Peritonitis - Abdominal Examination

PT

Peritonitis — Abdominal Examination

Focused clinical findings highlighting diffuse peritoneal irritation, localization, and red flags for urgent management.

Acute abdomen

Guarding & rigidity

Surgical emergency

Inspection

Patient often appears unwell and prefers to lie still. Guarding of the abdomen may be obvious with shallow respiration. Look for abdominal distension, surgical scars, external signs of peritoneal inflammation (erythema), and systemic signs such as fever, diaphoresis or pallor.

Palpation

Examine gently, starting away from the area of maximal pain. Widespread involuntary guarding and board-like rigidity suggest generalized peritonitis. Localized tenderness with rebound indicates focal peritoneal irritation. Note any palpable masses, localized peritoneal signs, or tenderness in classic areas (e.g., RIF for appendicitis, RUQ for perforated peptic ulcer).

Signs to elicit

Rebound tenderness, localized guarding, percussion tenderness, cough tenderness, percussion-induced tenderness.

Abdominal wall rigidity

Board-like, involuntary rigidity is a red flag for generalized peritonitis and possible perforation.

Associated findings

Abdominal distension, absent bowel sounds in paralytic ileus secondary to peritonitis, and palpable masses such as abscesses.

Percussion

Percussion may reveal generalized tenderness with dull areas if localized fluid collections or abscesses are present. Hyperresonance is less common. Guarding may limit reliable percussion in severe cases.

Auscultation

Bowel sounds may be hypoactive or absent in generalized peritonitis (paralytic ileus). High-pitched sounds are uncommon and suggest obstruction rather than peritonitis. Listen for associated chest findings such as reduced air entry that may suggest diaphragmatic irritation.

Special tests & bedside signs

Document rebound tenderness and localized peritonism. Test for rigidity and cough tenderness. Consider obturator and psoas tests for RIF irritation. PR exam may reveal fecal soiling or blood; note any signs of sepsis (tachycardia, hypotension, altered mental status).

Conclusion

Examination demonstrates signs consistent with peritonitis: widespread guarding, rebound tenderness, and reduced bowel sounds. These findings indicate peritoneal inflammation and require urgent surgical review and resuscitation. Identify likely source (perforation, intra-abdominal infection) and proceed with imaging and sepsis protocol.

Viva Summary (formal):

This patient demonstrates clinical signs of peritonitis: generalized involuntary guarding and rebound tenderness with diminished bowel sounds. Immediate resuscitation and urgent surgical evaluation are indicated; obtain chest and abdominal imaging and consider broad-spectrum antibiotics and fluid resuscitation.

Examination Tips (point form):

• Start with resuscitation and rapid assessment of ABCs before detailed exam if patient is unstable.
• Begin palpation away from the worst pain, and use gentle technique to avoid causing severe discomfort.
• Board-like rigidity and involuntary guarding are key signs of peritoneal irritation — treat these as surgical emergencies.
• Differentiate localized peritonitis (appendicitis, perforated viscus) from generalized peritonitis (perforation, widespread infection).
• Look for systemic sepsis signs: fever, tachycardia, hypotension, reduced urine output — start sepsis bundle promptly.
• Use bedside ultrasound (FAST or focused abdominal) to detect free fluid, collections, or signs of perforation; chest x-ray may show free air under diaphragm.
• Document and communicate findings clearly to the surgical team, including exact location of maximal tenderness and any positive bedside signs.

Prepared for emergency & surgical rounds

Updated: Oct 2025