Peritonitis physical examination

Peritonitis Main Page
Patient Information
Overview
Causes
Classification Spontaneous Bacterial Peritonitis Secondary Peritonitis
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]

Overview

• If a patient presents with a full, bulging abdomen, percussion of the flanks can provide valuable information to diagnose ascites. The presence of shifting dullness has 83% sensibility and 56% specificity to diagnose ascites. A patient without flank dullness has less than 10% chance of having ascites.

Physical Examination

Appearance of the patient

• The patient may appear toxic and in distress because of pain in the abdomen.
• Patients with peritonitis are usually ill-appearing, initially they appear alert, restless and irritable.They may later become apathetic and delirious.
• They are often noticed lying quietly supine,on the bed with the knees flexed and with frequent limited intercostal respirations because any motion intensifies the abdominal pain.

Vital signs

Temperature

• Hyperthermia (temperatures as high as 42° C) is a sign of infection and hypothermia (temperatures as low as 35° C) indicates septic shock.
• Hypothermia is a grave sign,seen late in the course of the disease in patients with on-going intra-abdominal sepsis or septic shock.

Pulse

• Tachycardia with weak, thready peripheral pulses represents decreased effective circulating blood volume,indicating a stage of shock later in the disease.

Respiration

• Tachypnea

Bloodpressure

• Hypertension can be seen if associated with any heart condition or renal disease.The blood pressure is maintained within normal limits early in the disease process and as peritonitis progresses, the blood pressure decreases due to volume lossdiarrhea or severe ascites.

Skin

• Skin over the abdomen is tense due to ascites.
• Skin changes due to cirrhosis may be seen like spider nevus.

Eyes

• Jaundice may be seen in cases of liver cirrhosis.
• Periorbital puffiness may be noticed in cases of renal failure.

Neck

• Jugular venous distension may be seen in cases of heart failure causing ascites.

Heart

• Signs of heart failure may be seen like S3.

Lungs

• Signs of any infection, or signs of volume overload in lungs due to heart failure.

Neurologic

Following may be noticed when spontaneous bacterial peritonitis complicates or due to underlying liver or renal failure.

• Stupor
• Confusion
• Seizures

Abdomen

• Restricted movements of the abdominal wall usually over the origin of the inflammatory process.
• Abdominal percussion reveals the region of maximal painfulness, which corresponds to the site of lesion, high tympanic sound as a result of intestinal gaseous dilatation, but sometimes dullness, caused by accumulation of great amount of exudate.
• On palpation there is muscular tension of the abdominal wall.
• Abdominal tenderness, and guarding, which are exacerbated by moving the peritoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place).
• Diffuse abdominal rigidity ("washboard abdomen") is a sign of generalized peritonitis.
• Reactive stage of disease: Abdominal pain, muscular rigidity and rebound tenderness are often present with a moderate tachycardia and hypertension.
• Toxic stage of the disease: abdominal pain and muscular rigidity tend to diminish, but on palpation the muscular tenderness and rebound tenderness remain on the same level. More evident are the signs of intestinal paresis (abdominal distension, absence of peristalsis). The general condition of the patient is worsened. The patient is apathetic, the skin is blanched or cyanotic. Progression of tachycardia, hypotension, hyperthermia is observed. Blood analysis revealed leukocytosis and left shift of the differential count.
• Terminal stage of the disease: Systemic signs of inflammation are evident.The pain disappears, but there may be intractable vomiting from congested fecal contents.The patient is dynamic, with drawn features and cyanotic skin.The pulse is tachycardic, hypovolemic and thready. The arterial pressure tends to diminish. There will be no significant peristalsis and no bowel sounds are heard on auscultation.Rebound tenderness is slightly expressed. The respiration is rapid, with congested rales, and oliguria develops. This clinical pattern resembles a septic shock. The prognosis in this stage is serious and the patient will die at this stage, if not stabilized.
• Usually tense due to ascites
• Marked abdominal tenderness to palpation is present, usually maximum over the organ in which the process originated.
• Direct and referred rebound tenderness is almost always present and signifies the irritation of the parietal peritoneum.
• Muscular rigidity of the abdominal wall produced by voluntary guarding and reflex muscular spasm is almost always present.
• Hyper-resonance on percussion if present,indicates the gaseous dissention of the intestine.
• Shifting dullness on percussion is noted in patients with ascites, but may be painful due to infection.
• Pneumoperitoneum, which results from gas/air in the peritoneal cavity, results usually from a ruptured hollow viscus produces liver dullness to percussion
• Bowel sounds vary along the course of peritonitis, are initially hypoactive, and may disappear later.Absence of bowel sounds may be the only manifestation of peritonitis in some patients, and a high index of suspicion is necessary
• The absence of any of these findings does not exclude peritonitis.
• Pelvic peritonitis usually causes less clinical manifestations. In such cases digital examination of the rectum and bimanual palpation of the pelvis and lower abdomen, reveals overhanging and painfulness of anterior rectal wall or posterior vaginal vault owing to accumulation of the exudate.