Abdominal Guarding

Abdominal Guarding: Excerpt from In a Page: Signs and Symptoms

Abdominal guarding refers to muscular rigidity of the abdomen upon palpation. It may be involuntary or voluntary. The examiner may try to limit the voluntary guarding during the physical examination by having the patient bend both knees and/or rest the head on a pillow, and asking the patient to voluntarily relax the abdominal muscles. Involuntary guarding may be an early sign of peritonitis.

Differential Diagnosis

• Appendicitis
• Pancreatitis
• Diverticulitis
• Abdominal wall strain/injury
• Pelvic inflammatory disease
• Ectopic pregnancy
• Bowel obstruction
• Ileus
• Pneumonia
• Dyspepsia
• Nephrolithiasis
• Peptic ulcer disease
• Abdominal aortic aneurysm
• Anxiety
• Malingering
• Spontaneous bacterial peritonitis (SBP)
• Mesenteric ischemia
• GERD
• Ovarian cyst
• Hepatic or splenic contusion/laceration
• Pneumoperitoneum secondary to trauma
• Urinary tract infection/pyelonephritis
• Zoster
  –Skin lesions may not be visible until another day or two
• Insect toxins (e.g., black widow spider)
• Abscess (e.g., iliopsoas)
• Incarcerated hernia
• Abdominal migraine
• Intussusception
• Volvulus

Workup and Diagnosis

• History and physical examination
• Initial laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, liver function tests, amylase/lipase, β-hCG, urinalysis, and urine culture
• CT scan is often indicated to diagnose appendicitis, diverticulitis, aneurysm, organ contusion or lacerations, and bowel obstruction
• Abdominal, pelvic, and/or transvaginal ultrasound may be diagnostic for appendicitis, aneurysm, peritonitis, ectopic pregnancy, ovarian cysts, and fluid/blood secondary to trauma
• Plain KUB X-rays may reveal bowel gas pattern and nephrolithiasis
• Paracentesis is diagnostic for spontaneous bacterial peritonitis and may provide symptomatic relief
• Empiric trial of medications may be useful for diagnosis and treatment of GERD/dyspepsia (H2 blocker or proton pump inhibitor), zoster (acyclovir), anxiety (lorazepam), and abdominal wall strain (NSAIDs)
• Cervical cultures to diagnose pelvic inflammatory disease
• Helicobacter pylori testing and upper GI endoscopy may be indicated for suspected cases of peptic ulcer disease

Treatment

• Immediate attention to hemodynamic status and life-threatening disease
  –Replace volume with normal saline and possibly a blood transfusion
  –Evidence of hemorrhage (e.g., ruptured AAA, ruptured ectopic pregnancy) or early sepsis (e.g., perforated diverticulitis, perforated bowel) may be a life-threatening emergency that requires urgent surgical intervention
• Place NG tube for obstruction or persistent vomiting
• Administer broad-spectrum empiric antibiodics if a perforated viscus or intra-abdominal infection is suspected
• Direct treatment toward the specific condition

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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