Abdominal Pain with Rebound Tenderness

In evaluating an acute abdomen, rebound tenderness is one of the most important signs of peritonitis. It is elicited by pressing deeply on the abdomen and then suddenly releasing pressure, which stretches the peritoneum and causes increased abdominal pain. Guarding and rebound often indicate immediate surgical evaluation, as delay can be life threatening. Children, elderly patients, and immunocompromised patients may have atypical presentations and are less likely to show peritoneal signs.

Differential Diagnosis

• Appendicitis is the most common etiology
• Cholecystitis
• Diverticulitis
• Gastroenteritis
• Pancreatitis
• Perforated duodenal ulcer
• Gastritis
• Biliary or renal colic
• Mesenteric ischemia
• Ruptured abdominal aortic aneurysm
• Bowel obstruction
• Bacterial peritonitis
• Intra-abdominal or pelvic abscess
• Colitis
• Urinary tract infection or pyelonephritis
• Perforated viscus
• Sickle cell crisis
• Gynecologic etiologies
  –Pelvic inflammatory disease
  –Tubo-ovarian abscess
  –Ruptured ectopic pregnancy
  –Ovarian cyst rupture or torsion
• Intussusception
• Nonabdominal causes of pain that mimic an acute abdomen are numerous and may include myocardial infarction, atypical angina, pericarditis, pneumonia, pulmonary embolus, and pelvic pathology (e.g., pelvic inflammatory disease, ovarian torsion)

Workup and Diagnosis

• Distinguish etiologies requiring emergent or urgent surgical intervention (e.g., ruptured aortic aneurysm, perforated viscus, appendicitis, intestinal obstruction, ischemic bowel, ruptured ectopic pregnancy) from non-emergent causes

• History and physical examination
  –Nature of pain, location, onset, duration, intensity, similarity to past episodes, aggravating and alleviating factors, guarding, bowel sounds, distension, presence of a mass, blood on rectal exam, and cervical or adnexal tenderness
  –In general, patients who present with extremely severe pain of immediate onset require surgical intervention
  –Crampy, colicky pain that occurs in waves implies distension of a hollow viscus (e.g., renal colic, intestinal obstruction)
  –Constant, localized pain implies inflammation (e.g., appendicitis, diverticulitis, cholecystitis)
  –Hypotension and shock may be present

• Initial tests include CBC, electrolytes, BUN/creatinine, LFTs, amylase/lipase, urinalysis, and pregnancy test
• Plain abdominal X-rays may reveal obstruction, perforation (free air), or other pathology
• Ultrasound is a quick, inexpensive test for biliary tract disease, AAA, ectopic pregnancy, or peritoneal fluid
• Abdominal CT will often establish the diagnosis for appendicitis, aortic aneurysm, and diverticulitis
• Diagnostic peritoneal lavage may be indicated in cases of suspected trauma, bowel perforation, or peritonitis

Treatment

• Hemodynamically unstable patients require immediate resuscitation
  –Replace volume with normal saline and/or blood transfusion
  –Evidence of hemorrhage (e.g., ruptured AAA, ruptured ectopic pregnancy) or early sepsis (e.g., perforated diverticulitis, perforated bowel) may represent a life-threatening emergency that requires urgent surgical intervention

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 Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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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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