acute bdomen - lippincott williams &...

34 l Nursing2009CriticalCare l Volume 4, Number 4 www.nursing2009criticalcare.com

DDetermining the cause of abdom-inal pain is often tricky and time-consuming. Because pain can benonspecific and the abdomen hasmany organs and structures,numerous potential causes haveto be ruled out as clinicians try topin down the source of pain.

Reasons for abdominal painfall into three broad categories:inflammation, organ distension,and ischemia. In some cases,the underlying cause is life-threatening, so a fast, accurateassessment is essential. In thisarticle, I’ll describe how to assessa patient with abdominal painand intervene appropriately. Let’sstart by looking at a couple ofhypothetical situations.

Laurie Greene, 42, comes toyour ED complaining of intermit-tent abdominal pain and bloatingthat she’s had for a month. Shereports no change in bowel habitsand no other significant medicalhistory.

When you examine Ms. Greene,you find a protrusion in the umbil-

ical, hypogastric, and left iliacregions. This area is dull to per-cussion; when you palpate it, younote a firm mass. A completeblood cell (CBC) count revealssevere anemia. A stat computedtomography (CT) scan of theabdomen and pelvis reveals abenign, totally encapsulated leftovarian tumor. The tumor isremoved, her anemia is resolved,and she’s doing well.

Patrick Leeson, 45, comes incomplaining of dull, achy peri-umbilical pain that migrated tohis right lower quadrant. He saysit started about 24 hours ago. Hehas no nausea or vomiting orchanges in bowel habits. He sayshe was treated for testicular can-cer 10 years ago and it beganwith abdominal pain similar towhat he’s experiencing now.

Mr. Leeson has an elevatedwhite blood cell count with a leftshift, possibly indicating a bacter-ial infection or inflammation. ACT scan of the abdomen andpelvis shows an inflamed appen-

dix. Mr. Leeson is admitted to thehospital for an appendectomyand recovers completely.

Narrowing things downSo where do you start when apatient has abdominal pain?Anatomically the abdomen isdivided into four quadrants andnine regions. You can use thesedivisions to narrow down thearea of complaint and documentyour findings (see Where does ithurt?). Remember, however, thatabdominal pain can be referredto many locations, including theshoulders, cardiac area (subster-nal and left chest), low and midback, and groin.

Besides pain location, the kindof pain provides clues to its cause.Type A delta nerve fibers inner-vate cutaneous tissues and theparietal peritoneum; stimulationfrom an irritant such as pus, blood,bile, or urine often leads to local-ized pain. Type C fibers innervatevisceral tissue, so visceral pain ismore generalized and deeper.

cute bdomen:

So many things—some life-threatening—

can cause abdominal pain.Here’s how to capture the clues

quickly and accurately.

ABy Susan Simmons Holcomb, ARNP-BC, PhD

What a pain!

www.nursing2009criticalcare.com July l Nursing2009CriticalCare l 35


Acute abdomen: What a pain!

Visceral pain can be dividedinto three subtypes:• Tension pain is caused byorgan distension, as from bowelobstruction or constipation.Blood accumulation from traumaand pus or fluid accumulationfrom infection or other causesalso can cause this pain. Tension

pain that’s described as colickymay be caused by increasedperistaltic contractile force as thebowel tries to eliminate irritatingsubstances. Patients with tensionpain may have trouble gettingcomfortable and squirm a lottrying to find a comfortableposition.

• Inflammatory pain may arisefrom inflammation of either thevisceral or parietal peritoneum,as in acute appendicitis. This painmay be described as deep andboring. Initially, if the visceralperitoneum is involved, the painmay be poorly localized; as theparietal peritoneum becomes

Right upper quadrant or

epigastric pain

from the biliary tree and liver

Suprapubic or sacral pain

from the rectum

Epigastric pain

from the stomach, duodenum, or pancreas

Periumbilical pain

from the small intestine,appendix, or proximal colon

Hypogastric pain

from the colon, bladder, oruterus. Colonic pain may be

more diffuse than illustrated.

Where does it hurt?You can use the four abdominal regions shown here and the nine abdominal regions shown below to help youdetermine what’s causing your patient’s abdominal pain.

Right hypochondriac

Right lumbar

Right iliac (or inguinal)

Epigastric

Umbilical

Hypogastric

Left lumbar

Left iliac (or inguinal)

Left hypochondriac

Right lower quadrant

Right upper quadrant Left upper

quadrant

Left lower quadrant

involved, the pain may becomelocalized. Most patients withinflammatory abdominal painwant to lie still. • Ischemic pain is the most seri-ous type of visceral pain—and,fortunately, the least commonbecause the affected area willbecome necrotic if blood flowisn’t promptly restored. Suddenin onset, this pain is extremelyintense, progressive in severity,and not relieved by analgesics.Like patients with inflammatorypain, patients with ischemic painwon’t want to move or changepositions. The most commoncause of ischemic abdominal painis strangulated bowel.1

Assessment pointersNow let’s look at how to beginyour assessment of a patient withabdominal pain. Take a healthhistory, gynecologic history forwomen, and family history ofabdominal conditions such asgastroesophageal reflux disease(GERD), gallbladder disease,renal calculi, colon cancer, orinflammatory bowel disease.

Ask the patient when the painbegan, where it’s located, andhow he’d describe its quality andintensity. Ask if the pain is con-stant or intermittent, if it wakeshim at night, and if anythingaggravates or relieves it. If hesays that food worsens or relievesabdominal pain, ask him whatkind of food. Assess and docu-ment whether he has associatedsigns and symptoms such asfever, nausea or vomiting, changein bowel habits, weight loss,heartburn, or rectal bleeding.

If he reports nausea and vomit-ing and a change in bowel habits,ask if he’s recently traveled,eaten food that was recalled,

drunk water that might havebeen contaminated, or goneswimming in lakes or publicpools. Ask about frequency ofbowel movements. If he reportsdiarrhea, ask if the diarrhea isliquid, loose, or a combinationand whether he’s noticed bloodin the stool.

If he’s had a change in bowelhabits without diarrhea, askabout the color and consistencyof the stool, whether it floats orsinks, and if it’s associated withmucus or change in odor.

Vomiting that precedes abdom-inal pain, or is associated withthe onset of abdominal pain, maysuggest infection as a possiblecause of pain. Abdominal painthat began before vomiting mayindicate appendicitis or, morerarely, cholecystitis. Suspectcholecystitis in patients withright upper quadrant abdominalpain and a family history of earlygallbladder disease.2 Other riskfactors for cholecystitis includebeing female, age 40 or older, andoverweight. Associated signs andsymptoms may include vomitingand fever.3

As you continue your assess-ment, ask if the patient is takingnew medications that mightcause abdominal pain (such as

nonsteroidal anti-inflammatorydrugs) or has recently been diag-nosed with a condition that mightbe associated with abdominalsymptoms, such as GERD.

In children, abdominalmigraine can cause abdominalpain. Look for a pattern of symp-toms, especially if the abdominalpain is associated with vomitingand is cyclical. Ask about fre-quency, duration, and associatedsymptoms such as vomiting. Alsoask about a personal or familyhistory of migraines.1

Your physical assessmentshould include inspection, auscul-tation, percussion, and palpation.• Inspect the abdomen for move-ment, such as fluid waves orincreased peristalsis. Look forscars from past surgeries; thepatient may have adhesions thatcould lead to bowel obstruction.Note the contour of the abdomen;generalized distension may indi-cate increased gas, but localbulges may indicate a distendedbladder or a hernia.• Auscultate for bowel sounds oradditional sounds such as bruits.Normal bowel sounds consist ofperistaltic clicks and gurglesoccurring at a rate of 5 to 34 perminute. Hypoactive bowelsounds may indicate an ileus.Hyperactive bowel sounds mayindicate early intestinal obstruc-tion. Arterial bruits with bothsystolic and diastolic componentsare abnormal sounds made byblood traveling through narrowedarteries such as the aorta orrenal, iliac, or femoral arteries. • Percussion can help you identifythe borders of organs such as theliver, as well as determine thepresence of air or solid massessuch as tumors. Normally you’llhear tympany (a drumlike sound)


If you suspect an aortic aneurysm,

palpation may be contraindicated

or best left to the physician.



Some causes of acute abdominal pain

Cause

Abdominal aortic aneurysm

Appendicitis

Cholecystitis

Constipation

Diverticulitis

Ectopic pregnancy, ruptured

Gastroenteritis

Ileus or bowel obstruction

Pancreatitis

Peptic ulcer disease

Peritonitis

Signs and symptoms

• Usually asymptomatic, but may cause back and abdominal pain• Pulsatile mass may be palpable.

• 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.

• Pain in the right upper quadrant (toward the epigastric area) can radiate to the shoulder orback.

• 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

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

• 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 quad-

rant.

• Sudden onset of lower left or right quadrant pain • Possible vaginal bleeding

• Diffuse abdominal cramping, possibly with nausea, vomiting, diarrhea, and fever• Possible hyperactive bowel sounds, abdominal distension, and diffuse tenderness on palpa-

tion

• Diffuse pain that comes in cramping waves lasting 5 to 15 minutes• 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

• 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• Rare signs include Grey Turner and Cullen’s signs.

• 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.

• Acute diffuse abdominal pain that can be associated with fever, nausea, and vomiting. Painincreases 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

over the stomach and intestines,areas that normally are air filled.You’ll hear dullness over solidareas such as the liver, spleen,tumors, or other masses.

If you think the patient’sabdominal pain may be relatedto pyelonephritis or renal calculi,assess for costovertebral angletenderness. Place the palm ofone hand in the right costoverte-bral angle and strike it with theulnar surface of your fist. Repeatin the left costovertebral angle.Pain with percussion suggestspyelonephritis.• Palpation lets you assess localversus generalized areas of ten-derness, as well as check formasses and enlarged organs.Palpation can go from light todeep, but keep in mind that apatient with abdominal pain maynot tolerate abdominal palpationat all. He may guard (tighten hisabdominal muscles), preventingyou from assessing the abdomenadequately via palpation. If thishappens, flexing his knees mayrelax the abdomen so you canpalpate it. If he’s very ticklish,you can circumvent the tickleresponse by placing his handbelow yours and palpating thearea first with his hand, thenswitching hands so you can pal-pate.4 If the presence of a bruitleads you to suspect that thepatient has an aortic aneurysm,palpation may be contraindicatedor best left to the physician.

To assess for specific areas oftenderness, use specific palpationtechniques. Murphy’s sign evalu-ates gallbladder tenderness andinflammation. Hook your fingersunder the patient’s right lowerribs or press them under the ribs,then ask the patient to take adeep breath. A sharp increase

in tenderness with a sudden stopin inspiratory effort constitutes apositive Murphy’s sign, indicat-ing acute cholecystitis.

Leave checking for reboundtenderness for last because itmay elicit enough pain that thepatient won’t let you touch hisabdomen again. Push your fin-gers into the area of tendernessslowly and firmly, then quicklylift them away. Rebound tender-ness is present if the pain wors-ens when you withdraw yourfingers. Rebound tenderness sug-gests peritoneal inflammation;for example, from appendicitis.

If you suspect that yourpatient has appendicitis, checkfor Rovsing’s sign and for referredrebound tenderness. Press deeplyand evenly in the patient’s leftlower quadrant, then quicklywithdraw your fingers. Pain inthe right lower quadrant duringleft-sided pressure (a positiveRovsing’s sign) suggests appen-dicitis, as does right lower quad-rant pain on quick withdrawal(referred rebound tenderness).• Special techniques to assessfor appendicitis include lookingfor a psoas or obturator sign.Place your hand just above thepatient’s right knee and ask him

to raise his thigh against yourresistance. Alternatively, askhim to turn onto his left side;then extend his right leg at thehip. Flexing the leg at the hipmakes the psoas muscle con-tract; extension stretches it.Increased abdominal pain oneither maneuver (a positivepsoas sign) suggests that thepsoas muscle is irritated byan inflamed appendix.

To elicit the obturator sign,ask the patient to bend his rightknee, then flex his right thigh atthe hip and rotate the leg inter-nally at the hip to stretch theinternal obturator muscle. Righthypogastric pain (a positiveobturator sign) suggests irrita-tion of the obturator muscle byan inflamed appendix.

Diagnostic testing and treatmentThe following lab studies mayhelp narrow down causes ofabdominal pain:• CBC count, for signs of infec-tion, cancer, and inflammation• complete metabolic profile,for blood glucose level, renal orhepatic dysfunction, electrolyteimbalances, or problems relatedto low albumin level• stool sample to look for infec-tion or parasites• urinalysis to look for infectionor evidence of renal calculi• amylase and lipase levels,which will be elevated in apatient with pancreatic problems. • Helicobacter pylori level tocheck for peptic ulcer disease • pregnancy test and microscop-ic examination of vaginal secre-tions in women, to rule outectopic pregnancy and infec-tions such as bacterial vaginosisor vulvovaginal candidiasis.


The causes ofabdominal pain arevaried, and so arethe treatments,

which range frommedicationsto surgery.

• sexually transmitted diseasetesting in sexually active menand women.

The following imaging studiesmay be done:• A CT scan may be the firstimaging test performed becauseit’s more sensitive, specific, andaccurate than a plain radi-ographic abdominal series.2

• An abdominal/pelvic ultra-sound is more diagnosticthan a plain X-ray and can helpclinicians identify renal stones,gallstones, appendicitis, andgynecologic problems.• Abdominal plain film radiogra-phy may reveal stones, boweldilation, fluid levels indicatingbowel obstruction, and stool andgas patterns.

For details on signs and symp-toms specific to common abdom-inal problems, see Some causes ofacute abdominal pain.

Because the causes of abdomi-nal pain are so varied, so are thetreatments. Generally, surgery isindicated for bowel obstruction,acute appendicitis, a rupturedovarian cyst, and aortic aneurysm.Antibiotics will be prescribed ifthe cause of pain is an infectionsuch as pyelonephritis or a lowerurinary tract infection. However,if the infection is due to anabscess, surgical drainage mayalso be performed. Abdominalpain due to viral gastroenteritiswill be treated with fluids, bowelrest, and antiemetics if thepatient is over age 12.

Your roleBecause some causes of abdominalpain are life-threatening, triagingpatients quickly and accuratelyis crucial. Other nursing interven-tions include ongoing assessments,managing the patient’s pain,

providing emotional support,restoring fluid and electrolyte bal-ance, and specific interventions totreat the pain’s underlying cause.If pain is associated with infec-tion, for example, you’ll also takesteps to regulate your patient’sbody temperature and adminis-ter antibiotics as prescribed.

Manage your patient’s painwith medications as orderedand nonpharmacologic inter-ventions, including positioning,back rubs, and heating pads(if not contraindicated).

To protect your patient againstcomplications such as cardiacdysrhythmias and seizures, main-tain fluid and electrolyte balance.Patients with diarrhea, vomiting,or fever are the most prone tofluid and electrolyte imbalances.Make sure electrolyte levelsare evaluated before electrolytereplacement begins and periodi-cally reassessed during replace-ment. Maintain accurate intakeand output records.

If your patient’s abdominalpain was caused by GERD, hiatalhernia, peptic ulcer disease, ordiverticulitis, teach him aboutfoods to avoid as well as how totime meals in relation to activities

and bedtime. He should avoidovereating in general and stayaway from fats, fried foods,spices, coffee, tea, tomato prod-ucts, and alcohol. (Some patientsshould avoid certain other foodsas well.) Tell him not to eat with-in 2 to 3 hours before bedtimeand not to lie down or exerciseimmediately after eating.

Advise him to try to maintaina normal weight and to loseweight if he’s overweight orobese; the risk of GERD and gall-bladder disease increases withweight. He should reduce stress,quit smoking, decrease or elimi-nate alcohol consumption, andreduce his use of medicationsthat can damage the esophagus,such as corticosteroids and nons-teroidal anti-inflammatory drugs,including aspirin.

Divide and conquerAlthough abdominal pain canbe tricky to diagnose and treat,remembering which structures liein which section and understand-ing the different types of pain canhelp you net clues to the sourceof the patient’s pain so he gets thehelp he needs—and fast. ❖

REFERENCES1. Miller SK, Alpert PT. Assessment anddifferential diagnosis of abdominal pain.The Nurse Practitioner. 31(7):39-47, July2006.

2. MacKersie AB, et al. Nontraumatic acuteabdominal pain: Unenhanced helical CTcompared with three-view acute abdominalseries. Radiology. 237(1):114-122, October2005.3. Trowbridge RL, et al. Does this patienthave acute cholecystitis? JAMA. 289(1):80-86, January 1, 2003.4. Smeltzer SC, et al. Brunner & Suddarth’sTextbook of Medical-Surgical Nursing, 11th edi-tion. Lippincott Williams & Wilkins, 2008.

Susan Simmons Holcomb is a nurse practition-erat Olathe (Kan.) Medical Services, Inc., and aconsultant in continuing nursing education atKansas City (Kan.) Community College.

This article originally appeared in the Septemberissue of Nursing2008.



Because some causesof abdominal pain are

life-threatening,triaging patients

quickly and accuratelyis crucial.

acute bdomen - lippincott williams &...

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