Identifying peritonism is a basic clinical skill in general surgery
Peritonism – key components
- Cough tenderness – localising pain with cough
- Involuntary guarding (see below)
- Percussion tenderness – localising tenderness with percussion
- Rebound tenderness – transient worsening pain following immediately release after deep palpation
Involuntary guarding (‘rigidiy’)
- Is the presence of persistently increased abdominal muscle tone due to peritoneal irritation. It needs to be distinguished from voluntary guarding from an anxious patient
- Its presence increases the specificity of a serious acute cause
- Eliciting the sign is more of an art than science requiring a gentle, reassuring and progressive approach of palpation
- Ensure the patient is given adequately analgesia and lying as comfortably as possible
- Gently palpate in all four quadrants to elicit the area of maximal tenderness
- Return to the area of maximal tenderness and gently palpate the area. Maintaining continual contact with the abdomen, attempt to distract the patient through conversation and focussed deep breathing whilst slowly increasing the pressure until the underlying abdominal musculature can be felt.
- Involuntary guarding will demonstrate persistent abdominal wall tension despite changes in respiration
- Whilst maintaining pressure with palpating hand, complete the exam with a test for percussion and rebound tenderness.
| Voluntary Guarding | Involuntary guarding | |
| Pathophysiology | Voluntary contraction of abdominal muscles in response to pain or anxiety | Increased muscle tone due to irritation of parietal peritoneum |
| Relieved with pillow under feet/back | Yes | No |
| Relieved with distraction | Yes | No |
| Relieved with analgesia | Yes | No |
| Relieved with distraction | Yes | No |
| Relieved with deep inspiration | Yes | No |