Which combination of findings suggests peritoneal perforation?

• A. Abdominal pain with shoulder tip pain, rebound tenderness, guarding, and distension
• B. Nausea and mild tingling in fingers
• C. Persistent diarrhea without pain
• D. Headache and neck stiffness

Answer: (A)

Peritoneal perforation causes chemical and bacterial irritation of the peritoneum, leading to an acute abdomen with classic signs of peritoneal irritation. Severe abdominal pain is often the first symptom, and the abdomen becomes very tender. Rebound tenderness occurs when gentle pressure is released, indicating underlying peritoneal irritation, while guarding reflects the abdominal wall’s protective muscle stiffness. Distension can develop as gas and intra-abdominal contents leak into the cavity. Shoulder tip pain, or referred pain to the shoulder, happens because diaphragmatic irritation from intraperitoneal irritation or air stimulates the phrenic nerve (C3–C5), producing that characteristic referred pain. Taken together, these findings point to perforation of the GI tract with peritonitis.

The other presentations don’t align with peritoneal irritation: nausea with mild tingling in the fingers is nonspecific and not a sign of peritoneal inflammation; persistent diarrhea without pain lacks the acute abdomen and peritoneal signs; and headache with neck stiffness suggests a neurological or meningeal process rather than intra-abdominal perforation.