Secondary peritonitis physical examination

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

Overview

On physical examination, the patient shows classic signs of acute abdomen as abdominal tenderness, rebound tenderness, rigidity, etc. With the progression of peritonitis, signs of septicemia and shock ensue.

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 if associated with sepsis, 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

• Cyanosis may be present as a sign of septicemia.

Abdomen

Practice guidelines for primary care of acute abdomen 2015.

Signs of peritonitis depending on the duration of the disease and degree of pathological alteration in the clinical course of peritonitis
Reactive	Toxic	Terminal
First 24 hours	24-72 hours	After 72 hours
Maximal manifestation of local signs of peritonitis	Gradually decreasing local signs and increasing signs of general intoxication.	Severe, often irreversible intoxication with sharply expressed local manifestations of peritoneal inflammation.
Abdominal pain, muscular rigidity and rebound tenderness are often present with a moderate tachycardia and hypertension	Abdominal pain and muscular rigidity tend to diminish, but on palpation, the muscular tenderness and rebound tenderness remain on the same level.Signs of intestinal paresis such as abdominal distension, the absence of peristalsis are more evident. 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	Systemic signs of inflammation are observed. The patient is dynamic, with drawn features and cyanotic skin.The pulse is tachycardic, hypovolemic and thready. The arterial pressure tends to diminish. The pain disappears, but there may be intractable vomiting from congested fecal contents. 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.

• Restricted movements of the abdominal wall usually over the origin of the inflammatory process are seen.
• Abdominal percussion reveals the region of maximal tenderness, which corresponds to the site of lesion, high tympanic sound as a result of intestinal gaseous dilatation, but sometimes dullness, caused by the accumulation of great amount of exudate.
• 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.
• 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 distention of the intestine.
• 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.