Acute Abdomen - Shaking Down the Suspects

8/4/2019 Acute Abdomen - Shaking Down the Suspects

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Acute abdomen:

Shaking down theAcute abdominal pain can be difficult to diagnose, requiringastute assessment skills and knowledge of abdominal anatomyto discover its cause. We show you how to quickly and accuratelyuncover 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.

2.3ANCC

CONTACT HOURS


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suspects

www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 43

Determining the cause of acute abdominalpain is often complex due to the many or-gans in the abdomen and the fact that painmay be nonspecific. Acute abdomen is ageneral diagnosis, typically referring to se-vere abdominal pain that occurs suddenlyover a short period (usually no longer than7 days) and often requires surgical interven-

tion. Symptoms may be severe and progress

rapidly, indicating a life-threatening process,so fast and accurate assessment is essential.

In this article, Ill describe how to assess apatient with acute abdominal pain and inter-vene appropriately.

What a pain!Acute abdominal pain is one of the top

three symptoms of patients presenting in

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44 Nursing made Incredibly Easy! January/February 2010 www.NursingMadeIncrediblyEasy.com

the ED. Reasons for acute abdominal painfall into six broad categories: inflammatorymay be a bacterial cause,such as acute appendicitis, diverticulitis, orpelvic inflammatory disease, or a chemicalcause, such as perforation of a peptic ulcerin which gastric contents cause a peritonealinfection or abscess mechanicalsuch as an ileus orobstruction neoplasticsuch as a tumor causing ob-

struction or impinging on nerves or vessels vascularsuch as a

superior mesenteric clotor atherosclerosis congenitalsuch

as esophageal atresia(the esophagus doesnt

connect normally withthe stomach), hernia, or malrota-

tion of the bowel traumaticsuch as blunt trauma, liverlaceration, or major organ damage sus-tained in a motor vehicle accident.

The four most common causes of acuteabdominal pain requiring surgery are acuteappendicitis, acute cholecystitis, small

bowel obstruction, and gynecologic disor-ders (see Some causes of acute abdominalpain). However, over 30% of patients withacute abdomen have nonspecific abdomi-nal pain, or pain for which no cause orsource can be identified. Its also possiblethat the patient is pain free or has minimalpain, which occurs more often in olderpatients, children, and women in the thirdtrimester of pregnancy.

Presentation may be confusing anddifficult for the patient to describe. Forinstance, a hepatic abscess may radiate tothe diaphragm and shoulder area, whereasappendicitis may present with pain in thepsoas muscle, and cholecystitis with pain inthe low and mid back (see Common sites ofreferred abdominal pain). The pain may belocalized or more generalized and deeper(visceral), sharp and constant or dull andintermittent, or any combination of these.

Visceral pain can be divided into threesubtypes: tension pain. This type of pain is caused

by organ distension, such as in bowel ob-struction or constipation. Blood accumula-tion from trauma and pus or fluid accumu-lation from infection may also cause tensionpain. Tension pain thats described as col-icky may be caused by increased peristalticcontractile force, such as when the boweltries to eliminate irritating substances. Pa-

tients with tension pain may have troublegetting comfortable. inflammatory pain. This type of painmay arise from inflammation of either thevisceral or parietal peritoneum, such as inacute appendicitis. It may be described asdeep and like a boring sensation. Initially,if the visceral peritoneum is involved, thepain may be poorly localized; as the parietalperitoneum becomes involved, the painmay become localized. Most patients withinflammatory abdominal pain want to liestill.

ischemic pain. This type of pain is themost serious. Sudden in onset, ischemicpain is extremely intense, progressive inseverity, and not relieved by analgesics.Like patients with inflammatory pain, pa-tients with ischemic pain wont want tomove or change positions. The most com-mon cause of ischemic abdominal pain isa strangulated bowel.

Narrowing things downSo where do you start when a patient hasabdominal pain? Besides identifying the

kind of pain the patient is experiencing,the pains location can provide clues to itscause. So its imperative that you know theanatomy and physiology of the abdominalarea. The abdomen is divided into four ar-eas, or quadrants: the upper left quadrant,the upper right quadrant, the lower leftquadrant, and the lower right quadrant(see Where does it hurt?). It can further be di-vided into nine regions (see Understandingthe abdominal regions).

Your patientsage may give

you clues. Forexample, acute

pancreatitisis usually seen

in adults.

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Some causes of acute abdominal painCause 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

Nausea and vomiting may occur

Biliary colic (pain that increases over 2 to 3 min and is sustained for

20 min or more)

Positive Murphy sign

Constipation Possible col icky to sharp pain that can mimic appendicit is

The patient may have diffuse tenderness on palpation, as well as

palpable stool

Diverticuli tis 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 withperitoneal signs; may indicate perforation

Hematemesis or melena suggests hemorrhage

Peritonit is 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, its diffuse

rather than localized

Guarding may be present

Possible signs and symptoms of shock

There are manycauses of acute

abdomen; usethis chart to

help narrowthem down.


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The patients age may also help narrowthe diagnosis. For example, appendicitis ismore common in the younger adolescent,whereas an obstruction of the large intestineis more common in patients over age 40.Acute pancreatitis or a perforated ulcer ismore often seen in the adult patient.Cholecystitis may be seen in a youngerpatient, but is more commonly seen inadults. Acute abdominal pain caused byvascular reasons is more common in patients

over age 70.Take a health history, gynecologic history

for a female patient, and family history ofabdominal conditions, such as gastroe-sophageal reflux disease (GERD), gallblad-der disease, renal calculi, colon cancer, orinflammatory bowel disease. Patients can

often provide clues to guide you to the cor-rect diagnosis; for example, a patient with ahistory of diabetes may have bowel ischemiaor renal dysfunction. A patient with alco-holism may have pancreatitis, liver disease,or poor renal functioning.

Ask the patient when the pain began,where its located, and how hed describe itsquality and intensity. Ask if the pain is con-stant or intermittent, if it wakes him at night,and if anything aggravates it or relieves it.

Remember to ask open-ended questions,such as What makes the pain better?, ratherthan Does laying down make the pain bet-ter? Determine where the pain was when itbegan because it may be different from whereit is now. Also, ask the patient what he wasdoing when the pain began. For example, if


Common sites of referred abdominal pain

Pancreatitis

Perforated

duodenal ulcer

Penetrating

duodenal

ulcer

Pancreatitis,

renal colic

Rectal lesions

Liver Heart

Biliary colicRenal

colic

Cholecystitis,

pancreatitis,duodenal ulcer

Small

intestine pain

Ureteral colic

Colon pain

Appendicitis Cholecystitis


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he indicates that the pain began after eating,ask him what kind of food he ate.

Continue your assessment by determin-ing the presence of nausea or vomiting,diarrhea or constipation, anorexia, recenttravel, or changes in medications (such astaking nonsteroidal anti-inflammatorydrugs [NSAIDs], which may cause abdomi-nal pain). Vomiting that precedes abdomi-nal pain, or is associated with the onset ofabdominal pain, may suggest infection as a

possible cause of pain. Abdominal painthat began before vomiting may indicateappendicitis or, more rarely, cholecystitis.If he reports diarrhea, ask if the diarrhea isliquid, loose, or a combination and whetherhe has noticed blood in the stool. If he hashad a change in bowel habits without diar-rhea, ask about the color and consistency ofthe stool, whether it floats or sinks, and ifits associated with mucus or change inodor. If he reports recent travel, he mayhave drank contaminated water or goneswimming in lakes or public pools.

Assess for jaundice, melena (black, tarrystool), hematochezia (maroon-coloredstool), hematemesis (vomiting blood), andhematuria (blood in the urine). Look at thepatients hemodynamic status. Does hehave a fever, rigors, hypotension, tachycar-dia, or pallor? Has he had a change in men-tal status? Often the patients position cangive clues as to the etiology of the pain:Writhing in pain is more representative ofcolicky pain, whereas knees pulled up and

flexed is more diagnostic of peritonitis. Forsigns and symptoms specific to commonabdominal problems, see Some causes ofacute abdominal pain.

Lets get physicalNext, conduct a physical assessment in thisorder: inspection, auscultation, percussion,and palpation (seeAssessing the abdomen).

Inspectthe abdomen for movement,such as fluid waves or increased peristal-sis. Look for scars from past surgeries; thepatient may have adhesions that could lead


Where does it hurt?

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, appen-

dix, or proximal colon

Hypogastric pain

from the colon, bladder, or

uterus. Colonic pain may be more

diffuse than illustrated.

Right lower

quadrant

Right upper

quadrant

Left upper

quadrant

Left lower

quadrant


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to bowel obstruction. Note the contour ofthe abdomen: Generalized distension mayindicate increased gas, but local bulgesmay indicate a distended bladder or ahernia.Auscultate the abdomen for bowel sounds

or additional sounds such as bruits. Normalbowel sounds consist of peristaltic clicks andgurgles occurring at a rate of 5 to 34 perminute. Hypoactive bowel sounds mayindicate an ileus. Hyperactive bowel sounds

may indicate early intestinal obstruction.Arterial bruits with both systolic and dias-tolic components are abnormal sounds

made by blood traveling through narrowedarteries such as the aorta or renal, iliac, orfemoral arteries.

Percuss to identify the borders of organsand to determine the presence of air or solidmasses such as tumors. Normally youllhear tympany (a drumlike sound) over thestomach and intestinesareas that are nor-mally filled with air. Youll hear dullnessover solid areas such as the liver, spleen,tumors, or other masses. If you think the

patients abdominal pain may be related topyelonephritis or renal calculi, assess forcostovertebral angle tenderness. Place the

Understanding the abdominal regions

Hypogastric (pubic)

Contains a portion of the sigmoid colon,

urinary bladder and ureters, and portions of

the small intestine

Umbilical

Includes sections of the small and large in-

testines, inferior vena cava, and abdominal

aorta

Epigastric

Contains most of the pancreas and por-

tions of the stomach, liver, inferior vena cava,

abdominal aorta, and duodenum

Right and left iliac (inguinal)

Include portions of the small and large in-

testines

Right and left lumbar (lateral)

Include portions of the small and large in-

testines and portions of the kidneys

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

Right

hypochondriac

region

Epigastric

region

Left

hypochondriac

region

Right lumbar

(lateral)

region

Umbilical

region

Left lumbar

(lateral)

region

Right iliac

(inguinal)

region

Hypogastric

region

Left iliac

(inguinal)

region


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A positiveMurphy sign

means troublefor me!

palm of one hand in the right costovertebralangle and strike it with the ulnar surfaceof your fist. Repeat in the left costoverte-

bral angle. Pain with percussion suggestspyelonephritis.

Palpate to assess local versus generalizedareas of tenderness, as well as to check formasses and enlarged organs. Palpation cango from light to deep, but keep in mind thata patient with abdominal pain may not toler-ate abdominal palpation at all. He may tight-

en his abdominal muscles, preventing youfrom assessing the abdomen adequately viapalpation. If this happens, flexing his kneesmay relax the abdomen so you can palpateit. If the presence of a bruit leads you to sus-pect that the patient has an aortic aneurysm,palpation may be contraindicated or best leftto the healthcare provider.

To assess for specific areas of tenderness,use specific palpation techniques. Murphysign evaluates gallbladder tenderness andinflammation. Hook your fingers underthe patients right lower ribs or press them

under his ribs, then ask him to take a deepbreath. A sharp increase in tenderness witha sudden stop in inspiratory effort consti-tutes a positive Murphy sign, indicatingacute cholecystitis.

If you suspect that your patient hasappendicitis, check for Rovsing sign and forreferred rebound tenderness. Press deeplyand evenly in the patients left lower quad-rant, then quickly withdraw your fingers.Pain in the right lower quadrant during left-sided pressure (a positive Rovsing sign) sug-gests appendicitis, as does right lower quad-

rant pain on quick withdrawal (referredrebound tenderness).

Other techniques to assess for appendici-tis include looking for a psoas or obturatorsign. Place your hand just above thepatients right knee and ask him to raise histhigh against your resistance. Alternatively,ask him to turn onto his left side and thenextend his right leg at the hip. Flexingthe leg at the hip makes the psoas musclecontract; extension stretches it. Increased

abdominal pain on either maneuver (a posi-tive psoas sign) suggests that the psoas mus-cle is irritated by an inflamed appendix. Toelicit the obturator sign, ask the patient to

bend his right knee, then flex his right thighat the hip and rotate the leg internally at thehip to stretch the internal obturator muscle.Right hypogastric pain (a positive obturatorsign) suggests irritation of the obturatormuscle by an inflamed appendix.

Diagnostic tools ofthe tradeAfter a complete history and physicalare obtained, imaging studies may not

be necessary for all acute abdomenpatients. If diagnostic testing is indi-cated, a computed tomography (CT)scan, an abdominal/pelvic ultra-sound, or an abdominal X-raymay be ordered.

A CT scan is the most frequentlyused tool for diagnosing acuteabdominal pain because its more spe-

cific, sensitive, and accurate than an X-ray. For acute abdomen, the CT scan mayinclude an I.V. or oral contrast medium andpossibly a rectal contrast medium. However,some patients will be unable to tolerate oralcontrast, such as a patient whos vomiting,unable to swallow, or is suspected of havinga bowel obstruction. With any kind of con-trast medium, it must be determined if thepatient has adequate renal functioning toclear it and that he isnt allergic to it.

Ultrasound is often used to evaluate thekidneys, liver, gallbladder, pancreas, spleen,

and abdominal aorta or other blood vessels.It can help identify renal stones, gallstones,appendicitis, and gynecologic problems.Because images are in real time, they canshow movement of an organ and bloodflow. Its fast, safe, and doesnt alwaysrequire any preliminary preparation orN.P.O. status. Although ultrasound may not

be the only test needed, it can help narrowthe differential diagnoses and assist in deter-mining the next step.


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The abdominal X-ray is also of use. It mayreveal fluid levels indicating bowel obstruc-tion, ileus, and stool and gas patterns. It canalso be used to identify problems with theurinary system such as kidney stones, ascites,abdominal masses, foreign objects, and injuryto the abdominal tissues.

In addition to imaging studies, lab studiesthat may help narrow the cause of acuteabdominal pain include: complete blood cell count for signs of

infection, cancer, and inflammation complete metabolic profile for

blood glucose levels, renal orhepatic dysfunction, electrolyteimbalances, or problems related tolow albumin level

stool sample to look for infectionor parasites urinalysis to look for infection or

evidence of renal calculi amylase and lipase levels, which will

be elevated in a patient with pancreaticproblems

Helicobacter pylori level to check for pepticulcer disease pregnancy test and microscopic examina-tion of vaginal secretions in women to ruleout ectopic pregnancy and infections suchas bacterial vaginosis or vulvovaginal can-didiasis sexually transmitted disease testing insexually active men and women.

Did someone say surgery?One of the primary goals when diagnosinga patient with acute abdomen is to deter-

mine if surgery is necessary and the timingof surgery. A patient presenting as toxicand unstable may need time in the CCU

before surgery is performed. However, thepatient may also need immediate surgery ifthe risk of waiting could be life-threatening.The balance of risk versus benefit must beweighed in treating the critically ill patientwith acute abdominal pain.

Generally, surgery is indicated for bowelobstruction, acute appendicitis, a ruptured

ovarian cyst, and aortic aneurysm. Antibioticswill be prescribed if the cause of pain is aninfection such as pyelonephritis or a lowerurinary tract infection. If the infection is dueto an abscess, surgical drainage may also

be performed. Abdominal pain due to viralgastroenteritis will be treated with fluids,

bowel rest, and antiemetics if the patient isover age 12.

Treatment is, of course, based on the diag-nosis. Surgery isnt always necessary.

Interventions galoreTriaging patients quickly and accurately iscrucial because some causes of abdominalpain are life-threatening. Other nursinginterventions include ongoing assessments,managing the patients pain, restoring fluidand electrolyte balance, specific interven-tions to treat the pains underlying cause,and providing emotional support.

Immediately report to the healthcareprovider any symptoms that indicate shockor instability. If the acute abdomen symp-

toms occur while the patient is hospitalizedfor another illness, reviewing all previouscare may shed light on the etiology of thepain. Assess previous lab results, changes inmedications, dye administration during test-ing, and treatment outcomes.

Manage your patients pain with medica-tions as ordered and nonpharmacologicinterventions, including positioning, backrubs, and heating pads (if not contraindi-cated). It was previously thought that pro-viding pain medication to a patient withacute abdomen would mask the pain and

make it more difficult to diagnose; however,this is an unfounded belief. Pain manage-ment will depend on the severity of the pain.If opioid management is needed, morphineis the drug of choice. If the patient is allergicto morphine, meperidine or ketorolac may

be ordered instead.To protect your patient against complica-

tions, such as cardiac dysrhythmias andseizures, you must maintain his fluid andelectrolyte balance. Patients with diarrhea,

If I have aproblem, your

patient willprobably need

surgery.


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vomiting, or fever are the most prone to suchimbalances. Make sure electrolyte levels areevaluated before electrolyte replacementbegins and periodically reassessed duringreplacement. Maintain accurate intake andoutput records.

If your patients abdominal pain wascaused by GERD, hiatal hernia, peptic ulcerdisease, or diverticulitis, teach him aboutfoods to avoid and how to time meals in rela-tion to activities and bedtime. He should

avoid overeating in general and stay awayfrom fats, fried foods, spices, coffee, tea,tomato products, and alcohol. Tell him not to

eat within 2 to 3 hours of bedtime and not tolie down or exercise immediately after eating.Advise him to try to maintain a normalweight and to lose weight if hes overweightor obese because the risk of GERD and gall-bladder disease increases with weight. Heshould reduce stress, quit smoking, decreaseor eliminate alcohol consumption, andreduce his use of medications that can dam-age the esophagus, such as corticosteroidsand NSAIDs (including aspirin).

Provide emotional support for the patientand his family. Let them know the plan fordiagnosing the pain and the results of any

Assessing the abdomen

Percussing the abdomen

Inspecting the abdomen Auscultating the abdomen

Palpating the abdomen


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Acute abdomen: Shaking down the suspects

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diagnostic testing. Provide instruction onpain management and positions of comfort.Instruct the patient on the use of the painmedication, how often he can receive it, andto report ineffectiveness or a reaction such asitching. After a diagnosis is made, providethe patient with information on treatmentoptions and how his hospital stay may pro-ceed. If surgery is indicated, discuss with thepatient and his family what will happen andwhen he can anticipate going to the OR.

Allow family members to visit before surgeryand keep them updated.

Follow the cluesAlthough acute abdominal pain can be dif-ficult to diagnose, knowing the anatomyand physiology of the abdomen and under-

standing the different types of abdominalpain can help you uncover clues to the causeof your patients pain so he can receive themost timely treatment possible.

Learn more about itAnatomy & Physiology Made Incredibly Visual! Philadelphia,PA: Lippincott Williams & Wilkins; 2009:5.

Holcomb SS. Acute abdomen: What a pain! Nursing2009Crit Care. 2009;4(4):34-40.

Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opi-ates affect the clinical evaluation of patients with acuteabdominal pain?JAMA. 2006;296(14):1764-1774.

Scott-Conner C, Perry R. Acute abdomen and pregnancy.http://emedicine.medscape.com/article/195976-overview.

Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner &Suddarths Textbook of Medical-Surgical Nursing. 11th ed.Philadelphia, PA: Lippincott Williams & Wilkins, 2008:1126,1128.

Zeller JL, Burke AE, Glass RM. Acute abdominal pain.JAMA. 2006;294(14):1800.

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