How to assess for cholecystitis and small bowel obstruction

22nd Feb 2021

In addition to appendicitis, an acute abdomen can also be caused by cholecystitis or small bowel obstruction. Let’s review some common peritoneal signs that are caused by cholecystitis and small bowel obstructions.

 

How to assess for cholecystitis 

Murphy’s sign

Cholecystitis typically causes a positive Murphy’s sign, which is the cessation of inspiration upon deep palpation of the right upper quadrant (RUQ). To assess for Murphy’s sign, follow these four steps starting on the patient’s right side and then repeating on the left side: 

  1. Ask the patient to take a full deep breath and exhale to relax.
  2. Gently place your hands on the right subcostal margin using the two-handed technique. 
  3. Ask the patient to take a deep breath in as you apply deep pressure.
  4. Release if the patient abruptly stops inspiration with deep palpation.

A positive Murphy’s sign involves cessation of inspiration and pain with palpation on the right (but not the left) side. This indicates acute cholecystitis because as the patient takes a deep breath, the abdominal contents are pushed down as the diaphragm contracts, and the gallbladder descends toward your hand. 

Patient inhaling and exhaling. Abdomen with physician’s hands on the subcostal margin. Patient inhaling. Patient with positive Murphy’s sign indicating possible cholecystitis. Illustration.

Figure 1. Steps to assess for Murphy’s sign include, 1) ask the patient to take a full deep breath and exhale to relax, 2) gently place your hands on the right subcostal margin using the two-hand technique, 3) ask the patient to take a deep breath in as you apply deep pressure, 4) release if the patient abruptly stops inspiration with deep palpation.

Check out this short video snippet from our Abdominal Examination Essentials Course that demonstrates deep palpation of the RUQ which results in cessation of inspiration and abrupt abdominal contraction:

 

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How to assess for small bowel obstruction

Small bowel obstructions, either partial or complete, also cause peritoneal signs. Most small bowel obstructions are partial and resolve with nonoperative conservative treatments. However, a complete obstruction is more serious and may require surgical intervention. 

A complete small bowel obstruction can cause increased pressure in the bowel lumen which leads to ischemia of the bowel wall. This increases the chance of perforation and bacterial leakage into the abdomen. 

Signs of small bowel obstruction

A patient with a complete obstruction may present with peritonitis, a distended and rigid abdomen, and guarding. Additional signs such as hypotension, tachycardia, fever, and shortness of breath may also be present. 

Torso with abdominal pain from a complete small bowel obstruction and a list of possible symptoms including a distended and rigid abdomen, guarding, hypotension, tachycardia, fever, and shortness of breath. Illustration.

Figure 2. A patient with complete small bowel obstruction will likely present with peritonitis, a distended and rigid abdomen, guarding, hypotension, tachycardia, fever, and shortness of breath.

Be sure to ask detailed history questions! Some of the presenting symptoms of peritonitis are very similar despite very different etiologies. For this reason, it’s important to remember to ask detailed history questions to help guide your differential diagnosis. Medmastery note.

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Recommended reading

  • de Dombal, FT. 1988. The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterol Suppl144: 35–42. PMID: 3043646
  • Jin, XW, Slomka, J, and Blixen, CE. 2002. Cultural and clinical issues in the care of Asian patients. Cleve Clin J Med69: 50, 53–54, 56–58. PMID: 11811720
  • Tseng, W-S and Streltzer, J. 2008. “Culture and clinical assessment”. In: Cultural Competence in Health Care. Boston: Springer. 
  • Wong, C. 2020. Liver fire in traditional Chinese medicine. verywellhealthhttps://www.verywellhealth.com