Correct answer:

Peritonitis is inevitably secondary to some precipitating lesion, which may itself have definite clinical features, e.g. the onset may be an attack of acute appendicitis or a perforated duodenal ulcer with appropriate symptoms and signs. Early peritonitis is characterized by severe pain; the patient wishes to lie still because any movement aggravates the agony. Irritation of the diaphragm may be accompanied by referred pain to the shoulder tip. Vomiting is frequent. The temperature is usually elevated and the pulse rises progressively. Examination at this time shows localized or generalized tenderness, depending on the extent of the peritonitis. The abdominal wall is held rigidly and rebound tenderness is present. The abdomen is silent, or the transmitted sounds of the heart beat and respiration may be detected. Rectal examination may show tenderness in the pouch of Douglas. In advanced peritonitis the abdomen becomes distended and tympanitic, signs of free fluid are present, the patient becomes increasingly toxic with a rapid, feeble pulse, vomiting is faeculent and the skin is moist, cold and cyanosed (the hippocratic facies).