Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

Detected by palpation, abdominal rigidity refers to abnormal muscle tension or inflexibility of the abdomen. Rigidity may be voluntary or involuntary. Voluntary rigidity reflects the patient’s fear or nervousness upon palpation; involuntary rigidity reflects potentially life-threatening peritoneal irritation or inflammation. (See Recognizing voluntary rigidity.)  

Involuntary rigidity most commonly results from GI disorders but may also result from pulmonary and vascular disorders and from the effects of insect toxins. It’s usually accompanied by fever, nausea, vomiting, and abdominal tenderness, distention, and pain.

Emergency interventions

Prepare to administer oxygen and to insert an I.V. line for fluid and blood replacement. The patient may require drugs to support blood pressure. Also prepare him for catheterization, and monitor intake and output.

A nasogastric tube may have to be inserted to relieve abdominal distention. Because emergency surgery may be necessary, prepare the patient for laboratory tests and X-rays.

History and physical examination

If the patient’s condition allows further assessment, take a brief history. Find out when the abdominal rigidity began. Is it associated with abdominal pain? If so, did the pain begin at the same time? Determine whether the rigidity is localized or generalized. Is it always present? Has its location changed or remained constant? Next, ask about aggravating or alleviating factors, such as position changes, coughing, vomiting, elimination, and walking.

Then explore other signs and symptoms. Inspect the abdomen for peristaltic waves, which may be visible in very thin patients. Also check for a visibly distended bowel loop. Next, auscultate bowel sounds. Perform light palpation to locate the rigidity and to determine its severity. Avoid deep palpation, which may exacerbate abdominal pain. Finally, check for poor skin turgor and dry mucous membranes, which indicate dehydration.

Medical causes

Abdominal aortic aneurysm (dissecting)

Mild to moderate abdominal rigidity occurs in abdominal aortic aneurysm, a life-threatening disorder. It’s typically accompanied by constant upper abdominal pain that may radiate to the lower back. The pain may worsen when the patient lies down and may be relieved when he leans forward or sits up. Before rupture, the aneurysm may produce a pulsating mass in the epigastrium, accompanied by a systolic bruit over the aorta. However, the mass stops pulsating after rupture. Associated signs and symptoms include mottled skin below the waist, absent femoral and pedal pulses, blood pressure that’s lower in the legs than in the arms, and mild to moderate abdominal tenderness with guarding. Significant blood loss causes signs of shock, such as tachycardia, tachypnea, and cool, clammy skin.

Mesenteric artery ischemia

This life-threatening disorder is characterized by 2 to 3 days of persistent, low-grade abdominal pain and diarrhea leading to sudden, severe abdominal pain and rigidity. Rigidity occurs in the central or periumbilical region and is accompanied by severe abdominal tenderness, fever, and signs of shock, such as tachycardia and hypotension. Other findings may include vomiting, anorexia, diarrhea, and constipation. Always suspect mesenteric artery ischemia in patients older than age 50 who have a history of heart failure, arrhythmias, cardiovascular infarct, or hypotension.

Peritonitis

Depending on the cause of peritonitis, abdominal rigidity may be localized or generalized. For example, if an inflamed appendix causes local peritonitis, rigidity may be localized in the right lower quadrant. If a perforated ulcer causes widespread peritonitis, rigidity may be generalized and, in severe cases, boardlike.

Peritonitis also causes sudden and severe abdominal pain that can be localized or generalized. It can also produce abdominal tenderness and distention, rebound tenderness, guarding, hyperalgesia, hypoactive or absent bowel sounds, nausea, and vomiting. Most patients also experience fever, chills, tachycardia, tachypnea, and hypotension.

Pneumonia

In lower lobe pneumonia, severe upper abdominal pain and tenderness accompany rigidity that diminishes with inspiration. Associated signs and symptoms include blood-tinged or rusty sputum, dyspnea, achiness, headache, fever, sudden onset of chills, crackles, egophony, decreased breath sounds, dullness on percussion, and a dry, hacking cough.

Other causes

Insect toxins

Insect stings and bites, especially black widow spider bites, release toxins that can produce generalized cramping abdominal pain, usually accompanied by rigidity. These toxins may also cause low-grade fever, nausea, vomiting, tremors, and burning sensations in the hands and feet. Some patients develop increased salivation, hypertension, paresis, and hyperactive reflexes. Children commonly are restless, have an expiratory grunt, and keep their legs flexed.

Special considerations

Continue to monitor the patient closely for signs of shock. Position him as comfortably as possible in a supine position, with his head flat on the table, arms at his sides, and knees slightly flexed to relax the abdominal muscles. Because analgesics may mask symptoms, withhold them until a tentative diagnosis has been made. Also withhold food and fluids and administer an I.V. antibiotic because emergency surgery may be required. Prepare the patient for diagnostic tests, which may include blood, urine, and stool studies; chest and abdominal X-rays; a computed tomography scan; magnetic resonance imaging; peritoneal lavage; and gastroscopy or colonoscopy. A pelvic or rectal examination may also be done.

Pediatric pointers

Voluntary rigidity may be difficult to distinguish from involuntary rigidity if associated pain makes the child restless, tense, or apprehensive. However, in any child with suspected involuntary rigidity, your priority is early detection of dehydration and shock, which can rapidly become life-threatening.

Abdominal rigidity in children can stem from gastric perforation, hypertrophic pyloric stenosis, duodenal obstruction, meconium ileus, intussusception, cystic fibrosis, celiac disease, and appendicitis.

Geriatric pointers

Advanced age and impaired cognition decrease pain perception and intensity. Weakening of abdominal muscles may decrease muscle spasms and rigidity.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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