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Journal of Indian Association of Pediatric Surgeons, Vol. 11, No. 2, April-June, 2006, pp. 110 Letter To Editor Adeniran's sign (in early generalized peritonitis in children) Adeniran JO Paediatric Surgical Unit, University of Ilorin Teaching Hospital, Ilorin, P. O. Box 5708, Ilorin, Nigeria. E-mail: adeniranjodr@yahoo.com Code Number: ip06028 Sir, Rebound tenderness elicited maximally at the umbilicus, in early peritonitis in children. The anterior abdominal wall has 3 sheets of muscles which are muscular posterolaterally and aponeurotic anteromedially. These are the external oblique, the internal oblique and the transverses abdominis. The external oblique musle arises from the lower 8 ribs, radiates downwards and forwards, encloses the transverses and is inserted to the linea alba with the other side. The internal oblique arises from the lumbar fascia and the iliac crest, radiates upwards and forwards and is inserted to the linea alba. The fibres of the transversus are horizontally disposed, to attach to the linea alba. This arrangement gives maximum strength to the abdominal wall. The whole abdominal cavity with its lining peritoneum, is therefore separated from the abdominal skin by these strong sheets of muscles and re-enforced near the pubis with the pyramidalis.[1] The situation is, however, different at the umbilicus. Developmentally the umbilical cord connects the baby to the mother, in utero. The muscles are therefore deficient at the umbilicus. After birth, the umbilical area is left only as the umbilical cicatrix or umbilical ring, where only the skin separates the peritoneum from the abdominal skin, without an intervening muscle. Only a fibrous reminant separates the peritoneum from skin.[2] Irritation of the peritoneum is therefore easier to elicit at the umbilicus. Irritation of the peritoneum in generalized peritonitis produces guarding, rigidity and rebound tenderness.[3],[4] But these signs are elicited through the thick muscles of the anterior abdominal wall. The peritonitis must therefore be grossly established, before these signs can be elicited. Umbilical hernias are common in infants and young children, especially of Afro-Carribean origin.[5] In children whose umbilical ring have previously closed, increased intra-abdominal pressure reopens the ring, causing eversion of the umbilicus.[2] In such children, only the thin skin separates the irritated peritoneum from the palpating finger. Rebound tenderness is thus most easily elicited at the umbilicus, in children with early peritonitis. If peritonitis is suspected in a child, either the index or middle finger ONLY is used to sharply press and release the everted umbilicus. Rebound tenderness elicited at this umbilicus makes ADENIRAN′S sign positive and confirms peritonitis. References
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