Is peritonitis characterized by a triad of guarding, rebound tenderness, and rigidity?

Peritonitis Clinical Triad: Guarding, Rebound Tenderness, and Rigidity

Yes, peritonitis is characterized by a clinical triad of guarding, rebound tenderness, and rigidity, which are key physical examination findings that suggest peritoneal inflammation. 1

Clinical Features of Peritonitis

Peritonitis presents with several characteristic findings on physical examination:

• Abdominal rigidity is a strong clinical indicator of peritonitis and represents involuntary contraction of the abdominal muscles in response to peritoneal inflammation 1
• Guarding is a protective muscular response to abdominal palpation that occurs in 74-95% of patients with peritonitis 1
• Rebound tenderness (pain that worsens when pressure is suddenly released) is another hallmark finding that occurs in most patients with peritonitis 1
• Abdominal pain and tenderness are nearly universal symptoms (74-95% of patients) 1
• Decreased bowel sounds are commonly observed due to associated ileus 1
• Tachycardia is present in approximately 62.5% of patients 1
• Fever (>38.5°C) is observed in about 38% of patients 1

Types of Peritonitis

Different types of peritonitis share these clinical findings but have distinct causes:

• Primary peritonitis (Spontaneous Bacterial Peritonitis - SBP):

  • Occurs without gastrointestinal tract disruption, typically in patients with cirrhosis 2
  • Usually monomicrobial (single organism) infection 2
  • Diagnosed by ascitic fluid analysis showing neutrophil count >250/mm³ 2
  • Managed primarily with antibiotics without surgical intervention 2

• Secondary peritonitis:

  • Results from gastrointestinal tract perforation or contamination 2
  • Typically polymicrobial infection 2
  • Requires both source control (surgical intervention) and antibiotic therapy 2
  • When perforation occurs at a tumor site, peritoneal contamination is usually localized; when proximal to a tumor, it results in diffuse peritonitis and potentially septic shock 3

• Tertiary peritonitis:

  • Recurrent infection occurring >48 hours after apparently successful treatment of secondary peritonitis 2
  • Often associated with multidrug-resistant organisms 2
  • Requires broader antimicrobial coverage and possibly additional surgical interventions 2

Diagnostic Approach

When peritonitis is suspected based on the clinical triad:

• Laboratory tests may show leukocytosis with left shift, elevated CRP, and increased serum lactate levels 1
• Imaging studies are essential for confirmation:
  • CT scan has the highest sensitivity and specificity for detecting peritonitis compared to ultrasound and plain X-ray 3
  • Abdominal ultrasound can identify free fluid in the abdomen and is a good screening tool, especially in resource-limited settings 1
  • Plain abdominal X-ray may show free air in cases of perforation but has lower sensitivity 3

Clinical Pitfalls and Caveats

• The absence of one or more components of the clinical triad does not rule out peritonitis - each symptom and sign may be absent in some cases 1
• Delayed diagnosis significantly increases mortality rates, especially in patients with diffuse peritonitis 1
• When perforation is suspected in a stable patient with positive findings on ultrasound or X-ray, a CT scan should be considered for better characterization 3
• In patients with cirrhosis, the clinical signs of peritonitis may be subtle or atypical 2
• Inadequate source control is associated with significantly elevated mortality rates 1

Management Considerations

• Source control procedures are recommended for nearly all patients with intra-abdominal infection, particularly secondary peritonitis 1
• Appropriate antibiotic therapy should be initiated promptly based on the suspected type of peritonitis 1
• Aggressive resuscitation along with early surgical treatment and antibiotics can improve outcomes 4

The clinical triad of guarding, rebound tenderness, and rigidity remains the cornerstone of peritonitis diagnosis, allowing for prompt recognition and management of this potentially life-threatening condition.