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After completing this case study, the reader should be able to:

  • Recognize the clinical manifestations of bacterial peritonitis.

  • Identify the normal microflora found in the various segments of the GI tract.

  • List the goals of antimicrobial therapy for bacterial peritonitis.

  • Recommend appropriate empiric and definitive antibiotic therapy for spontaneous bacterial peritonitis (also known as primary bacterial peritonitis).

  • Monitor antibiotic therapy for safety and efficacy.

  • Recommend secondary prophylaxis for spontaneous bacterial peritonitis.

  • Establish a long-term plan for the patient regarding alcohol abuse and hepatitis C, including monitoring parameters and counseling.


Chief Complaint

“My belly hurts so bad I can barely move.”


John Chavez is a 47-year-old Hispanic man who was brought to the ED by his wife. She stated that he has been suffering from nausea, vomiting, and severe abdominal pain for the last 2–3 days. His intake of food and fluids has been minimal over the past several days.


  • Cirrhosis, diagnosed 2014 with onset of ascites

  • GERD

  • Cholecystectomy 15 years ago

  • Chronic hepatitis C virus infection, diagnosed 2014


Mother was alcoholic; died 10 years ago in car accident. Father’s history unknown.


Retired construction worker; EtOH abuse with 10–12 cans of beer per day × 25 years, sober for 6 months; however, recently did binge drink after an argument with his wife; denies use of tobacco or illicit drugs; poor adherence to medications and dietary restrictions


  • Spironolactone 100 mg PO once daily

  • Omeprazole 20 mg PO once daily

  • Maalox 30 mL PO QID PRN




As noted in the HPI. Denies any hematemesis or melena.

Physical Examination


Thin man who appears older than his stated age, disoriented, and in severe pain


BP 154/82, P 102, RR 32, T 38.2°C; current Wt 92 kg, (IBW 68 kg)


Jaundiced, warm, coarse, and very dry. Spider angiomata present on chest, back and arms.


Yellow sclera; PERRLA; Oropharynges show poor dentition but are otherwise unremarkable

Neck/Lymph Nodes

Supple; normal size thyroid; no JVD or palpable lymph nodes


Lungs are CTA; shallow and frequent breathing


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