Secondary Peritonitis due to a MISSED cause

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65 yr old male, labourer by occupation, chronic smoker and alcoholic came with complaints of:

  Vomitings followed by abdominal distension associated with abdominal pain and shortness of breath since 20days.
  Pedal edema G-2, pitting type, for a week which got subsided later.

 Loss of appetite & constipation since 15 days.

History of presenting illness:

    I was apparently normal 20 days back then I developed vomitings 6 episodes in the evening containing food particles and yellowish liquid after binge drinking (actually I gave up alcohol for 3 months and now I had this country drink) followed by Abdominal distention which I noticed the next day morning and it was associated with abdominal pain which was diffuse below the my belly button and also difficulty in breathing. I also developed low grade fever, intermittent, subsided with sweating. then I lost my appetite and later constipation added to my problems. then after week i noticed my legs are swollen upto my knees, later i felt burning sensation while urinating (may be i was not taking enough water)
  Personal history

 pt takes mixed diet, decreased sleep and appetite due to pain and distension resp.
Sedentary lifestyle

Chronic smoker 50pack years

Chronic alcoholic [since 35yrs] takes brandy 180ml/day.

Not a diabetic.

Not a hypertensive. No h/o previous surgeries or BTs.

GENERAL EXAMINATION

Patient appears to be thin built ,undernourised, febrile.

•       No Pallor

•       Icterus present

•       No cyanosis

•       No kylonycia

•       No lympadenopathy.

•       Bilateral pedal edema present. G-2 pitting type.

•       Disturbed sleep due to severe abdominal pain.

•       Bladder regular with burning micturition, constipation present.
vitals: pulse 105bpm, BP 140/100, RR 22cycles/min, spO2 94
On examination abdomen distended with umbilicus everted, fluid thrill present,on auscultation basal crepts present.

ROUTINE INVESTIGATIONS:

Ø   HEAMOGLOBIN          11

Ø    TOTAL COUNT          17400

Ø   TOTAL BILIRUBIN     3.I

Ø   DIRECT BILIRUBIN   I.3

Ø    ALBUMIN                  2.3

Ø   USG abdomen   : large loculated ascitis.

Ø   CECT abdomen  : large loculated ascitis with bilateral pleural effusion,No signs  of liver failure.

ASCITIC FLUID ANALYSIS:

Sugar                56 (60-100)

Protein              3.6(<2.5)

Amylase           26

SAAG               1.5(<1.1)

Total count      4400cells/cumm

Neutrophils      90

Lymphocytes  10

Cultures            isolated E Coli  sensitive to AMIKACIN, GENTAMYCIN, MEROPENEM

Ascitic fluid aspirate growing E coli

FINAL DIAGNOSIS
  MASSIVE ASCITIS

           ? LIVER FAILURE.

           ? SPONTANEOUS BACTERIAL PERITONITIS

           ? SECONDARY BACTERIAL PERITONITIS

           ?FOLLOWING  SEALED BOWEL PERFORATION

UPPER GI ENDOSCOPY:

Hiatus hernia.

Bowel perforation was ruled out.

Liver failure was ruled out.

FINAL DIAGNOSIS:           MASSIVE ASCITIS

              ? SPONTANEOUS BACTERIAL PERITONITIS

So This was a case of a secondary peritonitis with perforation that was treated successfully with antibiotics and surgical intervention. Although the case did have certain characteristics of SBP, such as monomicrobial infection and improvement of absolute neutrophil count after 48 h of antibiotics, persistence of patient symptomatology prompted further evaluation to look for an alternate diagnosis. Runyon’s criteria have an estimated sensitivity and specificity for predicting secondary bacterial peritonitis of 67 and 96%, respectively and our patient met the criteria."Runyon’s Criteria for secondary bacterial peritonitis requires two of these three features:
total protein >1 g/dL, glucose <50 mg/dL (2.8 mM), and lactate dehydrodgenase above the upper limit of normal for serum."
http://emcrit.org/pulmcrit/secondary-bacterial-peritonitis/

That together with the lack of improvement prompted us to probe further. A repeat paracentesis is not necessary for all patients with infected ascites but should be considered in patients with one or more characteristics of secondary peritonitis as detailed above. Re-categorizing this case from SBP to secondary peritonitis allowed us to advocate for a likely curative surgical intervention.

as the patient is elderly malignancy was also suspected and cytology was done as shown in above slide image. No malignant cells were seen. The USG doesn't show any obvious malignancy.

               SECOND ADMISSION:

Patient presented with similar complaints of
 Abdominal distention

     Loss of appetite with loss of weight. He lost about 10kg in a span of one month.

ASCITIC FLUID ANALYSIS:

Sugar                   36

Protein                1.5

SAAG                   0.5

Counts                 1300cells/cumm.

Cultures              : isolated E coli

CECT abdomen with iv contrast was advised - SUSPECTED GALL BLADDER PERFORATION

pt was subjected to DIAGNOSTIC LAPAROSCOPY and GALL BLADDER PERFORATION was confirmed.

FINAL DIAGNOSIS

MASSIVE TENSE ASCITIS secondary to GALL BLADDER PERFORATION [sealed]