A25. Physical signs of the acute abdomen

See also topic B42 for differential diagnosis.

Physical examination of acute abdomen

Inspection

Finding Suspicious for
Inspect for any hernias
Patient lies completely still (any small movement causes pain) with knees bent Peritonitis
Patients is curled up, writhes in agony, wants to keep moving Biliary or renal colic

Auscultation

Finding Suspicious for
Abnormally active, high-pitched bowel sounds Early bowel obstruction
Absent bowel sounds Late bowel obstruction
Bruit on auscultation Abdominal aortic aneurysm

Percussion

Finding Suspicious for
Even gentle percussion causes pain Peritonitis
Shifting dullness on percussion Ascites

Palpation

Finding Suspicious for
Palpate the whole abdomen to locate the area of maximal pain, first superficially then deeper
Palpate for hepatomegaly or splenomegaly
Palpate for any masses
Muscular rigidity or “guarding” on palpation Peritonitis
Rebound tenderness Peritonitis
Markle sign/Heel-drop test Peritonitis
Maximal pain at the McBurney’s point Appendicitis
Palpation of contralateral McBurney’s point elicits pain at the McBurney’s point (Rovsing sign) Appendicitis
Psoas sign Appendicitis, especially retrocaecal appendicitis
Obturator sign Appendicitis, especially pelvic appendicitis
Carnett sign Abdominal wall pathology (rather than visceral pathology)
Murphy sign Cholecystitis
Pain out of proportion to physical findings (severe pain but nontender, soft abdomen) Mesenteric ischaemia

Peritonitis may be local or generalised, and the physical findings will follow this. It’s important to know that, because the visceral organs aren’t innervated with somatic pain fibres, appendicitis isn’t painful in itself but causes pain because it causes localised peritonitis in the overlying peritoneum.

Markle sign is tested by asking the patient to stand on their toes and suddenly drop down on the heels with an audible thump, which causes localised pain. An alternative way to elicit this sign is to lift the patient’s legs slightly off the bed and striking the patient’s heels.

Carnett sign refers to increased tenderness when the abdominal wall muscles are voluntarily contracted.

Murphy sign refers to the patient abruptly stopping a deep inspiration during palpation of the upper right quadrant due to sudden pain. This occurs because during inspiration, the tender gallbladder is pushed caudally by the expanding lungs, eventually hitting the palpating hand. Note that Murphy sign is not sensitive in elderly.

Psoas sign is elicited by asking the patient to lie on the left side with the hip flexed, and the examiner passively extending the right hip. This causes pain in the right lower quadrant in the case of appendicitis because the right psoas muscle lies beneath the appendix, and so stretching or contracting it elicits pain.

Obturator sign is elicited by the examiner flexing the patient’s right hip and knee, followed by internal rotation of the right hip. This causes pain in the right lower quadrant in the case of appendicitis because the right obturator internus muscle lies beneath the appendix, and so stretching or contracting it elicits pain.

Digital rectal examination

See topic A26.


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A23. Hemoptoe, hematemesis

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A26. Differential diagnosis of bloody stool. The significance of rectal digital investigation

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