23 - Peritonism

KYJ23- Peritonism

Peritonism- and assessing the Abdomen

During a secondary assessment of a drowsy  patient post road traffic crash, a colleague reports that the abdomen is distended, rigid, and has rebound tenderness. There is no obvious bruising, but bowel sounds are absent.  How would you interpret this information?

Assessing an abdomen uses the three techniques of Inspection, Auscultation and Palpation in that order - think -  "look, listen , feel"

Look- Inspection
First observe the skin surface of the abdomen. Look for scars, bruises, lacerations and abrasions. Inspect contour of the abdomen and determine if it is symmetrical. Is there distension?
Presence of abdominal distension is seen in drowning victims, intraabdominal bleeding (organ rupture), or very distressed young children after crying.
Upper abdomen distension is usually less significant than lower abdo distension, which is sinister. In these circumstances you should maintain a high index of suspicion for a large intra peritoneal haemorrhage . Finally make an educated guess if the abdominal enlargement is trauma related, pregnancy or simply lifestyle girth enlargement ( beer gut ).

Listen - auscultation
Using the umbilicus as a land mark, mentally divide the abdomen left to right, and upper to lower quadrants .
Place the diaphragm on each quadrant to determine if bowel sounds are present. Normal finding is that within 60 seconds in each quadrant, bowel sounds should be heard. In stress and shock, the trauma patient's cardiovascular system will reduce blood flow to the gut. Peristalsis will reduce or stop, giving rise to a silent abdomen.
Bowel sounds also switch off if there is abdominal organ injury, so a silent abdomen is an unreliable piece of data to confirm intraabdominal pathology.  Still, it is valuable in the context of a thorough assessment.

Feel - Palpation
During trauma palpation, you are assessing for the following 3 things:
Pain- :
pain on pressing into each quadrant or on rebound ( ie when pressure  is released) the sensation of pain or tenderness is restricted to a patient who is conscious enough to feel it. Both pain on palpation and rebound tenderness is an ominous symptom of intraperitoneal bleeding , or organ damage, leakage of bowel contents.
Guarding:
Is the tensing up of a muscle group when a painful stimulus is expected. If you were to threaten to tickle a toddlers tummy, they would tense up their abdominal muscles.  This voluntary guarding is a normal finding. It is however abnormal for a patient to exhibit involuntary guarding. This finding is referred to as Rigidity. And is an ominous sign, especially if the patient is unconscious and technically can't perceive pain.
Organ Symmetry:
When systematically palpating each quadrant, feeling the size and contour of large organs is a skill best practiced. An enlarged liver or spleen can indicate a sub capsular haemorrhage, but is subtle and difficult to assess on palpation alone.

Peritonism refers to the rigid, tender to palpate, or rebound tenderness, and involuntary guarding. It is an important finding in the trauma patient and is highly suggestive of abdominal bleeding. Coupled with absent bowel sounds +\- distension, and this is a patient going for a Laparotomy or CT scan at the very least.

The normal abdomen is soft, non tender to palpate, has bowel sounds in 3 of 4 quadrants and no new distension.
Know normal so you can recognise abnormal. Practice on your kids, your partner or even healthy patients during a routine assessment, and hone your skills in Abdominal Assessment.