×
MedSchool: Ace Your OSCEsThe Medical Company
 
 
 
 
 
GET - On the App Store
View
Gastro Exam
 
 

Assessing For Peritonism

 
 
 
Bookmark
On this page:Percussion TendernessRebound TendernessAbdominal Rigidity
 View Topic Outline

Overview

  • Peritonism refers to inflammation of the peritoneum, which suggests acute abdominal pathology that should be rapidly diagnosed and treated.

    • Causes of Peritonitis

    • Infection post perforation - appendix, diverticulitis, IBD, perforated ulcer, surgical anastomosis
    • Spontaneous bacterial peritonitis (SBP)
    • Blood - endometriosis, ruptured ovarian cyst, trauma
    • Bile - post-surgical
    • Urine - pelvic trauma
    • Pancreatic fluid - pancreatitis

Percussion Tenderness

  • Percussion tenderness provides an incredibly superficial stimulus to the abdomen, and if this is sufficient to cause pain then peritonism should be suspected.

    • How to Elicit

    • Gently percuss the abdominal wall over an area of tenderness. Note whether percussion tenderness is localised or generalised.

Rebound Tenderness

  • Rebound tenderness, also known as the Blumberg sign, refers to tenderness that is worse on removal of the palpating hand than it is on pressing.
  • This clinical sign suggests peritonism, or localised inflammation of the peritoneum.

    • How to Elicit

    • Apply pressure to the patient's abdomen over a tender area for 5-10 seconds. Remove the pressure suddenly, and ask the patient if it hurts more when you press or remove your hand.

Abdominal Rigidity

  • Firmness of the abdominal wall muscles may be due to guarding or rigidity. It is important to determine whether this is voluntary, due to the patient's apprehension, or involuntary - a sign of peritonism.

    • Interpretation

    • Guarding - refers to a voluntary muscle contraction, to protect from pain.
    • Rigidity - refers to an involuntary muscle spasm due to underlying inflammation.

    • Feel For

    • Tense abdominal muscles, generally isolated over one segment.

    • Causes of Abdominal Rigidity

    • Infection post perforation - appendix, diverticulitis, IBD, perforated ulcer, surgical anastomosis
    • Spontaneous bacterial peritonitis (SBP)
    • Blood - endometriosis, ruptured ovarian cyst, trauma
    • Bile - post-surgical
    • Urine - pelvic trauma
    • Pancreatic fluid - pancreatitis
 
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Want more info like this?
  • Your electronic clinical medicine handbook
  • Guides to help pass your exams
  • Tools every medical student needs
  • Quick diagrams to have the answers, fast
  • Quizzes to test your knowledge
Sign Up Now
   
 
 
 

Read More...

 Adams PC, Barton JC. Haemochromatosis. The Lancet. 2007;370:1855-1860. Ahmed R, McNamara S, Gandevia S, Halmagyi GM. Paradoxical abdominal wall movement in bilateral diaphragmatic paralysis. Practical neurology. 2012;12:184. Allen K. Hereditary Haemochromatosis: Diagnosis and Management. Australian Family Physician. 2010;39:938-941. Al?Himdani S, Ud?Din S, Gilmore S, Bayat A. Striae distensae: a comprehensive review and evidence?based evaluation of prophylaxis and treatment. British Journal of Dermatology. 2014;170:527-547. Appasani S, Kochhar S, Nagi B, Gupta V, Kochhar R. Benign gastric outlet obstruction--spectrum and management. Tropical gastroenterology : official journal of the Digestive Diseases Foundation. 2011;32:259. Baid H. A critical review of auscultating bowel sounds. British Journal of Nursing. 2009 Oct; 18(18): 1125-1129. Beech N, Goh R, Lynham A. Management of dental infections by medical practitioners. Australian Family Physician. 2014;43:289-291. Belabbes S, Lamsiah T, Zainoun B, Choho A, Drissi M. Trichobezoar: Unusual cause of epigastric mass. Indian Journal of Gastroenterology. 2015;34:277-278. Besur SV, Tadakamalla A, Talluri SK. Pyoderma gangrenosum. QJM : monthly journal of the Association of Physicians. 2012;105:1219-1220.
Blaker P, Wilkinson M. Chronic constipation: diagnosis and current treatment options. Prescriber. 2010;21:30-45.
 Brown RB. Benign prostatomegaly, carcinoma and prostatitis. Australian family physician. 1986;15:1551, 1553. Bull-Henry K, Al-Kawas FH. Evaluation of occult gastrointestinal bleeding. American family physician. 2013;87:430. Byrd JA, Bruce AJ, Rogers 3, Roy S. Glossitis and other tongue disorders. Dermatologic clinics. 2003;21:123. Callewaert B, Malfait F, Loeys B, De Paepe A. Ehlers-Danlos syndromes and Marfan syndrome. Best Practice & Research Clinical Rheumatology. 2008;22:165-189. Carlson HE. Approach to the patient with gynecomastia. The Journal of clinical endocrinology and metabolism. 2011;96:15-21. Castell DO, Frank BB. Abdominal examination: role of percussion and auscultation. Postgrad Med. 1977 Dec; 62(6): 131-4. Chakma SM, Singh RL, Parmekar MV, et al. Spectrum of perforation peritonitis. Journal of clinical and diagnostic research : JCDR. 2013;7:2518.
Chicken W, Davidson T. Gynaecomastia: assessment and management. Trends in Urology & Men's Health. 2013;4:17-20.
 Clinical anatomy and the physical examination Part I: Thorax, abdomen, perineum, and pelvis. Clinical anatomy 2001; 14 (5): 332.
Darby I. Drugs and gingival bleeding. Australian Prescriber. 2006;29:154.
 Davey WW. Rovsing's Sign. The British Medical Journal. 1956;2:28-30.
David M, Pelberg J, Kuntz C. Grey Turner's sign. QJM : monthly journal of the Association of Physicians. 2013;2012;106:481.
Detry O, De Roover A. Spider Angiomas. The New England Journal of Medicine. 2009;360:280-280.
 Devani A, Barankin B. Dermacase. Angular cheilitis. Canadian family physician Médecin de famille canadien. 2007;53:1011, 1022. Douglass AB, Douglass JM. Common dental emergencies. American family physician. 2003;67:511. Eipper DF, Gifford RW, Stewart BH, Alfidi RJ, McCormack LJ, Vidt DG. Abdominal bruits in renovascular hypertension. The American Journal of Cardiology. 1976;37:48-52. Erickson K, Donovan TE, Swift EJ. Dental Erosion. Journal of Esthetic and Restorative Dentistry. 2013;25:212-212. Fargo MV, Latimer KM. Evaluation and management of common anorectal conditions. American family physician. 2012;85:624. Franckowiak JJ, Jackman RJ. The etiology of pilonidal sinus. Diseases of the colon and rectum. 1962;5:28-36. Franklin GA, Richardson JD, Brown AL, et al. Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries. The American surgeon. 2007;73:611. Gendreau L, Loewy ZG. Epidemiology and Etiology of Denture Stomatitis. Journal of Prosthodontics. 2011;20:251-260. Ghasemi A, Gorouhi F, Rashighi?Firoozabadi M, Jafarian S, Firooz A. Striae gravidarum: associated factors. Journal of the European Academy of Dermatology and Venereology. 2007;21:743-746. Ghosn SH, Kibbi A. Cutaneous manifestations of liver diseases. Clinics in Dermatology. 2008;26:274-282.
Gilliland PF, Deller JJ, Hall R. A Bruit Due to Renal-Artery Stenosis: Value of Auscultation in the Diagnosis of Renal Hypertension. The New England Journal of Medicine. 1961;264:659-660.
 Glancy DG. Intestinal obstruction. Surgery (Oxford). 2014;32:204-211. Grover CA, Sternbach G. Charles McBurney: McBurney's point. The Journal of emergency medicine. 2012;42:578. Gupta K, Dhawan A, Abel C, Talley N, Attia J. A Re-evaluation of the scratch test for locating the liver edge. BMC Gastroenterology. 2013; 13: 35. Gupta SK, Gupta R, Singh G, Gupta S. Perforation Peritonitis:A Two Year Experience. JK Science. 2010;12:141-144. Gupta T, Kansal NK. Medical image. A benign glossal lesion. The New Zealand Medical Journal (Online). 2014;127. Haresaku S, Hanioka T, Tsutsui A, Watanabe T. Association of lip pigmentation with smoking and gingival melanin pigmentation. Oral Diseases. Harris S. Cullen's sign revisited. Am J Med. 2008;121:682-683. Hazin R, Tarek I. Abu-Rajab Tamimi, Abuzetun JY, Zein NN. Recognizing and treating cutaneous signs of liver disease. Cleveland Clinic Journal of Medicine. 2009;76:599-606. Hibberts F, Bushell C. Physical assessment in gastroenterology: abdominal examination. Gastrointestinal Nursing. 2007 Sep; 5(7): 24-30. Hol L, van Leerdam ME, van Ballegooijen M, et al. Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy. Gut. 2010;59:62. Huang BL, Chandra S, Shih DQ. Skin manifestations of inflammatory bowel disease. Frontiers in physiology. 2012;3:13. Jaka H, Mchembe MD, Rambau PF, Chalya PL. Gastric outlet obstruction at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 184 cases. BMC surgery. 2013;13:41-41. Jones JT. Pigmentation of lips and buccal mucosa associated with intestinal polyposis. South African medical journal. 1953;27:930. Kamath N, Bhatia S, Singh H, Shetty A, Shetty S. Hereditary hemorrhagic telangiectasia. North American journal of medical sciences. 2015;7:125-128. Kawar N, Gajendrareddy PK, Hart TC, Nouneh R, Maniar N, Alrayyes S. Periodontal Disease for the Primary Care Physician. Disease-a-Month. 2011;57:174-183. Korber A, Dissemond J. Black Hairy Tongue. The New England Journal of Medicine. 2006;354:67-67. Kuehn HG, Gebbensleben O, Hilger Y, Rohde H. Relationship between anal symptoms and anal findings. International journal of medical sciences. 2009;6:77-84. Kundu N, Abouhassan W, Ibikunle C. Perianal mass. Eplasty. 2011;11:ic7. Laugier P, Hunziker N, Olmos L. Essential melanic pigmentation of the mouth and the lips. Annales de dermatologie et de vénéréologie. 1977;104:181. Lenane P, Powell F. Oral pigmentation. Journal of the European Academy of Dermatology and Venereology. 2000;14:448-465. Lourenco SV, Silva MAM, Nico MMS. An ulcer on the lip. Clinical & Experimental Dermatology. 2005;30:199-200. Lund JN, Scholefield JH. Internal sphincter spasm in anal fissure. The British journal of surgery. 1997;84:1723-1724. Magalhães AC, Wiegand A, Young A, Schlueter N. Dental erosion. International journal of dentistry. 2012;2012:356021. Mandel L. Salivary Gland Disorders. Dental Clinics of North America. 2011;55:121-140. Mantas AM, Wells J, Trotter J. Kayser-Fleischer rings of acute Wilson's disease. Proceedings (Baylor University. Medical Center). 2013;26:166-167. Masferrer E, Jucgla A. Geographic Tongue. New England Journal of Medicine. 2009;361:e44. Masha L, Bernard S. Grey Turner's sign suggesting retroperitoneal haemorrhage. Lancet (London, England). 2014;383:1920. McGirt LY, Martins CR. Dermatologic Diagnoses in the Perianal Area. Clinics in Colon and Rectal Surgery. 2004;17:241-245. Mowat C, Stanley AJ. Review article: spontaneous bacterial peritonitis--diagnosis, treatment and prevention. Alimentary pharmacology & therapeutics. 2001;15:1851.
Musana K, Yale SH. John Benjamin Murphy (1857 - 1916). Clinical medicine & research. 2005;3:110-112.
 Musana KA, Yale SH. Murphy's Sign. Clin Med Res. 2005 Aug; 3(3): 132.
Mushtaq F, Tudor G, El-Hadi S. Rectal bleeding in children – causes and investigations. Paediatrics and Child Health. 2014;24:491-500.
 Narula HS, Carlson HE. Gynaecomastia--pathophysiology, diagnosis and treatment. Nature reviews. Endocrinology. 2014;10:684-698. Nautiyal A. Liver palms (palmar erythema). Am J Med. 2010;123:596-597. Nguyen DH, Martin JT. Common dental infections in the primary care setting. American Family Physician. 2008;77:797.
Niederau C, Lange S, Frühauf M, Thiel A. Cutaneous signs of liver disease: value for prognosis of severe fibrosis and cirrhosis. Zeitschrift für Gastroenterologie. 2006;43:P220.
 Niewoehner CB, Schorer AE. Gynaecomastia and Breast Cancer in Men. BMJ: British Medical Journal. 2008;336:709-713. Parikh K, Ali MA, Wong RCK. Unusual Causes of Upper Gastrointestinal Bleeding. Gastrointestinal endoscopy clinics of North America. 2015;25:583-605. Parikh RP, Upadhyay KJ. Cullen's sign for acute haemorrhagic pancreatitis. The Indian journal of medical research. 2013;137:1210-1210. Perera GA. A Note on Palmar Erythema (So-Called Liver Palms). JAMA. 1942; 119: 1417-1418. Perlman SL, Boder Deceased E, Sedgewick RP, Gatti RA. Ataxia-telangiectasia. Handbook of clinical neurology. 2012;103:307. Pfenninger JL, Zainea GG. Common anorectal conditions: Part I. Symptoms and complaints. American family physician. 2001;63:2391. Pines J, Uscher Pines L, Hall A, Hunter J, Srinivasan R, Ghaemmaghami C. The interrater variation of ED abdominal examination findings in patients with acute abdominal pain. Am J Emerg Med. 2005 Jul; 23(4): 483-7. Potter MA, Bartolo DCC. Proctalgia fugax. European Journal of Gastroenterology & Hepatology. 2001;13:1289-1290. Prosenz J, Hirtler L. Rovsing sign revisited-effects of an erroneous translation on medical teaching and research. Journal of surgical education. 2014;71:738. Rahbour G, Ullah MR, Yassin N, Thomas GP. Cullen's sign - Case report with a review of the literature. International Journal of Surgery Case Reports. 2012;3:143-146. Raina S, Jaryal A. Dupuytren's contracture. The Indian journal of medical research. 2012;136:502. Reamy B. Common tongue conditions in primary care. Am Fam Physician. 2010;81:627. Reese GE, von Roon AC, Tekkis PP. Haemorrhoids. BMJ clinical evidence. 2009;2009. Reunala T. Dermatitis herpetiformis: Coeliac disease of the skin. Annals of Medicine. 1998;30:416-418. Schrag A, Schott JM. Kayser-Fleischer Rings in Wilson's Disease. The New England Journal of Medicine. 2012;366. Schumaker HB. The Diagnosis of Coarctation of the Aorta with Particular Reference to the Importance of Absent or Diminished Abdominal Aortic Pulsation. Annals of Surgery. 1952 Jan; 135(1): 111-113. Scully C, Shotts R. ABC Of Oral Health: Mouth Ulcers And Other Causes Of Orofacial Soreness And Pain. BMJ: British Medical Journal. 2000;321:162-165. Seo AY, Kim N, Oh DH. Abdominal Bloating: Pathophysiology and Treatment. J Neurogastroenterol Motil. 2013 Oct; 19(4): 433-453, Seupaul RA, Collins R. Physical Examination of the Liver. Annals of Emergency Medicine. 2001; 45(5): 553-555. Shafer N. A new method of abdominal examination: preliminary report. Curr Ther Res Clin Exp. 1967 Feb; 9(2): 82-4. Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatologic therapy. 2010;23:230-242. Shenenberger D, Barlow T. Photo quiz. Ulcer on lower lip of deployed serviceman. Ecthyma. American family physician. 2011;83:601.
Sherlock KE, Turner W, Elsayed S, et al. The Evaluation of Digital Rectal Examination for Assessment of Anal Tone. Global Spine Journal. 2012;2:P104.
 Sheth TN, Choudry NK, Bowes M, Detsky AS. The Relation of Conjunctival Pallor to the Presence of Anaemia. J Gen Intern Med. Feb 1997; 12(2): 102-106. Shimazaki Y, Soh I, Saito T, et al. Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. Journal of dental research. 2001;80:340-345. Shimizu T, Tokuda Y. Visible intestinal peristalsis. BMJ case reports. 2013;2013:bcr2013201748-bcr2013201748. Shovlin CL. Hereditary haemorrhagic telangiectasia: Pathophysiology, diagnosis and treatment. Blood Reviews. 2010;24:203-219. Singh A, Verma R, Murari A, Agrawal A. Oral candidiasis: An overview. Journal of Oral and Maxillofacial Pathology. 2014;18:81-85. Singh G. Nails in systemic disease. Indian journal of dermatology, venereology and leprology. 2011;77:646-651.
Skinner N, Junker JA, Flake D. What is angular cheilitis and how is it treated?. Journal of Family Practice. 2005;54:470.
 Sood A, Paik A, Lee E. Dupuytren's Contracture. Eplasty. 2013;13:ic1. Sugerman DT. Anal Fissure. JAMA. 2014;311:1171-1171. Sundriyal D, Kumar N, Dubey SK, Walia M. Virchow's node. Case Reports. 2013 Sep 12;2013:bcr2013200749. Tack J, Müller?Lissner S, Stanghellini V, et al. Diagnosis and treatment of chronic constipation – a European perspective. Neurogastroenterology & Motility. 2011;23:697-710. Tingle LE, Molina D, Calvert CW. Acute pericarditis. Am Fam Physician. 2007 Nov 15;76(10):1509-14. toopler ET, Kuperstein AS. Glossitis secondary to vitamin B12 deficiency anemia. Canadian Medical Association journal. 2013;185:E582-E582. Townley WA, Baker R, Sheppard N, Grobbelaar AO. Dupuytren's Contracture Unfolded. BMJ: British Medical Journal. 2006;332:397-400. Tripathi RC, Sidrys LA. 'Conjunctival Icterus,' Not 'Scleral Icterus'. JAMA. 1979;242:2558-2558. Van Meegdenburg MM, Heineman E, Broens PMA. Pudendal Neuropathy Alone Results in Urge Incontinence Rather Than in Complete Fecal Incontinence. Diseases of the Colon & Rectum. 2015;58:1186-1193.
Vedamurthy M, Vedamurthy A. Spider nevi: A presenting feature of chronic liver disease. Indian Journal of Dermatology, Venereology and Leprology. 2008;74:397-398.
 Vine L, McCracken G, Needs S, Ryley N, George K. PTU-117 Cutaneous Stigmata Of Chronic Liver Disease; What Do They Mean? Gut. 2014;63 Suppl 1:A90-A90.
Waintraub D, Felig DM. An unusual cause of a rectal mass: a malpositioned pessary. The American journal of gastroenterology. 2015;110:1140.
 Walshe JM. The Kayser-Fleischer ring. British journal of hospital medicine (London, England : 2005). 2014;75:C38.
Wolff HH. Familial Intestinal Polyposis with pigmentation of lips, oral mucosa, face and digits. The Lancet. 1952;259:446-448.
 Yasui H. Rovsing's Sign. The British Medical Journal. 1958;1:1163-1163. Zoli V, Silvani S, Vincenzi C, Tosti A. Allergic Contact Cheilitis. Contact Dermatitis. 2006;54:296-297.