Acute abdomen: Shaking down the Acute abdominal pain can be difficult to diagnose, requiring astute assessment skills and knowledge of abdominal anatomy 2.3 ANCC to discover its cause. We show you how to quickly and accurately CONTACT HOURS uncover the clues so your patient can get the help he needs.

By Amy Wisniewski, BSN, RN, CCM Lehigh Valley Home Care • Allentown, Pa.

The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity. NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 43 suspects Determining the cause of acute abdominal rapidly, indicating a life-threatening process, pain is often complex due to the many or- so fast and accurate assessment is essential. gans in the abdomen and the fact that pain In this article, I’ll describe how to assess a may be nonspecific. Acute abdomen is a patient with acute abdominal pain and inter- general diagnosis, typically referring to se- vene appropriately. vere abdominal pain that occurs suddenly over a short period (usually no longer than What a pain! 7 days) and often requires surgical interven- Acute abdominal pain is one of the top tion. Symptoms may be severe and progress three symptoms of patients presenting in

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the ED. Reasons for acute abdominal pain Visceral pain can be divided into three Your patient’s fall into six broad categories: subtypes: age may give • inflammatory—may be a bacterial cause, • tension pain. This type of pain is caused you clues. For such as acute appendicitis, diverticulitis, or by organ distension, such as in bowel ob- example, acute pelvic inflammatory disease, or a chemical struction or constipation. Blood accumula- pancreatitis cause, such as perforation of a peptic ulcer tion from trauma and pus or fluid accumu- is usually seen in which gastric contents cause a peritoneal lation from infection may also cause tension in adults. infection or abscess pain. Tension pain that’s described as col- • mechanical—such as an ileus or icky may be caused by increased peristaltic obstruction contractile force, such as when the bowel • neoplastic—such as a tumor causing ob- tries to eliminate irritating substances. Pa- struction or impinging on nerves or vessels tients with tension pain may have trouble • vascular—such as a getting comfortable. superior mesenteric clot • inflammatory pain. This type of pain or atherosclerosis may arise from inflammation of either the • congenital—such visceral or parietal peritoneum, such as in as esophageal atresia acute appendicitis. It may be described as (the esophagus doesn’t deep and like a boring sensation. Initially, connect normally with if the visceral peritoneum is involved, the the stomach), hernia, or malrota- pain may be poorly localized; as the parietal tion of the bowel peritoneum becomes involved, the pain • traumatic—such as blunt trauma, liver may become localized. Most patients with laceration, or major organ damage sus- inflammatory abdominal pain want to lie tained in a motor vehicle accident. still. The four most common causes of acute • ischemic pain. This type of pain is the abdominal pain requiring surgery are acute most serious. Sudden in onset, ischemic appendicitis, acute cholecystitis, small pain is extremely intense, progressive in bowel obstruction, and gynecologic disor- severity, and not relieved by analgesics. ders (see Some causes of acute abdominal Like patients with inflammatory pain, pa- pain). However, over 30% of patients with tients with ischemic pain won’t want to acute abdomen have nonspecific abdomi- move or change positions. The most com- nal pain, or pain for which no cause or mon cause of ischemic abdominal pain is source can be identified. It’s also possible a strangulated bowel. that the patient is pain free or has minimal pain, which occurs more often in older Narrowing things down patients, children, and women in the third So where do you start when a patient has trimester of pregnancy. abdominal pain? Besides identifying the Presentation may be confusing and kind of pain the patient is experiencing, difficult for the patient to describe. For the pain’s location can provide clues to its instance, a hepatic abscess may radiate to cause. So it’s imperative that you know the the diaphragm and shoulder area, whereas anatomy and physiology of the abdominal appendicitis may present with pain in the area. The abdomen is divided into four ar- psoas muscle, and cholecystitis with pain in eas, or quadrants: the upper left quadrant, the low and mid back (see Common sites of the upper right quadrant, the lower left referred abdominal pain). The pain may be quadrant, and the lower right quadrant localized or more generalized and deeper (see Where does it hurt?). It can further be di- (visceral), sharp and constant or dull and vided into nine regions (see Understanding intermittent, or any combination of these. the abdominal regions).

44 Nursing made Incredibly Easy! January/February 2010 www.NursingMadeIncrediblyEasy.com Some causes of acute abdominal pain Cause Signs and symptoms Abdominal aortic • Usually asymptomatic, but may cause back and abdominal pain aneurysm • Pulsatile mass may be palpable Appendicitis • Abdominal pain over umbilicus, moving to the right lower quadrant • Often associated with fever • The clinical exam may show rebound tenderness and positive obturator, psoas, and Rovsing signs • Complete blood cell count will show an increase in white blood cell count with a shift to the left and increased neutrophils Cholecystitis • Pain in the right upper quadrant (toward the epigastric area) that may radiate to the shoulder or back There are many • Nausea and vomiting may occur causes of acute • Biliary colic (pain that increases over 2 to 3 min and is sustained for abdomen; use 20 min or more) • Positive Murphy sign this chart to Constipation • Possible colicky to sharp pain that can mimic appendicitis help narrow • The patient may have diffuse tenderness on palpation, as well as them down. palpable stool Diverticulitis • Left lower quadrant pain, often worse after eating and improved after defecation • Possible fever • Possible diarrhea or constipation • Abdomen may be distended and tympanic and tender to palpation over the left lower quadrant Ileus or bowel • Diffuse pain that comes in cramping waves lasting 5 to 15 min obstruction • Nausea, followed by vomiting when the bowel obstructs • Stool may be passed distal to the obstruction and may also involve diarrhea • Abdomen may be distended with high-pitched bowel sounds • Diffuse tenderness and guarding Pancreatitis • Pain in the right upper quadrant to epigastric area, possibly radiating to the back; can be associated with nausea and vomiting, as well as fever • Possible ileus • In severe cases, shock, jaundice, and pleural effusion are present • Rare signs include Grey Turner and Cullen signs Peptic ulcer disease • Usually epigastric pain 1 to 3 h after meals and often associated with nighttime awakenings • Sudden and severe pain with radiation to the right shoulder, along with peritoneal signs; may indicate perforation • Hematemesis or melena suggests hemorrhage Peritonitis • Acute diffuse abdominal pain that may be associated with fever, nausea, and vomiting • Pain increases with any motion • Abdominal distension and rigidity • Rebound tenderness is present but, unlike in appendicitis, it’s diffuse rather than localized • Guarding may be present • Possible signs and symptoms of shock www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 45 The patient’s age may also help narrow often provide clues to guide you to the cor- the diagnosis. For example, appendicitis is rect diagnosis; for example, a patient with a more common in the younger adolescent, history of diabetes may have bowel ischemia whereas an obstruction of the large intestine or renal dysfunction. A patient with alco- is more common in patients over age 40. holism may have pancreatitis, liver disease, Acute pancreatitis or a perforated ulcer is or poor renal functioning. more often seen in the adult patient. Ask the patient when the pain began, Cholecystitis may be seen in a younger where it’s located, and how he’d describe its patient, but is more commonly seen in quality and intensity. Ask if the pain is con- adults. Acute abdominal pain caused by stant or intermittent, if it wakes him at night, vascular reasons is more common in patients and if anything aggravates it or relieves it. over age 70. Remember to ask open-ended questions, Take a health history, gynecologic history such as “What makes the pain better?,” rather for a female patient, and family history of than “Does laying down make the pain bet- abdominal conditions, such as gastroe- ter?” Determine where the pain was when it sophageal reflux disease (GERD), gallblad- began because it may be different from where der disease, renal calculi, colon cancer, or it is now. Also, ask the patient what he was inflammatory bowel disease. Patients can doing when the pain began. For example, if

Common sites of referred abdominal pain

Perforated Pancreatitis duodenal ulcer

Liver Heart Penetrating duodenal ulcer

Renal Biliary colic colic

Cholecystitis, pancreatitis, duodenal ulcer

Appendicitis Cholecystitis Small Pancreatitis, Colon pain intestine pain renal colic

Ureteral colic Rectal lesions

46 Nursing made Incredibly Easy! January/February 2010 www.NursingMadeIncrediblyEasy.com he indicates that the pain began after eating, Assess for jaundice, melena (black, tarry ask him what kind of food he ate. stool), hematochezia (maroon-colored Continue your assessment by determin- stool), hematemesis (vomiting blood), and ing the presence of nausea or vomiting, hematuria (blood in the urine). Look at the diarrhea or constipation, anorexia, recent patient’s hemodynamic status. Does he travel, or changes in medications (such as have a fever, rigors, hypotension, tachycar- taking nonsteroidal anti-inflammatory dia, or pallor? Has he had a change in men- drugs [NSAIDs], which may cause abdomi- tal status? Often the patient’s position can nal pain). Vomiting that precedes abdomi- give clues as to the etiology of the pain: nal pain, or is associated with the onset of Writhing in pain is more representative of abdominal pain, may suggest infection as a colicky pain, whereas knees pulled up and possible cause of pain. Abdominal pain flexed is more diagnostic of peritonitis. For that began before vomiting may indicate signs and symptoms specific to common appendicitis or, more rarely, cholecystitis. abdominal problems, see Some causes of If he reports diarrhea, ask if the diarrhea is acute abdominal pain. liquid, loose, or a combination and whether he has noticed blood in the stool. If he has Let’s get physical had a change in bowel habits without diar- Next, conduct a physical assessment in this rhea, ask about the color and consistency of order: inspection, auscultation, percussion, the stool, whether it floats or sinks, and if and palpation (see Assessing the abdomen). it’s associated with mucus or change in Inspect the abdomen for movement, odor. If he reports recent travel, he may such as fluid waves or increased peristal- have drank contaminated water or gone sis. Look for scars from past surgeries; the swimming in lakes or public pools. patient may have adhesions that could lead

Where does it hurt?

Epigastric pain Right upper Left upper Right upper quadrant or quadrant quadrant from the stomach, epigastric pain duodenum, or pancreas from the biliary tree and liver Periumbilical pain Right lower Left lower from the small intestine, appen- quadrant quadrant dix, or proximal colon Suprapubic or sacral pain from the rectum Hypogastric pain from the colon, bladder, or uterus. Colonic pain may be more diffuse than illustrated.

www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 47 to bowel obstruction. Note the contour of made by blood traveling through narrowed the abdomen: Generalized distension may arteries such as the aorta or renal, iliac, or indicate increased gas, but local bulges femoral arteries. may indicate a distended bladder or a Percuss to identify the borders of organs hernia. and to determine the presence of air or solid Auscultate the abdomen for bowel sounds masses such as tumors. Normally you’ll or additional sounds such as bruits. Normal hear tympany (a drumlike sound) over the bowel sounds consist of peristaltic clicks and stomach and intestines—areas that are nor- gurgles occurring at a rate of 5 to 34 per mally filled with air. You’ll hear dullness minute. Hypoactive bowel sounds may over solid areas such as the liver, spleen, indicate an ileus. Hyperactive bowel sounds tumors, or other masses. If you think the may indicate early intestinal obstruction. patient’s abdominal pain may be related to Arterial bruits with both systolic and dias- pyelonephritis or renal calculi, assess for tolic components are abnormal sounds costovertebral angle tenderness. Place the

Understanding the abdominal regions Right and left hypochondriac ■ Contain the diaphragm, portions of the kid- neys, the right side of the liver, the spleen, and part of the pancreas

Epigastric ■ Contains most of the pancreas and por- tions of the stomach, liver, inferior vena cava, abdominal aorta, and duodenum

Right and left lumbar (lateral) ■ Include portions of the small and large in- Right Left Epigastric testines and portions of the kidneys hypochondriac hypochondriac region region region Umbilical ■ Includes sections of the small and large in- testines, inferior vena cava, and abdominal aorta Right lumbar Left lumbar Umbilical (lateral) (lateral) region region region Right and left iliac (inguinal) ■ Include portions of the small and large in- testines

Right iliac Left iliac Hypogastric Hypogastric (pubic) (inguinal) (inguinal) region ■ Contains a portion of the sigmoid colon, region region urinary bladder and ureters, and portions of the small intestine

48 Nursing made Incredibly Easy! January/February 2010 www.NursingMadeIncrediblyEasy.com palm of one hand in the right costovertebral abdominal pain on either maneuver (a posi- angle and strike it with the ulnar surface tive psoas sign) suggests that the psoas mus- A positive of your fist. Repeat in the left costoverte- cle is irritated by an inflamed appendix. To Murphy sign bral angle. Pain with percussion suggests elicit the obturator sign, ask the patient to means trouble pyelonephritis. bend his right knee, then flex his right thigh for me! Palpate to assess local versus generalized at the hip and rotate the leg internally at the areas of tenderness, as well as to check for hip to stretch the internal obturator muscle. masses and enlarged organs. Palpation can Right hypogastric pain (a positive obturator go from light to deep, but keep in mind that sign) suggests irritation of the obturator a patient with abdominal pain may not toler- muscle by an inflamed appendix. ate abdominal palpation at all. He may tight- en his abdominal muscles, preventing you Diagnostic tools of from assessing the abdomen adequately via the trade palpation. If this happens, flexing his knees After a complete history and physical may relax the abdomen so you can palpate are obtained, imaging studies may not it. If the presence of a bruit leads you to sus- be necessary for all acute abdomen pect that the patient has an aortic aneurysm, patients. If diagnostic testing is indi- palpation may be contraindicated or best left cated, a computed tomography (CT) to the healthcare provider. scan, an abdominal/pelvic ultra- To assess for specific areas of tenderness, sound, or an abdominal X-ray use specific palpation techniques. Murphy may be ordered. sign evaluates gallbladder tenderness and A CT scan is the most frequently inflammation. Hook your fingers under used tool for diagnosing acute the patient’s right lower ribs or press them abdominal pain because it’s more spe- under his ribs, then ask him to take a deep cific, sensitive, and accurate than an X- breath. A sharp increase in tenderness with ray. For acute abdomen, the CT scan may a sudden stop in inspiratory effort consti- include an I.V. or oral contrast medium and tutes a positive Murphy sign, indicating possibly a rectal contrast medium. However, acute cholecystitis. some patients will be unable to tolerate oral If you suspect that your patient has contrast, such as a patient who’s vomiting, appendicitis, check for Rovsing sign and for unable to swallow, or is suspected of having referred rebound tenderness. Press deeply a bowel obstruction. With any kind of con- and evenly in the patient’s left lower quad- trast medium, it must be determined if the rant, then quickly withdraw your fingers. patient has adequate renal functioning to Pain in the right lower quadrant during left- clear it and that he isn’t allergic to it. sided pressure (a positive Rovsing sign) sug- Ultrasound is often used to evaluate the gests appendicitis, as does right lower quad- kidneys, liver, gallbladder, pancreas, spleen, rant pain on quick withdrawal (referred and abdominal aorta or other blood vessels. rebound tenderness). It can help identify renal stones, gallstones, Other techniques to assess for appendici- appendicitis, and gynecologic problems. tis include looking for a psoas or obturator Because images are in real time, they can sign. Place your hand just above the show movement of an organ and blood patient’s right knee and ask him to raise his flow. It’s fast, safe, and doesn’t always thigh against your resistance. Alternatively, require any preliminary preparation or ask him to turn onto his left side and then N.P.O. status. Although ultrasound may not extend his right leg at the hip. Flexing be the only test needed, it can help narrow the leg at the hip makes the psoas muscle the differential diagnoses and assist in deter- contract; extension stretches it. Increased mining the next step. www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 49 The abdominal X-ray is also of use. It may ovarian cyst, and aortic aneurysm. Antibiotics If I have a reveal fluid levels indicating bowel obstruc- will be prescribed if the cause of pain is an problem, your tion, ileus, and stool and gas patterns. It can infection such as pyelonephritis or a lower patient will also be used to identify problems with the urinary tract infection. If the infection is due probably need urinary system such as kidney stones, ascites, to an abscess, surgical drainage may also surgery. abdominal masses, foreign objects, and injury be performed. Abdominal pain due to viral to the abdominal tissues. gastroenteritis will be treated with fluids, In addition to imaging studies, lab studies bowel rest, and antiemetics if the patient is that may help narrow the cause of acute over age 12. abdominal pain include: Treatment is, of course, based on the diag- • complete blood cell count for signs of nosis. Surgery isn’t always necessary. infection, cancer, and inflammation • complete metabolic profile for Interventions galore blood glucose levels, renal or Triaging patients quickly and accurately is hepatic dysfunction, electrolyte crucial because some causes of abdominal imbalances, or problems related to pain are life-threatening. Other nursing low albumin level interventions include ongoing assessments, • stool sample to look for infection managing the patient’s pain, restoring fluid or parasites and electrolyte balance, specific interven- • urinalysis to look for infection or tions to treat the pain’s underlying cause, evidence of renal calculi and providing emotional support. • amylase and lipase levels, which will Immediately report to the healthcare be elevated in a patient with pancreatic provider any symptoms that indicate shock problems or instability. If the acute abdomen symp- • Helicobacter pylori level to check for peptic toms occur while the patient is hospitalized ulcer disease for another illness, reviewing all previous • pregnancy test and microscopic examina- care may shed light on the etiology of the tion of vaginal secretions in women to rule pain. Assess previous lab results, changes in out ectopic pregnancy and infections such medications, dye administration during test- as bacterial vaginosis or vulvovaginal can- ing, and treatment outcomes. didiasis Manage your patient’s pain with medica- • sexually transmitted disease testing in tions as ordered and nonpharmacologic sexually active men and women. interventions, including positioning, back rubs, and heating pads (if not contraindi - Did someone say surgery? cated). It was previously thought that pro- One of the primary goals when diagnosing viding pain medication to a patient with a patient with acute abdomen is to deter- acute abdomen would mask the pain and mine if surgery is necessary and the timing make it more difficult to diagnose; however, of surgery. A patient presenting as toxic this is an unfounded belief. Pain manage- and unstable may need time in the CCU ment will depend on the severity of the pain. before surgery is performed. However, the If opioid management is needed, morphine patient may also need immediate surgery if is the drug of choice. If the patient is allergic the risk of waiting could be life-threatening. to morphine, meperidine or ketorolac may The balance of risk versus benefit must be be ordered instead. weighed in treating the critically ill patient To protect your patient against complica- with acute abdominal pain. tions, such as cardiac dysrhythmias and Generally, surgery is indicated for bowel seizures, you must maintain his fluid and obstruction, acute appendicitis, a ruptured electrolyte balance. Patients with diarrhea,

50 Nursing made Incredibly Easy! January/February 2010 www.NursingMadeIncrediblyEasy.com vomiting, or fever are the most prone to such eat within 2 to 3 hours of bedtime and not to imbalances. Make sure electrolyte levels are lie down or exercise immediately after eating. evaluated before electrolyte replacement Advise him to try to maintain a normal begins and periodically reassessed during weight and to lose weight if he’s overweight replacement. Maintain accurate intake and or obese because the risk of GERD and gall- output records. bladder disease increases with weight. He If your patient’s abdominal pain was should reduce stress, quit smoking, decrease caused by GERD, hiatal hernia, peptic ulcer or eliminate alcohol consumption, and disease, or diverticulitis, teach him about reduce his use of medications that can dam- foods to avoid and how to time meals in rela- age the esophagus, such as corticosteroids tion to activities and bedtime. He should and NSAIDs (including aspirin). avoid overeating in general and stay away Provide emotional support for the patient from fats, fried foods, spices, coffee, tea, and his family. Let them know the plan for tomato products, and alcohol. Tell him not to diagnosing the pain and the results of any

Assessing the abdomen

Inspecting the abdomen Auscultating the abdomen

Percussing the abdomen Palpating the abdomen

www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 51 diagnostic testing. Provide instruction on standing the different types of abdominal pain management and positions of comfort. pain can help you uncover clues to the cause Instruct the patient on the use of the pain of your patient’s pain so he can receive the medication, how often he can receive it, and most timely treatment possible. ■ to report ineffectiveness or a reaction such as itching. After a diagnosis is made, provide the patient with information on treatment Learn more about it Anatomy & Physiology Made Incredibly Visual! Philadelphia, options and how his hospital stay may pro- PA: Lippincott Williams & Wilkins; 2009:5. ceed. If surgery is indicated, discuss with the Holcomb SS. Acute abdomen: What a pain! Nursing2009 patient and his family what will happen and Crit Care. 2009;4(4):34-40. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opi- when he can anticipate going to the OR. ates affect the clinical evaluation of patients with acute The more Allow family members to visit before surgery abdominal pain? JAMA. 2006;296(14):1764-1774. CE, the and keep them updated. Scott-Conner C, Perry R. Acute abdomen and pregnancy. merrier! http://emedicine.medscape.com/article/195976-overview. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Follow the clues Suddarth’s Textbook of Medical-Surgical Nursing. 11th ed. Although acute abdominal pain can be dif- Philadelphia, PA: Lippincott Williams & Wilkins, 2008: 1126,1128. ficult to diagnose, knowing the anatomy Zeller JL, Burke AE, Glass RM. Acute abdominal pain. and physiology of the abdomen and under- JAMA. 2006;294(14):1800.

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