114. DPR | History and Physical Exam of the Gastrointestinal System Part I

A 71-year-old woman presents with severe abdominal pain and vomiting. On inspection, you note periumbilical ecchymosis. Auscultation reveals absent bowel sounds after 3 minutes, and the abdomen shows no respiratory motion. Percussion reveals diffuse dullness. What diagnosis is most strongly supported?

A. Acute cholecystitis
B. Hemoperitoneum
C. Small bowel obstruction
D. Pyelonephritis
E. Irritable bowel syndrome

B

• A. Acute cholecystitis
  RUQ tenderness + positive Murphy’s sign are required. Not present.
  No mention of periumbilical ecchymosis in cholecystitis.
  ( page 87)

• B. Hemoperitoneum — CORRECT
  Cullen’s sign = periumbilical ecchymosis, which indicates hemoperitoneum.
  Lecture slide: “Cullen’s sign: Periumbilical ecchymosis → hemoperitoneum.”
  ( page 27)
  Absent bowel sounds after 2–3 minutes → peritonitis/bleeding. (page 37)
  Absent respiratory motion → peritoneal irritation / acute abdomen. (page 30)

• C. Small bowel obstruction
  Early obstruction = hyperactive, high-pitched rushes + visible peristalsis.
  Not absent bowel sounds. Not Cullen’s sign.
  ( pages 31, 36, 38)

• D. Pyelonephritis
  Requires CVA tenderness. (page 15, 80)
  Not present.

• E. Irritable bowel syndrome
  Bowel sounds normal, no peritoneal signs, no ecchymosis.
  IBS never causes Cullen’s sign.
  (—IBS appears only in alternating diarrhea patterns)

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