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.

Vital Signs

Temperature

• May have increase in temperature due to infection.
• It may decreased if disease progresses to septic shock.

Blood Pressure

• Hypertension can be seen if associated with any heart condition or renal disease.
• Hypotension can be seen in cases of volume loss due diarrhea or severe ascites.

Pulse

• May be normal or increased in rate due to infection.
• It may be low in volume due to dehydration.

Skin

• Skin over 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.

Abdomen

• Tense and distended abdomen is noticed.
• Tenderness on palpation.
• Shifting dullness on percussion, but it may be painful due to infection.

Neurologic

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

• Stupor
• Confusion
• Seizures

Physical Examination

Appearance of the patient

• 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

• Hyperthermia (temperatures as high as 42° C) and hypothermia (temperatures as low as 35° C) may be present depending on the stage of the disease.
• Hypothermia is a grave sign,seen late in the course of the disease in patients with on-going intra-abdominal sepsis or septic shock.
• Tachycardia with weak, thready peripheral pulses represents decreased effective circulating blood volume,indicating a stage of shock later in the disease.
• Tachypnea
• The blood pressure is maintained within normal limits early in the disease process and as peritonitis progresses, the blood pressure decreases to shock levels.

Abdomen

• 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.
• 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