Sandbox: PE

Overview

Examination reveals signs of acute abdomen and in advanced cases, shows signs of shock and septicemia.

Physical Examination

Appearance of the patient

• Patients with peritonitis are usually ill-appearing.
• Initially they appear alerted, 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.

Blood Pressure

• 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 but as peritonitis progresses, the blood pressure decreases due to volume loss diarrhea or severe ascites.

Pulse

• Tachycardia with weak, thready peripheral pulses represents decreased effective circulating blood volume, indicating a stage of shock later in the disease.
• May be normal or increased in rate due to infection.
• It may be low in volume due to dehydration.

Respiration

• Tachypnea due to infection and increased demand.

Skin

• Skin over abdomen is tense due to ascites.
• Skin changes such as spider nevus, palmar erythema, large abdominal wall collateral veins are suggestive of parenchymal liver disease and portal hypertension

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

• Usually tense and distended due to ascites
• Marked abdominal tenderness to palpation is present.
• Shifting dullness on percussion is noted in patients with ascites, but may be painful due to infection.
• 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.

Extremities

• When present, peripheral edema in patients with liver disease is usually found in the lower extremities and occasionally may involve the abdominal wall. Patients with nephrotic syndrome or cardiac failure may have total body edema (anasarca).