cute bdomen: ABy Susan Simmons Holcomb, ARNP,BC, PhD

DETERMINING THE CAUSE of ab- hypogastric, and left iliac regions. This the hospital for an appendectomy and dominal pain is often tricky and time- area is dull to percussion; when you recovers completely. consuming. Because pain can be non- palpate it, you note a firm mass. A specific and the has many complete blood cell (CBC) count Narrowing things down organs and structures, numerous poten- reveals severe anemia. A stat computed So where do you start when a patient tial causes have to be ruled out as clini- tomography (CT) scan of the abdomen has ? Anatomically the cians try to pin down the source of pain. and pelvis reveals a benign, totally abdomen is divided into four quad- Reasons for abdominal pain fall into encapsulated left ovarian tumor. The rants and nine regions. You can use three broad categories: inflammation, tumor is removed, her anemia is these divisions to narrow down the organ distension, and ischemia. In resolved, and she’s doing well. area of complaint and document your some cases, the underlying cause is Patrick Leeson, 45, comes in com- findings (see Where does it hurt?). life-threatening, so a fast, accurate plaining of dull, achy periumbilical pain Remember, however, that abdominal assessment is essential. In this article, that migrated to his right lower quad- pain can be referred to many locations, I’ll describe how to assess a patient rant. He says it started about 24 hours including the shoulders, cardiac area with abdominal pain and intervene ago. He has no or or (substernal and left chest), low and appropriately. Let’s start by looking at a changes in bowel habits. He says he was mid back, and groin. couple of hypothetical situations. treated for testicular cancer 10 years ago Besides pain location, the kind of Laurie Greene, 42, comes to your and it began with abdominal pain simi- pain provides clues to its cause. Type A ED complaining of intermittent lar to what he’s experiencing now. delta nerve fibers innervate cutaneous abdominal pain and that she’s Mr. Leeson has an elevated white tissues and the parietal peritoneum; had for a month. She reports no blood cell count with a left shift, possi- stimulation from an irritant such as change in bowel habits and no other bly indicating a bacterial infection or pus, blood, bile, or urine often leads to significant medical history. inflammation. A CT scan of the localized pain. Type C fibers innervate When you examine Ms. Greene, you abdomen and pelvis shows an inflamed visceral tissue, so visceral pain is more find a protrusion in the umbilical, . Mr. Leeson is admitted to generalized and deeper.

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So many things—some life-threatening—can cause abdominal pain. Here’s how to capture the clues quickly and accurately.

What a pain!

www.nursing2008.com September | Nursing2008 | 35 Visceral pain can be divided into from infection or other causes also can may have trouble getting comfortable three subtypes: cause this pain. Tension pain that’s and squirm a lot trying to find a com- • Tension pain is caused by organ dis- described as colicky may be caused by fortable position. tension, as from bowel obstruction or increased peristaltic contractile force as • Inflammatory pain may arise from . Blood accumulation from the bowel tries to eliminate irritating inflammation of either the visceral or trauma and pus or fluid accumulation substances. Patients with tension pain parietal peritoneum, as in acute appen- dicitis. This pain may be Where does it hurt? described as deep and bor- ing. Initially, if the visceral You can use the four abdominal regions shown here and the nine abdominal regions peritoneum is involved, the shown below to help you determine what’s causing your patient’s abdominal pain. pain may be poorly local- ized; as the parietal peri- toneum becomes involved, the pain may become local- Right upper ized. Most patients with quadrant or inflammatory abdominal epigastric pain Epigastric pain pain want to lie still. Right upper Left upper from the biliary quadrant quadrant from the stomach, • Ischemic pain is the most tree and duodenum, serious type of visceral or pancreas pain—-and, fortunately, the Periumbilical pain least common because the from the small Right lower Left lower affected area will become Suprapubic or quadrant quadrant intestine, appendix, necrotic if blood flow isn’t or proximal colon sacral pain from promptly restored. Sudden the rectum Hypogastric pain in onset, this pain is from the colon, extremely intense, progres- bladder, or uterus. sive in severity, and not Colonic pain may be relieved by analgesics. Like more diffuse than patients with inflammatory illustrated. pain, patients with ischemic pain won’t want to move or change positions. The most common cause of ischemic abdominal pain is strangu- Right hypochondriac Epigastric Left hypochondriac lated bowel.1

Assessment pointers Now let’s look at how to Right lumbar Umbilical Left lumbar begin your assessment of a patient with abdominal pain. Take a health history, gyne- cologic history for women, Left iliac (or inguinal) Right iliac (or inguinal) Hypogastric and family history of abdominal conditions such as gastroesophageal reflux disease (GERD), gallbladder disease, renal calculi, colon

36 | Nursing2008 | September www.nursing2008.com cancer, or inflammatory bowel disease. sounds may indicate an ileus. Hyper- Ask the patient when the pain active bowel sounds may indicate early began, where it’s located, and how he’d intestinal obstruction. Arterial bruits describe its quality and intensity. Ask if with both systolic and diastolic compo- the pain is constant or intermittent, if nents are abnormal sounds made by it wakes him at night, and if anything If you blood traveling through narrowed aggravates or relieves it. If he says that suspect arteries such as the aorta or renal, iliac, food worsens or relieves abdominal or femoral arteries. pain, ask him what kind of food. an aortic • Percussion can help you identify the Assess and document whether he has aneurysm, borders of organs such as the liver, as associated such as palpation may well as determine the presence of air or fever, nausea or vomiting, change in be contraindicated solid masses such as tumors. Normally bowel habits, weight loss, , you’ll hear tympany (a drumlike or rectal bleeding. or best left to sound) over the stomach and If he reports nausea and vomiting the physician. intestines, areas that normally are air and a change in bowel habits, ask if filled. You’ll hear dullness over solid he’s recently traveled, eaten food that (such as nonsteroidal anti-inflammatory areas such as the liver, spleen, tumors, was recalled, drunk water that might drugs) or has recently been diagnosed or other masses. have been contaminated, or gone with a condition that might be associ- • Palpation lets you assess local versus swimming in lakes or public pools. ated with abdominal symptoms, such generalized areas of tenderness, as well Ask about frequency of bowel move- as GERD. as check for masses and enlarged ments. If he reports , ask if the In children, abdominal migraine can organs. Palpation can go from light to diarrhea is liquid, loose, or a combina- cause abdominal pain. Look for a pat- deep, but keep in mind that a patient tion and whether he’s noticed blood in tern of symptoms, especially if the with abdominal pain may not tolerate the stool. abdominal pain is associated with abdominal palpation at all. He may If he’s had a change in bowel habits vomiting and is cyclical. Ask about fre- guard (tighten his abdominal muscles), without diarrhea, ask about the color quency, duration, and associated symp- preventing you from assessing the and consistency of the stool, whether it toms such as vomiting. Also ask about abdomen adequately via palpation. If floats or sinks, and if it’s associated a personal or family history of this happens, flexing his knees may with mucus or change in odor. migraines.1 relax the abdomen so you can palpate Vomiting that precedes abdominal Your physical assessment should it. If he’s very ticklish, you can cir- pain, or is associated with the onset of include inspection, auscultation, per- cumvent the tickle response by plac- abdominal pain, may suggest infection cussion, and palpation. ing his hand below yours and palpat- as a possible cause of pain. Abdominal • Inspect the abdomen for movement, ing the area first with his hand, then pain that began before vomiting may such as fluid waves or increased peri- switching hands so you can palpate.4 indicate or, more rarely, stalsis. Look for scars from past surg- If the presence of a bruit leads you to . Suspect cholecystitis in eries; the patient may have adhesions suspect that the patient has an aortic patients with right upper quadrant that could lead to bowel obstruction. aneurysm, palpation may be con- abdominal pain and a family history of Note the contour of the abdomen; gen- traindicated or best left to the physi- early gallbladder disease.2 Other risk eralized distension may indicate in- cian. factors for cholecystitis include being creased gas, but local bulges may indi- To assess for specific areas of tender- female, age 40 or older, and over- cate a distended bladder or a . ness, use specific palpation techniques. weight. Associated signs and symp- • Auscultate for bowel sounds or addi- Murphy’s sign evaluates gallbladder ten- toms may include vomiting and fever.3 tional sounds such as bruits. Normal derness and inflammation. Hook your As you continue your assessment, bowel sounds consist of peristaltic fingers under the patient’s right lower ask if the patient is taking new medica- clicks and gurgles occurring at a rate of ribs or press them under the ribs, then tions that might cause abdominal pain 5 to 34 per minute. Hypoactive bowel ask the patient to take a deep breath. A www.nursing2008.com September | Nursing2008 | 37 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 right lower quadrant • Often associated with fever. Clinical exam may show rebound tenderness and positive obturator, psoas, and Rovsing’s signs. • Complete blood cell count will show an increase in white blood cells with a shift to the left and increased neutrophils.

Cholecystitis • Pain in the right upper quadrant (toward the epigastric area) can radiate to the shoulder or back. • Nausea and vomiting may occur. • Biliary colic (pain that increases over 2 to 3 minutes and is sustained for 20 minutes or more) • Positive Murphy’s sign

Constipation • Possible colicky to sharp pain that can mimic appendicitis • Patient may have diffuse tenderness on palpation as well as 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.

Ectopic pregnancy, • Sudden onset of lower left or right quadrant pain ruptured • Possible vaginal bleeding

Gastroenteritis • Diffuse abdominal cramping, possibly with nausea, vomiting, diarrhea, and fever • Possible hyperactive bowel sounds, , and diffuse tenderness on palpation

Ileus or bowel • Diffuse pain that comes in cramping waves lasting 5 to 15 minutes 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, , and pleural effusion • Rare signs include Grey Turner and Cullen’s signs.

Peptic ulcer disease • Usually epigastric pain 1 to 3 hours 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 can be associated with fever, nausea, and vomiting. Pain increases with any motion. • Abdominal distension and rigidity. Rebound tenderness present but, unlike in appendicitis, is diffuse rather than localized. Guarding may be present. • Possible signs and symptoms of shock

38 | Nursing2008 | September www.nursing2008.com sharp increase in tenderness with a examination of vaginal secretions in sudden stop in inspiratory effort con- women, to rule out ectopic pregnancy stitutes a positive Murphy’s sign, indi- and infections such as bacterial vagi- cating acute cholecystitis. nosis or vulvovaginal candidiasis. Leave checking for rebound ten- • sexually transmitted disease testing derness for last because it may elicit in sexually active men and women. enough pain that the patient won’t Because some causes of The following imaging studies may let you touch his abdomen again. abdominal pain are be done: Push your fingers into the area of life-threatening, triaging • A CT scan may be the first imaging tenderness slowly and firmly, then patients quickly and accurately test performed because it’s more sen- quickly lift them away. Rebound ten- is crucial. sitive, specific, and accurate than a derness is present if the pain wors- plain radiographic abdominal series.2 ens when you withdraw your fin- • An abdominal/pelvic ultrasound is gers. Rebound tenderness suggests ) suggests irritation of more diagnostic than a plain X-ray peritoneal inflammation; for exam- the obturator muscle by an inflamed and can help clinicians identify renal ple, from appendicitis. appendix. stones, gallstones, appendicitis, and If you suspect that your patient has If you think the patient’s abdomi- gynecologic problems. appendicitis, check for Rovsing’s sign nal pain may be related to pyeloneph- • Abdominal plain film radiography and for referred rebound tenderness. ritis or renal calculi, assess for cos- may reveal stones, bowel dilation, Press deeply and evenly in the tovertebral angle tenderness. Place fluid levels indicating bowel obstruc- patient’s left lower quadrant, then the palm of one hand in the right cos- tion, and stool and gas patterns. quickly withdraw your fingers. Pain tovertebral angle and strike it with For details on signs and symptoms in the right lower quadrant during the ulnar surface of your fist. Repeat specific to common abdominal prob- left-sided pressure (a positive in the left costovertebral angle. Pain lems, see Some causes of acute abdomi- Rovsing’s sign) suggests appendicitis, with percussion suggests pyelo- nal pain. as does right lower quadrant pain on nephritis. Because the causes of abdominal quick withdrawal (referred rebound pain are so varied, so are the treat- tenderness). Diagnostic testing ments. Generally, surgery is indicated You can also assess for appendicitis and treatment for bowel obstruction, acute appen- by looking for a psoas or obturator The following lab studies may help nar- dicitis, a ruptured ovarian cyst, and sign. Place your hand just above the row down causes of abdominal pain: aortic aneurysm. Antibiotics will be patient’s right knee and ask him to • CBC count, for signs of infection, prescribed if the cause of pain is an raise his thigh against your resistance. cancer, and inflammation infection such as pyelonephritis or a Alternatively, ask him to turn onto his • complete metabolic profile, for lower urinary tract infection. left side; then extend his right leg at blood glucose level, renal or hepatic However, if the infection is due to an the hip. Flexing the leg at the hip dysfunction, electrolyte imbalances, abscess, surgical drainage may also be makes the psoas muscle contract; or problems related to low albumin performed. Abdominal pain due to extension stretches it. Increased level viral gastroenteritis will be treated abdominal pain on either maneuver • stool sample to look for infection or with fluids, bowel rest, and antiemet- (a positive ) suggests that parasites ics if the patient is over age 12. the psoas muscle is irritated by an • urinalysis to look for infection or inflamed appendix. evidence of renal calculi Your role To elicit the obturator sign, ask the • amylase and lipase levels, which Because some causes of abdominal patient to bend his right knee, then will be elevated in a patient with pan- pain are life-threatening, triaging flex his right thigh at the hip and creatic problems. patients quickly and accurately is rotate the leg internally at the hip to • Helicobacter pylori level to check for crucial. Other nursing interventions stretch the internal obturator muscle. peptic ulcer disease include ongoing assessments, manag- Right hypogastric pain (a positive • pregnancy test and microscopic ing the patient’s pain, providing emo- www.nursing2008.com September | Nursing2008 | 39 tional support, restoring fluid and was caused by GERD, hiatal hernia, Divide and conquer electrolyte balance, and specific inter- peptic ulcer disease, or diverticulitis, Although abdominal pain can be tricky ventions to treat the pain’s underlying teach him about foods to avoid as to diagnose and treat, remembering cause. If pain is associated with infec- well as how to time meals in relation which structures lie in which section tion, for example, you’ll also take to activities and bedtime. He should and understanding the different types steps to regulate your patient’s body avoid overeating in general and stay of pain can help you net clues to the temperature and administer antibi- away from fats, fried foods, spices, source of the patient’s pain so he gets otics as prescribed. coffee, tea, tomato products, and the help he needs—and fast. " Manage your patient’s pain with alcohol. (Some patients should avoid REFERENCES medications as ordered and nonphar- certain other foods as well.) Tell him 1. Miller SK, Alpert PT. Assessment and differ- macologic interventions, including not to eat within 2 to 3 hours before ential diagnosis of abdominal pain. The Nurse positioning, back rubs, and heating bedtime and not to lie down or exer- Practitioner. 31(7):39-47, July 2006. 2. MacKersie AB, et al. Nontraumatic acute ab- pads (if not contraindicated). cise immediately after eating. dominal pain: Unenhanced helical CT com- To protect your patient against Advise him to try to maintain a nor- pared with three-view acute abdominal series. Radiology. 237(1):114-122, October 2005. complications such as cardiac dys- mal weight and to lose weight if he’s 3. Trowbridge RL, et al. Does this patient have rhythmias and seizures, maintain overweight or obese; the risk of GERD acute cholecystitis? JAMA. 289(1):80-86, Janu- electrolyte balance. Patients with and gallbladder disease increases with ary 1, 2003. diarrhea, vomiting, or fever are the weight. He should reduce stress, quit 4. Smeltzer SC, et al. Brunner & Suddarth’s Text- book of Medical-Surgical Nursing, 11th edition. most prone to electrolyte imbalances. smoking, decrease or eliminate alco- Lippincott Williams & Wilkins, 2008. Make sure electrolyte levels are evalu- hol consumption, and reduce his use Susan Simmons Holcomb is a nurse practitioner at ated before electrolyte replacement of medications that can damage the Olathe (Kan.) Medical Services, Inc., and a consul- begins and periodically reassessed esophagus, such as corticosteroids and tant in continuing nursing education at Kansas City (Kan.) Community College. during replacement. nonsteroidal anti-inflammatory drugs, The author has disclosed that she has no financial If your patient’s abdominal pain including aspirin. relationships related to this article.

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