea but no vomiting
  • No change in bowel movements
  • No recent surgeries


  • Stage IV pancreatic cancer
  • Asthma
  • Chronic back pain
  • ETOH abuse (quit about 2 months prior)
  • Chronic pancreatitis

Physical Exam 

VS - T: 98F, HR: 120, BP: 147/91, RR: 22, Ox: 93%

  • General: appears uncomfortable, cannot sit still on stretcher
  • HEENT: no scleral icterus
  • CV: tachycardic
  • Pulm: lungs CTA b/l
  • Abdomen: distended, firm, epigastric and RLQ tenderness, voluntary guarding in RLQ, no rebound tenderness

Initial DDX

  • SBO, acute perforation, appendicitis, pancreatitis, diverticulitis, mesenteric ischemia, cholecystitis, spontaneous bacterial peritonitis (SBP) 

Initial ED management 

  • IV fluids, pain medication, anti-emetics
  • Taken directly to CT scan

CT Scan abd/pelvis interpretatiion:

  • “Increase in abdominal/pelvic ascites, with thickening and enhancement of peritoneal lining, which may be reactive versus represent changes of peritonitis; please correlate with physical examination.”


Further ED management and clinical course

  • Broad spectrum antibiotics started including vancomycin, cefepime and metronidazole
  • Repeat temperature 102.7 F 
  • Diagnostic paracentesis performed: WBC in peritoneal fluid: >44,700
  • Peritoneal fluid grows many gram-negative rods and many gram-positive cocci 


Spontaneous Bacterial Peritonitis Pearls

  • Criteria for spontaneous bacterial paracentesis >250 PMN (for patients on peritoneal dialysis, cell count >100 with >50% neutrophils
  • Initial antibiotic options can be third generation cephalosporins or ciprofloxacin 
  • Supplemental treatment with albumin infusion 1.5 g/kg has been shown to decrease mortality (see this excellent review from Rebel EM here
  • Disposition is usually admission for IV antibiotics and albumin therapy
  • In patients with abdominal pain/fever/altered mental status and ascites, SBP should be on the differential and obtaining a diagnostic (not necessarily therapeutic) paracentesis in the ED should be part of the workup!!




Koulaouzidis A, Bhat S, Karagiannidis A, Tan WC, Linaker BD. Spontaneous bacterial peritonitis. Postgrad Med J. 2007;83(980):379-383. doi:10.1136/pgmj.2006.056168

Tholey, D. (2021, December 14). Spontaneous bacterial peritonitis (SBP) - hepatic and biliary disorders. Merck Manuals Professional Edition. Retrieved December 20, 2021, from