Acute abdomen

This is just as important as the abdominal examination. It should be carried out in the left lateral position. Insert the well-lubricated gloved finger posteriorly into the sacral hollow. Move the finger around in the arc of a circle until it impinges on the peritoneum of the rectovesical or rectouterine pouch. If the patient winces with pain when the finger impinges on the peritoneum, this is a sign of peritonitis in the most dependent part of the pelvis. The pain disappears when the finger comes off the peritoneum as it completes the circle and returns to the sacral hollow. The correct annotation of a positive rectal examination should be ‘tender anteriorly’. ‘Tender high up in the right’ is inappropriate. There seems to be a misconception among medical students that you are feeling the area of the appendix. You are feeling for tenderness due to inflammation of the pelvic peritoneum caused by infected exudates draining to the most dependent part of the pelvis, i.e. the rectovesical or rectouterine pouch.