[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Abdomen](https://durgical.com/en/clinical-exam/#a-abdomen) › Acute abdomen and peritoneal irritation [Clinical exam](https://durgical.com/en/clinical-exam/) · [Abdomen](https://durgical.com/en/clinical-exam/#a-abdomen) # Acute abdomen and peritoneal irritation - Syndrome Severe, recent abdominal pain that may need urgent surgery; the exam looks for signs that the peritoneum is inflamed. Updated 2026-11-01 **See it in 3D:** [Peritoneum](https://durgical.com/en/anatomy/peritoneum/) · [Appendix](https://durgical.com/en/anatomy/vermiform-appendix/) · [Gallbladder](https://durgical.com/en/anatomy/gallbladder/) · [Pancreas](https://durgical.com/en/anatomy/pancreas/) · [Sigmoid colon](https://durgical.com/en/anatomy/sigmoid-colon/) · [Greater omentum](https://durgical.com/en/anatomy/greater-omentum/) ## Key points - Visceral pain is dull, poorly localized and midline; parietal (peritoneal) pain is sharp, well localized and worse with movement or coughing. - Signs of peritoneal irritation: involuntary guarding, board-like rigidity, rebound tenderness (Blumberg) and pain on gentle percussion or coughing. - The patient with peritonitis lies still; the patient with colic (renal or biliary) writhes and cannot find a position. - Pain out of proportion to the exam, with a soft abdomen, suggests mesenteric ischemia. - In every person of reproductive age who can be pregnant, ectopic pregnancy is ruled out. - Nursing: inspect, auscultate, percuss, then palpate, leaving the painful area for last; record and report the vital signs. ## What it is An acute abdomen is abdominal pain of recent onset (hours to a few days) that demands ruling out a surgical or serious cause. Peritoneal irritation is its most important finding: it means the inflammation has reached the parietal peritoneum. Recognizing it at the bedside sets the urgency of imaging and of a surgical review. ## Key findings - Pained facies, guarded posture and stillness; or restlessness in colic. - Fever and tachycardia; hypotension and cold skin in sepsis or hemorrhage. - Guarding, generalized rigidity and rebound tenderness. - Reduced or absent bowel sounds in generalized peritonitis. - Named signs that point to the organ: Murphy, McBurney, Rovsing, psoas, obturator, Cullen and Grey Turner. - The hernial orifices are always examined, and a rectal and pelvic exam are considered. ## Pathophysiology - Visceral pain: distension, spasm or ischemia of a hollow organ stimulates autonomic fibers that enter the cord at several levels, so the pain feels diffuse and midline (epigastric, periumbilical or hypogastric). - Parietal pain: once inflammation touches the parietal peritoneum, which has segmental somatic innervation, the pain localizes right over the organ involved. - That shift explains the classic migration of appendicitis pain: first periumbilical (visceral), then in the right lower quadrant (parietal). - Referred pain: irritation of the diaphragm (subphrenic blood or pus) can be felt in the shoulder through the phrenic nerve roots. - Reflex contraction of the abdominal muscles protects the inflamed peritoneum; it starts voluntary and becomes involuntary and diffuse. ## Common causes - Right lower quadrant: acute appendicitis. - Right upper quadrant: acute cholecystitis, cholangitis. - Epigastric pain radiating like a belt to the back: acute pancreatitis; sudden diffuse pain with rigidity: perforated peptic ulcer. - Left lower quadrant in an older adult: diverticulitis. - Colicky pain with vomiting and distension: bowel obstruction. - Causes not to miss: ruptured ectopic pregnancy, abdominal aortic aneurysm, mesenteric ischemia and extra-abdominal causes such as inferior myocardial infarction or lower-lobe pneumonia. ## Tests that confirm it - Pregnancy test in people of reproductive age who can be pregnant. - Blood count, lipase, liver tests and urinalysis as the suspicion dictates. - Ultrasound (gallbladder, appendix in children and pregnancy, pelvis) or contrast CT in adults; an upright chest X-ray looks for free air under the diaphragm. ## Memory aid 'Still means peritoneum, restless means colic': the patient's stillness gives away an inflamed peritoneum. ## Test yourself Think of the answer, then tap the question to see it. ## Why does appendicitis pain start around the umbilicus and then move to the right lower quadrant? At first the distended appendix causes visceral, diffuse periumbilical pain; when inflammation reaches the somatically innervated parietal peritoneum, the pain localizes to the right lower quadrant. ## What separates voluntary guarding from involuntary rigidity? Voluntary guarding eases when the patient relaxes or is distracted; involuntary rigidity persists because it is a reflex to an inflamed peritoneum and suggests peritonitis. ## What does very severe abdominal pain with a soft, barely tender abdomen suggest? Pain out of proportion to the exam, especially in an older adult with atrial fibrillation or vascular disease, suggests acute mesenteric ischemia. ## In what order is the abdomen examined, and why is the painful area palpated last? Inspection, auscultation, percussion, palpation; palpating last avoids altering bowel sounds, and leaving the painful area for last keeps pain-guarding from blocking the rest of the exam. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/acute-abdomen-and-peritoneal-irritation/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Peritoneum](https://durgical.com/en/anatomy/peritoneum/) - [Appendix](https://durgical.com/en/anatomy/vermiform-appendix/) - [Gallbladder](https://durgical.com/en/anatomy/gallbladder/) - [Pancreas](https://durgical.com/en/anatomy/pancreas/) - [Sigmoid colon](https://durgical.com/en/anatomy/sigmoid-colon/) - [Greater omentum](https://durgical.com/en/anatomy/greater-omentum/) ## Related - [Abdominal palpation: light and deep, guarding and masses](https://durgical.com/en/clinical-exam/abdominal-palpation-light-and-deep-guarding-and-masses/) - [Rebound tenderness (Blumberg sign)](https://durgical.com/en/clinical-exam/rebound-tenderness/) - [Murphy sign](https://durgical.com/en/clinical-exam/murphy-sign/) - [McBurney point](https://durgical.com/en/clinical-exam/mcburney-point/) - [Rovsing, psoas and obturator signs](https://durgical.com/en/clinical-exam/rovsing-psoas-and-obturator-signs/) - [Cullen and Grey Turner signs](https://durgical.com/en/clinical-exam/cullen-and-grey-turner-signs/) - [Bowel obstruction syndrome](https://durgical.com/en/clinical-exam/bowel-obstruction-syndrome/) - [Shock: the clinical signs and the types](https://durgical.com/en/clinical-exam/shock-the-clinical-signs-and-the-types/) ## Related conditions - [Acute appendicitis](https://durgical.com/en/conditions/acute-appendicitis/) - [Acute cholecystitis](https://durgical.com/en/conditions/acute-cholecystitis/) - [Acute pancreatitis](https://durgical.com/en/conditions/acute-pancreatitis/) - [Diverticular disease and diverticulitis](https://durgical.com/en/conditions/diverticular-disease-and-diverticulitis/) - [Peritonitis](https://durgical.com/en/conditions/peritonitis/) - [Peptic ulcer disease](https://durgical.com/en/conditions/peptic-ulcer-disease/) - [Acute mesenteric ischaemia](https://durgical.com/en/conditions/acute-mesenteric-ischaemia/) - [Ectopic pregnancy](https://durgical.com/en/conditions/ectopic-pregnancy/) - [Abdominal aortic aneurysm](https://durgical.com/en/conditions/abdominal-aortic-aneurysm/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis. Sources: [Abdominal Pain | MedlinePlus](https://medlineplus.gov/abdominalpain.html) (MedlinePlus, U.S. National Library of Medicine, 2026); [Peritonitis: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/001335.htm) (MedlinePlus, U.S. National Library of Medicine, 2026); [Appendicitis | MedlinePlus](https://medlineplus.gov/appendicitis.html) (MedlinePlus, U.S. National Library of Medicine, 2026). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/acute-abdomen-and-peritoneal-irritation/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/acute-abdomen-and-peritoneal-irritation/