Rebound tenderness
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| Rebound tenderness Classification and external resources |
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- Rebound tenderness is one of the most important signs of peritonitis when evaluating an acute abdomen.
- Increased abdominal pain is caused by pressing deeply on the abdomen, suddenly releasing pressure and therefore stretches the peritoneum.
- Immunocompromised, children and the elderly are less likely to show peritoneal signs and may have atypical presentations.
- Delay of immediate surgical intervention for rebound and guarding may be life threatening.
- Rebound tenderness is a clinical sign that a doctor may detect in physical examination of a patient's abdomen. It refers to pain upon removal of pressure rather than application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.)
- It represents aggravation of the parietal layer of peritoneum by stretching or moving.
- Rebound is regarded as one of the classic local signs of peritonitis which differentiates it from diseases such as appendicitis. The others are tenderness and guarding.
- However, in recent years the value of rebound tenderness has been questioned, since it may not add any diagnostic value beyond the observation that the patient has severe tenderness.
Differential Diagnosis
In alphabetical order. [1] [1]
- Appendicitis
- Bacterial peritonitis
- Biliary or renal colic
- Bowel obstruction
- Cholecystitis
- Colitis
- Diverticulitis
- Gastritis
- Gastroenteritis
- Gynecologic etiologies
- Ovarian cyst torsion or rupture
- Ruptured ectopic pregnancy
- Tubo-ovarian abscess
- Pelvic Inflammatory Disease
- Intra-abdominal or pelvic abscess
- Intussusception
- Mesenteric ischemia
- Nonabdominal causes of pain. For example:
- Atypical angina
- Myocardial Infarction
- Pelvic pathology
- Pericarditis
- Pneumonia
- Pulmonary embolus
- Pancreatitis
- Perforated duodenal ulcer
- Perforated viscus
- Ruptured abdominal aortic aneurysm
- Sickle cell crisis
Diagnosis
History and Symptoms
- Location of pain, nature, intensity, onset, duration
- Guarding
- Past episodes
- Distention
- Bowel sounds
- Blood on rectal exam
- Presence of mass
- Cervical or adnexal tenderness
- Factors that alleviate pain
- Factors that aggravate pain
- Crampy, colicky pain occuring in waves (distention)
- Pain that is constant and localized in nature (inflammation)
- Shock
- Hypotension
Laboratory Findings
- Complete blood count (CBC)
- BUN (blood urea nitrogen)/creatinine
- LFTs (liver function tests)
- Pregnancy test
- Urinalysis
- Amylase/lipase
Electrolyte and Biomarker Studies
X-Ray
- Obstruction, perforation or other pathologies revealed by abdominal X-ray.
Echocardiography or Ultrasound
- Ultrasound can test for the following:
- Abdominal aortic aneurysm
- Ectopic pregnancy
- Biliary disorders
- Diverticulitis
Other Diagnostic Studies
- Peritoneal lavage recommended for suspected trauma, peritonitis, or bowel perforation
- Persistent vomiting and obstruction require a nasogastric tub
Treatment
- Immediately replace volume with saline and/or blood transfusion for those patients are are hemodynamically unstable
- Bowel rest for diverticulitis or bowel obstruction (possible colon resection)
Pharmacotherapy
Acute Pharmacotherapies
- If intra-abdominal infection or perforated viscus is suspected, administer proper course of antibiotics
Indications for Surgery
- Life threatening emergencies such as; early sepsis or evidence of hemorrhage, require immediate surgical intervention
- Ruptured aneurysm, ectopic pregnancy, bowel perforation or ther pathologies require definite surgical repair.
References
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
