Tension signs

Distension pain as a result of tension

In clinical practice, pain caused by tension of the ligamentous apparatus and overstretching of hollow organ walls is classified as distension pain. This type of pain has specific characteristics that distinguish it from other pathological processes in the abdominal cavity.

Patients typically describe such pain as dull and aching. It is characterized by relatively low intensity. An important diagnostic feature is diffuse localization: the patient cannot point to a clear point of maximal tenderness, and the pain itself lacks pronounced zones of radiation. Unlike conditions caused by smooth muscle spasm, the administration of antispasmodics for distension pain usually does not bring relief to the patient.

Typical clinical examples of conditions accompanied by tension and overstretching signs include marked flatulence, as well as pathologies occurring with decreased secretory and motor functions of the stomach (e.g., hyposecretory gastritis).

Differential diagnosis: spastic and vascular pain

For an accurate diagnosis, tension signs must be differentiated from other mechanisms of abdominal pain development, primarily spastic and vascular ones.

• Spastic pain occurs as a result of acute spasm of the smooth muscles of hollow organs. Unlike distension pain, it is paroxysmal in nature (colic), occurs and stops suddenly, and is distinguished by high intensity. Such pain is usually clearly localized and has specific pathways of radiation. Administration of antispasmodics significantly reduces the intensity of the pain syndrome. The condition may be accompanied by vomiting (not bringing relief), local tension of the abdominal wall muscles, and reflex fever. Examples: biliary, renal, intestinal colic, pain in peptic ulcer disease.
• Vascular pain develops against the background of ischemia or organ necrosis due to thrombosis, embolism, or spasm of feeding arteries. It occurs suddenly, is constant, diffuse, and extremely intense, intensifying over time to unbearable levels. With the development of necrosis in the ischemic area, vascular pain naturally transforms into peritoneal pain. Examples: mesenteric vessel thrombosis, exacerbation of chronic ischemic bowel disease ("abdominal angina").

Signs of peritoneal and meningeal irritation

During physical examination, it is crucial to distinguish peritoneal tension signs from true signs of its irritation. Peritoneal pain develops when the inflammatory process spreads directly to the parietal layer of the peritoneum. The pain is constant and continuously increasing. The onset can be either gradual or acute (in case of hollow organ perforation).

Objective examination reveals characteristic local physical findings:

1. Limited participation of the abdomen in the act of respiration.
2. Pronounced tension of the anterior abdominal wall muscles (defance).
3. Positive peritoneal irritation sign (Blumberg's sign).
4. Weakening or complete disappearance of bowel sounds (intestinal paresis).

Simultaneously, general symptoms increase: signs of systemic intoxication, fever, leukocytosis, vomiting, and a high risk of acute vascular failure. A similar picture is typical for peritonitis of any origin.

Additionally, in clinical practice, signs of meningeal irritation are distinguished (mild meningeal syndrome), which include mild nuchal rigidity and a doubtful Kernig's sign.

Clinical case of syndromic analysis

Let us examine the manifestation of various pain and intoxication syndromes using a complex clinical problem as an example. A patient with a burdened epidemiological history (staying in the forest, drinking unboiled spring water, contact with a wild boar carcass) presents with a complex clinical picture.

The following leading syndromes are identified:

• Abdominal syndrome: sharp tenderness upon palpation of the abdomen in all regions, however, signs of peritoneal irritation are absent.
• Myalgic syndrome: sharp tenderness of the muscles of the anterior abdominal wall, back, and calves, forcing the patient to assume a passive position.
• Intoxication syndrome: febrile fever (39.3°C), lethargy, tachycardia against the background of arterial hypotension, facial hyperemia, and scleral vessel injection.
• Jaundice and hepatomegaly syndrome: icterus, hepatomegaly (+2 cm), dark urine, and pale stools.
• Renal syndrome: oliguria, positive costovertebral angle tenderness sign (Pasternatsky's sign).
• Hemorrhagic syndrome: petechial rash, hemorrhages in the outer corners of the eyes.

Laboratory tests reveal pronounced leukocytosis with a stab shift to the left, accelerated ESR, elevated creatinine, urea, bilirubin, alkaline phosphatase, and transaminases. Acute viral hepatitis is excluded serologically (HBsAg, anti-HBcor IgM, anti-HAV IgM, anti-HCV — negative). This picture requires differential diagnosis with hemorrhagic fever with renal syndrome (HFRS), malaria, and sepsis, but is most typical for leptospirosis. In this case, abdominal pain is caused not by peritoneal irritation, but by a pronounced myalgic component and systemic damage.

Class and exam questions

What else to study on this topic

• Differential diagnosis of leptospirosis with viral hepatitis, HFRS, malaria, and sepsis.
• Markers of acute kidney injury and cytolysis syndrome in biochemical blood analysis.
• Indications for hemodialysis in acute renal failure.
• Features of taking an epidemiological history in zoonotic and natural focal infections.
• Management of alcohol withdrawal in surgical and narcological practice.

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Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.