CHEST
Ultrasound Corner
Patient With Cirrhosis and Presumed Spontaneous Bacterial Peritonitis Robert A. Jones, DO; Matthew Tabbut, MD; Ziad Shaman, MD, FCCP; and Diane Gramer, RDMS, RVT
CHEST 2014; 146(1):e11–e13
patient in his 40s was brought to the ED Amale from the medicine clinic for admission with a pre-
sumptive diagnosis of spontaneous bacterial peritonitis (SBP). His medical history included hypertension, cirrhosis, liver cancer, and diverticulosis. The patient had had two prior admissions for SBP, and he felt like he had “that stomach infection again.” On presentation, the patient’s vitals were as follows: BP, 90/54 mm Hg; heart rate, 112/min; temperature, 38.4°C; respiratory rate, 28/min; and oxygen saturation, 94% on room air. Physical examination revealed an ill-appearing man. His abdomen was distended with diffuse tenderness and guarding. Pertinent laboratory values were as follows: WBC count, 17,400/mL with 28% bands; hemoglobin, 8.7 g/dL; platelet count, 85,000/mmol; prothrombin time/international normalized ratio, 2.1; creatinine, 3.8 mg/dL; and total bilirubin, 4.8 mg/dL. Bedside ultrasonography was used to verify the presence of ascitic fluid and to identify the best entry point for paracentesis (Video 1). Based on the interpretation of the video and the patient’s clinical presentation, what would be the most logical next step?
Manuscript received December 18, 2013; revision accepted February 18, 2014. Affiliations: From the Department of Emergency Medicine (Drs Jones and Tabbut and Ms Gramer), and the Department of Pulmonary/Critical Care (Dr Shaman), MetroHealth Medical Center, Cleveland, OH. Correspondence to: Robert A. Jones, DO, MetroHealth Medical Center, Department of Emergency Medicine, 2500 MetroHealth Dr, Cleveland, OH 44109; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-2997 journal.publications.chestnet.org
CHEST / 146 / 1 / JULY 2014
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Next steps: Treat for secondary peritonitis and obtain emergent general surgery consultation. The patient has pneumoperitoneum due to a gasforming infection of the sigmoid colon. This patient presented with findings consistent with SBP. Although paracentesis is generally a safe procedure, it can be associated with significant complications, and there is a potential benefit in terms of patient safety in the routine use of ultrasound to avoid injuring abdominal organs and major abdominal wall vasculature. A recent case report of an inferior epigastric artery laceration that occurred during a therapeutic paracentesis resulting in the patient’s death emphasizes the potential benefit of ultrasound.1 Bedside ultrasound was performed on this patient using both a 5-2 MHz curvilinear transducer and a 12-5 MHz linear transducer. The curvilinear transducer was used first to evaluate the peritoneal cavity and to assess the distribution of the ascitic fluid to determine the safest point of entry for the needle. A large volume of ascites was noted during the examination (Video 1). The ascitic fluid was complex in appearance. Although ultrasound cannot be used to distinguish infected from noninfected fluid, it suggested that this fluid was exudative. Additionally, it was noted that the peritoneal stripe had an enhanced appearance (highly echogenic), and reverberations were present posterior to the peritoneal stripe, which was concerning for pneumoperitoneum. Further evaluation of the peritoneal cavity revealed that echogenic reflectors were emanating from a section of the sigmoid colon, and these echogenic reflectors were rising to the peritoneal stripe in this supine patient (Video 1). The loop of bowel had multiple outpouchings noted, consistent with the patient’s history of diverticulosis. Based on these ultrasound findings, the diagnosis went from SBP to secondary peritonitis with pneumoperitoneum from a complicated diverticulitis. General surgery consultation was emergently obtained. Fluid resuscitation was continued, and the patient was started on broad-spectrum antibiotics. The general surgeons recommended performing a CT scan of the abdomen and performing ultrasound-guided paracentesis because the vitals had improved with fluid resuscitation. The fluid analysis was found to be consistent with a secondary peritonitis based on Runyon’s criteria (a minimum of two of the following criteria: total protein . 1.0 g/dL, glucose , 50 mg/dL, and lactate dehydrogenase greater than the upper limit of normal for the serum).2 This patient had 6,483 cells/mm, with a Gram stain showing multiple gram-negative rods. The patient met all three of Runyon’s criteria with total protein of 1.8 g/dL, glucose of 34 mg/dL, and lactate e12
dehydrogenase 1.6 times the upper limit of normal for the serum. The CT scan revealed pneumoperitoneum, with the suspected source being a sigmoid diverticular infection. Emergent operative intervention was recommended but was refused by the patient and his wife. The patient opted for comfort care measures and died 4 h later. Discussion This case demonstrates a potential role for bedside ultrasound in the evaluation of the patient with potential SBP. The distinction between secondary bacterial peritonitis and SBP is vital because the therapies are different. The mortality of secondary bacterial peritonitis approaches 100% if treatment consists of antibiotics only, with no operative intervention.2 Although the diagnosis of pneumoperitoneum is traditionally based on radiographic evidence on an upright chest radiograph, ultrasound has shown promise in the detection of pneumoperitoneum. Seitz and Reising3 first described the sonographic detection of free air with ultrasound. Chen and colleagues4 found that ultrasonography is a more sensitive modality than plain radiography for the diagnosis of pneumoperitoneum, with ultrasound having a sensitivity of 93% and a specificity of 64%. Sonographically, air appears as echogenic areas with posterior reverberation artifacts (Videos 1, 2).4 The presence of air within the bowel has an identical appearance to that of free peritoneal air, and, in some cases, it may be difficult to determine the exact location of the air. The presence of ascites should make the detection of pneumoperitoneum easier because the fluid separates the bowel from the peritoneal stripe. Enhancement of the peritoneal stripe in the presence of pneumoperitoneum has been demonstrated in several studies.5,6 The presence of even minute amounts of pneumoperitoneum against the anterior peritoneal wall will result in an enhancement of its appearance (Videos 1, 2). Patients with ascites may demonstrate the presence of air bubbles within the ascitic fluid.7 During real-time scanning of this patient, echogenic reflectors caused by the presence of gas bubbles could be seen moving to the anterior peritoneal line, mimicking surface-to-air missiles (Videos 1, 2). In conclusion, bedside ultrasound can be used to detect the presence of pneumoperitoneum. The sonographic findings associated with pneumoperitoneum should be sought when scanning patients with acute abdominal pain or patients with suspected SBP undergoing diagnostic paracentesis. Ultrasound Corner
Reverberations 1. Ultrasound can be very helpful in locating a safe point for needle entry during paracentesis. Ultrasound can be used to identify fluid location, key abdominal structures to avoid, and major abdominal wall vasculature. 2. Ultrasound can be used to diagnose pneumoperitoneum. 3. The presence of an enhanced peritoneal stripe is easier to see when ascites is present. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: To analyze this case with the videos, see the online version of this article.
journal.publications.chestnet.org
References 1. Sekiguchi H, Suzuki J, Daniels CE. Making paracentesis safer: a proposal for the use of bedside abdominal and vascular ultrasonography to prevent a fatal complication. Chest. 2013;143(4):1136-1139. 2. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology. 1990;98(1):127-133. 3. Seitz K, Reising KD. Sonographic detection of free air in the abdominal cavity [in German]. Ultraschall Med. 1982; 3(1):4-6. 4. Chen SC, Yen ZS, Wang HP, Lin FY, Hsu CY, Chen WJ. Ultrasonography is superior to plain radiography in the diagnosis of pneumoperitoneum. Br J Surg. 2002;89(3):351-354. 5. Muradali D, Wilson S, Burns PN, Shapiro H, Hope-Simpson D. A specific sign of pneumoperitoneum on sonography: enhancement of the peritoneal stripe. AJR Am J Roentgenol. 1999; 173(5):1257-1262. 6. Asrani A. Sonographic diagnosis of pneumoperitoneum using the ‘enhancement of the peritoneal stripe sign.’ A prospective study. Emerg Radiol. 2007;14(1):29-39. 7. Lee DH, Lim JH, Ko YT, Yoon Y. Sonographic detection of pneumoperitoneum in patients with acute abdomen. AJR Am J Roentgenol. 1990;154(1):107-109.
CHEST / 146 / 1 / JULY 2014
e13
Ultrasound Corner
Patient With Cirrhosis and Presumed Spontaneous Bacterial Peritonitis Robert A. Jones, DO; Matthew Tabbut, MD; Ziad Shaman, MD, FCCP; and Diane Gramer, RDMS, RVT
CHEST 2014; 146(1):e11–e13
patient in his 40s was brought to the ED Amale from the medicine clinic for admission with a pre-
sumptive diagnosis of spontaneous bacterial peritonitis (SBP). His medical history included hypertension, cirrhosis, liver cancer, and diverticulosis. The patient had had two prior admissions for SBP, and he felt like he had “that stomach infection again.” On presentation, the patient’s vitals were as follows: BP, 90/54 mm Hg; heart rate, 112/min; temperature, 38.4°C; respiratory rate, 28/min; and oxygen saturation, 94% on room air. Physical examination revealed an ill-appearing man. His abdomen was distended with diffuse tenderness and guarding. Pertinent laboratory values were as follows: WBC count, 17,400/mL with 28% bands; hemoglobin, 8.7 g/dL; platelet count, 85,000/mmol; prothrombin time/international normalized ratio, 2.1; creatinine, 3.8 mg/dL; and total bilirubin, 4.8 mg/dL. Bedside ultrasonography was used to verify the presence of ascitic fluid and to identify the best entry point for paracentesis (Video 1). Based on the interpretation of the video and the patient’s clinical presentation, what would be the most logical next step?
Manuscript received December 18, 2013; revision accepted February 18, 2014. Affiliations: From the Department of Emergency Medicine (Drs Jones and Tabbut and Ms Gramer), and the Department of Pulmonary/Critical Care (Dr Shaman), MetroHealth Medical Center, Cleveland, OH. Correspondence to: Robert A. Jones, DO, MetroHealth Medical Center, Department of Emergency Medicine, 2500 MetroHealth Dr, Cleveland, OH 44109; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-2997 journal.publications.chestnet.org
CHEST / 146 / 1 / JULY 2014
e11
Next steps: Treat for secondary peritonitis and obtain emergent general surgery consultation. The patient has pneumoperitoneum due to a gasforming infection of the sigmoid colon. This patient presented with findings consistent with SBP. Although paracentesis is generally a safe procedure, it can be associated with significant complications, and there is a potential benefit in terms of patient safety in the routine use of ultrasound to avoid injuring abdominal organs and major abdominal wall vasculature. A recent case report of an inferior epigastric artery laceration that occurred during a therapeutic paracentesis resulting in the patient’s death emphasizes the potential benefit of ultrasound.1 Bedside ultrasound was performed on this patient using both a 5-2 MHz curvilinear transducer and a 12-5 MHz linear transducer. The curvilinear transducer was used first to evaluate the peritoneal cavity and to assess the distribution of the ascitic fluid to determine the safest point of entry for the needle. A large volume of ascites was noted during the examination (Video 1). The ascitic fluid was complex in appearance. Although ultrasound cannot be used to distinguish infected from noninfected fluid, it suggested that this fluid was exudative. Additionally, it was noted that the peritoneal stripe had an enhanced appearance (highly echogenic), and reverberations were present posterior to the peritoneal stripe, which was concerning for pneumoperitoneum. Further evaluation of the peritoneal cavity revealed that echogenic reflectors were emanating from a section of the sigmoid colon, and these echogenic reflectors were rising to the peritoneal stripe in this supine patient (Video 1). The loop of bowel had multiple outpouchings noted, consistent with the patient’s history of diverticulosis. Based on these ultrasound findings, the diagnosis went from SBP to secondary peritonitis with pneumoperitoneum from a complicated diverticulitis. General surgery consultation was emergently obtained. Fluid resuscitation was continued, and the patient was started on broad-spectrum antibiotics. The general surgeons recommended performing a CT scan of the abdomen and performing ultrasound-guided paracentesis because the vitals had improved with fluid resuscitation. The fluid analysis was found to be consistent with a secondary peritonitis based on Runyon’s criteria (a minimum of two of the following criteria: total protein . 1.0 g/dL, glucose , 50 mg/dL, and lactate dehydrogenase greater than the upper limit of normal for the serum).2 This patient had 6,483 cells/mm, with a Gram stain showing multiple gram-negative rods. The patient met all three of Runyon’s criteria with total protein of 1.8 g/dL, glucose of 34 mg/dL, and lactate e12
dehydrogenase 1.6 times the upper limit of normal for the serum. The CT scan revealed pneumoperitoneum, with the suspected source being a sigmoid diverticular infection. Emergent operative intervention was recommended but was refused by the patient and his wife. The patient opted for comfort care measures and died 4 h later. Discussion This case demonstrates a potential role for bedside ultrasound in the evaluation of the patient with potential SBP. The distinction between secondary bacterial peritonitis and SBP is vital because the therapies are different. The mortality of secondary bacterial peritonitis approaches 100% if treatment consists of antibiotics only, with no operative intervention.2 Although the diagnosis of pneumoperitoneum is traditionally based on radiographic evidence on an upright chest radiograph, ultrasound has shown promise in the detection of pneumoperitoneum. Seitz and Reising3 first described the sonographic detection of free air with ultrasound. Chen and colleagues4 found that ultrasonography is a more sensitive modality than plain radiography for the diagnosis of pneumoperitoneum, with ultrasound having a sensitivity of 93% and a specificity of 64%. Sonographically, air appears as echogenic areas with posterior reverberation artifacts (Videos 1, 2).4 The presence of air within the bowel has an identical appearance to that of free peritoneal air, and, in some cases, it may be difficult to determine the exact location of the air. The presence of ascites should make the detection of pneumoperitoneum easier because the fluid separates the bowel from the peritoneal stripe. Enhancement of the peritoneal stripe in the presence of pneumoperitoneum has been demonstrated in several studies.5,6 The presence of even minute amounts of pneumoperitoneum against the anterior peritoneal wall will result in an enhancement of its appearance (Videos 1, 2). Patients with ascites may demonstrate the presence of air bubbles within the ascitic fluid.7 During real-time scanning of this patient, echogenic reflectors caused by the presence of gas bubbles could be seen moving to the anterior peritoneal line, mimicking surface-to-air missiles (Videos 1, 2). In conclusion, bedside ultrasound can be used to detect the presence of pneumoperitoneum. The sonographic findings associated with pneumoperitoneum should be sought when scanning patients with acute abdominal pain or patients with suspected SBP undergoing diagnostic paracentesis. Ultrasound Corner
Reverberations 1. Ultrasound can be very helpful in locating a safe point for needle entry during paracentesis. Ultrasound can be used to identify fluid location, key abdominal structures to avoid, and major abdominal wall vasculature. 2. Ultrasound can be used to diagnose pneumoperitoneum. 3. The presence of an enhanced peritoneal stripe is easier to see when ascites is present. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: To analyze this case with the videos, see the online version of this article.
journal.publications.chestnet.org
References 1. Sekiguchi H, Suzuki J, Daniels CE. Making paracentesis safer: a proposal for the use of bedside abdominal and vascular ultrasonography to prevent a fatal complication. Chest. 2013;143(4):1136-1139. 2. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology. 1990;98(1):127-133. 3. Seitz K, Reising KD. Sonographic detection of free air in the abdominal cavity [in German]. Ultraschall Med. 1982; 3(1):4-6. 4. Chen SC, Yen ZS, Wang HP, Lin FY, Hsu CY, Chen WJ. Ultrasonography is superior to plain radiography in the diagnosis of pneumoperitoneum. Br J Surg. 2002;89(3):351-354. 5. Muradali D, Wilson S, Burns PN, Shapiro H, Hope-Simpson D. A specific sign of pneumoperitoneum on sonography: enhancement of the peritoneal stripe. AJR Am J Roentgenol. 1999; 173(5):1257-1262. 6. Asrani A. Sonographic diagnosis of pneumoperitoneum using the ‘enhancement of the peritoneal stripe sign.’ A prospective study. Emerg Radiol. 2007;14(1):29-39. 7. Lee DH, Lim JH, Ko YT, Yoon Y. Sonographic detection of pneumoperitoneum in patients with acute abdomen. AJR Am J Roentgenol. 1990;154(1):107-109.
CHEST / 146 / 1 / JULY 2014
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