Which signs indicate perforation of the abdomen?

• A. Abdominal pain with shoulder tip pain, rebound tenderness, guarding, distension
• B. Nausea without abdominal tenderness
• C. Persistent hiccups without other symptoms
• D. Jaundice and dark urine

Answer: (A)

Perforation of a hollow abdominal organ causes the contents and air to spill into the peritoneal cavity, leading to irritation and inflammation of the peritoneum (peritonitis). This produces an acute abdomen with severe pain and protective muscle guarding, plus rebound tenderness as the abdomen is pressed and released. The free air under the diaphragm also irritates the phrenic nerve, causing referred pain to the shoulder tip (Kehr’s sign). The combination of sharp abdominal pain with abdominal tenderness that is rebound and guarded, along with distension from gas and fluid, strongly points to perforation.

Nausea without tenderness doesn’t reflect peritoneal irritation. Persistent hiccups can occur with diaphragmatic irritation but isn’t a classic standalone sign of perforation. Jaundice and dark urine suggest liver, biliary, or hemolytic issues, not perforation.