A male patient in his 40s was brought to the ED from the medicine clinic for admission with a presumptive 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/μL 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).