Rebound tenderness

Rebound tenderness

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Overview

Rebound tenderness is one of the most important signs of peritonitis when evaluating an acute abdomen. In recent years the value of rebound tenderness has been questioned, since it may not add any diagnostic value beyond the observation that the patient has severe tenderness.

Pathophysiology

Rebound tenderness is thought to be due to stretching of the peritoneum.

Physical examination technique

Rebound tenderness is a clinical sign that a doctor may detect in physical examination of a patient's abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.) To elicit the sign, gentle pressure is placed on the abdomen and then the hand is lifted suddenly. A sudden increase in abdominal pain occurs when the examiner's hand is lifted. The other physical examination findings to distinguish rebound tenderness from are abdominal tenderness and guarding.

Epidemiology and demographcis

Immunocompromised, children and the elderly are less likely to show peritoneal signs and may have atypical presentations.

Differential diagnosis of causes of rebound tenderness

In alphabetical order.

• Appendicitis
• Bacterial peritonitis
• Biliary colic or renal colic
• Bowel obstruction
• Cholecystitis
• Colitis
• Diverticulitis
• Gastritis
• Gastroenteritis
• Gynecologic etiologies

  • Ovarian cyst torsion or rupture
  • Ruptured ectopic pregnancy
  • Tubo-ovarian abscess
  • Pelvic Inflammatory Disease

• Intra-abdominal or pelvic abscess
• Intussusception
• Mesenteric ischemia
• Nonabdominal causes of pain. For example:

  • Atypical angina
  • Myocardial Infarction
  • Pelvic pathology
  • Pericarditis
  • Pneumonia
  • Pulmonary embolus

• Pancreatitis
• Perforated duodenal ulcer
• Perforated viscus
• Ruptured abdominal aortic aneurysm
• Sickle cell crisis

Diagnosis

History and Symptoms

• Location of pain, nature, intensity, onset, duration
• Guarding
• Past episodes
• Distention
• Bowel sounds
• Blood on rectal exam
• Presence of mass
• Cervical or adnexal tenderness
• Factors that alleviate pain
• Factors that aggravate pain
• Crampy, colicky pain occuring in waves (distention)
• Pain that is constant and localized in nature (inflammation)
• Shock
• Hypotension

Laboratory Findings

• Complete blood count (CBC)
• BUN (blood urea nitrogen)/creatinine
• LFTs (liver function tests)
• Pregnancy test
• Urinalysis
• Amylase/lipase

Electrolyte and Biomarker Studies

• Electrolytes

X-Ray

• Obstruction, perforation or other pathologies revealed by abdominal X-ray.

Echocardiography or Ultrasound

• Ultrasound can test for the following:

  • Abdominal aortic aneurysm
  • Ectopic pregnancy
  • Biliary disorders
  • Diverticulitis

Other Diagnostic Studies

• Peritoneal lavage recommended for suspected trauma, peritonitis, or bowel perforation
• Persistent vomiting and obstruction require a nasogastric tub

Treatment

• Surgery
• Immediately replace volume with saline and/or blood transfusion for those patients are are hemodynamically unstable
• Bowel rest for diverticulitis or bowel obstruction (possible colon resection)

Pharmacotherapy

Acute Pharmacotherapies

• If intra-abdominal infection or perforated viscus is suspected, administer proper course of antibiotics

Indications for Surgery

• Life threatening emergencies such as; early sepsis or evidence of hemorrhage, require immediate surgical intervention
• Ruptured aneurysm, ectopic pregnancy, bowel perforation or ther pathologies require definite surgical repair.

References

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