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ABDOMINAL PAIN 11
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left-upper-quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and
low-grade fever.
◆ Uterine leiomyomas (fibroids). If large
enough, these common, benign uterine tumors
produce a round, multinodular mass in the
suprapubic region. The patient’s chief complaint
is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and
pressure on surrounding organs may cause
back pain, constipation, and urinary frequency
or urgency. Edema and varicosities of the lower
extremities may develop. Rapid fibroid growth
in perimenopausal or postmenopausal women
needs further evaluation.
S
PECIAL CONSIDERATIONS
Discovery of an abdominal mass commonly
causes anxiety. Offer emotional support to the
patient and his family as they await the diagnosis. Position the patient comfortably, and
administer drugs for pain or anxiety as
needed.
If an abdominal mass causes bowel obstruction, watch for indications of peritonitis—
abdominal pain and rebound tenderness—and
for signs of shock, such as tachycardia and hypotension.
P
EDIATRIC POINTERS
Detecting an abdominal mass in an infant can
be quite a challenge. However, these tips will
make palpation easier for you: Allow an infant
to suck on his bottle or pacifier to prevent crying, which causes abdominal rigidity and interferes with palpation. Avoid tickling him because
laughter also causes abdominal rigidity. Also,
reduce his apprehension by distracting him with
cheerful conversation. Rest your hand on his
abdomen for a few moments before palpation.
If he remains sensitive, place his hand under
yours as you palpate. Consider allowing the
child to remain on the parent’s or caregiver’s
lap. A gentle rectal examination should also be
performed.
In neonates, most abdominal masses result
from renal disorders, such as polycystic kidney
disease or congenital hydronephrosis. In older
infants and children, abdominal masses usually
are caused by enlarged organs, such as the liver
and spleen.
Other common causes include Wilms’ tumor,
neuroblastoma, intussusception, volvulus,
Hirschsprung’s disease (congenital megacolon),
pyloric stenosis, and abdominal abscess.
G
ERIATRIC POINTERS
Ultrasonography should be used to evaluate a
prominent midepigastric mass in thin elderly
patients.
P
ATIENT COUNSELING
Carefully explain diagnostic tests, which may
include blood and urine studies, abdominal Xrays, barium enema, computed tomography
scan, ultrasonography, radioisotope scan, and
gastroscopy or sigmoidoscopy. A pelvic or rectal
examination is usually indicated.
Abdominal pain
Abdominal pain usually results from a GI disorder, but it can also be caused by a reproductive,
genitourinary (GU), musculoskeletal, or vascular
disorder; drug use; or ingestion of toxins. At
times, such pain signals life-threatening complications.
Abdominal pain arises from the abdominopelvic viscera, the parietal peritoneum,
or the capsules of the liver, kidney, or spleen. It
may be acute or chronic and diffuse or localized. Visceral pain develops slowly into a deep,
dull, aching pain that’s poorly localized in the
epigastric, periumbilical, or lower midabdominal (hypogastric) region. In contrast, somatic
(parietal, peritoneal) pain produces a sharp,
more intense, and well-localized discomfort
that rapidly follows the insult. Movement or
coughing aggravates this pain. (See Abdominal
pain: Types and locations, page 12.)
Pain may also be referred to the abdomen
from another site with the same or similar nerve
supply. This sharp, well-localized, referred pain is
felt in skin or deeper tissues and may coexist
with skin hyperesthesia and muscle hyperalgesia.
Mechanisms that produce abdominal pain include stretching or tension of the gut wall, traction on the peritoneum or mesentery, vigorous
intestinal contraction, inflammation, ischemia,
and sensory nerve irritation.
EMERGENCY INTERVENTIONS If the
patient is experiencing sudden and severe
abdominal pain, quickly take his vital signs and
palpate pulses below the waist. Be alert for signs
of hypovolemic shock, such as tachycardia and
hypotension. Obtain I.V. access.
Emergency surgery may be required if the patient also has mottled skin below the waist and a
pulsating epigastric mass or rebound tenderness
and rigidity.
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Abdominal pain: Types and locations
Affected organ
Stomach
Small intestine
Appendix
Proximal colon
Distal colon
Gallbladder
Ureters
Pancreas
Ovaries, fallopian
Visceral pain
Middle epigastrium
Periumbilical area
Periumbilical area
Periumbilical area and
right flank for ascending
colon
Hypogastrium and left
flank for descending
colon
Middle epigastrium
Costovertebral angle
Middle epigastrium and
left upper quadrant
Hypogastrium and groin
tubes, and uterus
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient has no life-threatening signs or
symptoms, take his history. Ask him if he has
had this type of pain before. Have him describe
the pain—for example, is it dull, sharp, stabbing, or burning? Ask if anything relieves the
pain or makes it worse. Ask the patient if the
pain is constant or intermittent and when
the pain began. Constant, steady abdominal
pain suggests organ perforation, ischemia, or
inflammation or blood in the peritoneal cavity.
Intermittent, cramping abdominal pain suggests the patient may have an obstruction of a
hollow organ.
If pain is intermittent, find out the duration of
a typical episode. In addition, ask the patient
where the pain is located and if it radiates to
other areas.
Find out if movement, coughing, exertion,
vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report
abdominal pain as indigestion or gas pain, so
have him describe it in detail.
Parietal pain
Middle epigastrium and
left upper quadrant
Over affected site
Right lower quadrant
Over affected site
Over affected site
Right upper quadrant
Over affected site
Middle epigastrium and
left upper quadrant
Over affected site
Ask the patient about substance abuse and
any history of vascular, GI, GU, or reproductive
disorders. Ask the female patient the date of her
last menses and if she has had changes in her
menstrual pattern or dyspareunia.
Also ask about appetite changes and the onset
and frequency of nausea or vomiting. Find out
about increased flatulence, constipation, diarrhea,
and changes in stool consistency. When was his
last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?
Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and
mucous membranes. Inspect his abdomen for
distention or visible peristaltic waves and, if indicated, measure his abdominal girth.
Auscultate for bowel sounds and characterize
their motility. Percuss all quadrants, noting the
percussion sounds. Palpate the entire abdomen
for masses, rigidity, and tenderness. Check for
costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Abdominal pain: Causes and asso-
ciated findings, pages 14 to 19.)
Referred pain
Shoulders
Midback (rare)
Right lower quadrant
Right lower quadrant
and back (rare)
Left lower quadrant and
back (rare)
Right subscapular area
Groin; scrotum in men,
labia in women (rare)
Back and left shoulder
Inner thighs
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13
M
EDICAL CAUSES
◆ Abdominal aortic aneurysm (dissecting).
Initially, abdominal aortic aneurysm—a lifethreatening disorder—may produce dull lower
abdominal, lower back, or severe chest pain. In
most cases, however, it produces constant upper abdominal pain, which may worsen when
the patient lies down and may abate when he
leans forward or sits up. Palpation may reveal
an epigastric mass that pulsates before rupture
but not after it.
Other findings may include mottled skin below the waist, absent femoral and pedal pulses,
blood pressure that’s lower in the legs than in
the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity.
Signs of shock, such as tachycardia and tachypnea, may appear.
◆ Abdominal cancer. Abdominal pain usually
occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness,
depression, an abdominal mass, and abdominal
distention.
◆ Abdominal trauma. Generalized or local-
ized abdominal pain occurs with ecchymoses
on the abdomen; abdominal tenderness; vomiting; and, with hemorrhage into the peritoneal
cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs
of hypovolemic shock, such as hypotension and
a rapid, thready pulse.
◆ Adrenal crisis. Severe abdominal pain ap-
pears early along with nausea, vomiting, dehydration, profound weakness, anorexia, and
fever. Later signs are progressive loss of consciousness, hypotension, tachycardia, oliguria,
cool and clammy skin, and increased motor activity, which may progress to delirium or
seizures.
◆ Anthrax, GI. Anthrax is an acute infectious
disease that’s caused by the gram-positive,
spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in
wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the
soil for many years. The disease can occur in
humans exposed to infected animals, tissue
from infected animals, or biological agents.
Most natural cases occur in agricultural regions
worldwide. Anthrax may occur in cutaneous, inhaled, or GI forms.
GI anthrax is caused by eating contaminated
meat from an infected animal. Initial signs and
symptoms include anorexia, nausea, vomiting,
and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.
◆ Appendicitis. Appendicitis is a life-
threatening disorder in which pain initially
occurs in the epigastric or umbilical region.
Anorexia, nausea, and vomiting may occur
after the onset of pain. Pain localizes at
McBurney’s point in the right lower quadrant
and is accompanied by abdominal rigidity,
increasing tenderness (especially over
McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms
include malaise, constipation (or diarrhea),
low-grade fever, and tachycardia.
◆ Cholecystitis. Severe pain in the right up-
per quadrant may arise suddenly or increase
gradually over several hours, usually after
meals. It may radiate to the right shoulder,
chest, or back. Accompanying the pain are
anorexia, nausea, vomiting, fever, abdominal
rigidity and tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited
when the examiner palpates the right upper
quadrant as the patient takes a deep breath) is
common.
◆ Cholelithiasis. Patients may suffer sudden,
severe, and paroxysmal pain in the right upper
quadrant lasting several minutes to several
hours. The pain may radiate to the epigastrium,
back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes
bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent
indigestion.
◆ Cirrhosis. Dull abdominal aching occurs ear-
ly and is usually accompanied by anorexia, indigestion, nausea, vomiting, and constipation or
diarrhea. Subsequent right-upper-quadrant pain
worsens when the patient sits up or leans forward. Associated signs include fever, ascites,
leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be
present.
◆ Crohn’s disease. An acute attack causes se-
vere cramping pain in the lower abdomen, typically preceded by weeks or months of milder
cramping pain. Crohn’s disease may also cause
diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness
(Text continues on page 18.)
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SIGNS & SYMPTOMS
Abdominal pain: Causes and associated findings
Major associated signs and symptoms
Common
causes
Abdominal aortic
aneurysm
(dissecting)
Abdominal cancer
Abdominal trauma
Adrenal crisis
Anthrax, GI
Appendicitis
Cholecystitis
Cholelithiasis
Cirrhosis
Crohn’s disease
Cystitis
Diabetic
ketoacidosis
Diverticulitis
Duodenal ulcer
Ectopic pregnancy
Endometriosis
Escherichia coli
O157:H7
Gastric ulcer
Gastritis
Gastroenteritis
Heart failure
Abdominal
distention
Abdominal mass
Abdominal rigidity
Abdominal
tenderness
Amenorrhea
Anorexia
Bowel sounds,
absent
Bowel sounds,
hyperactive
Bowel sounds,
hypoactive
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Breath odor, fruity
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Chest pain
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Constipation
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Costovertebral
angle tenderness
Cough
Diarrhea
Dyspnea
Fever
Kussmaul’s
respirations
Nausea
Oliguria or anuria
Skin lesions
Skin mottling
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ABDOMINAL PAIN 15
Tachycardia
Tachypnea
Urinary frequency
Vomiting
Weakness
Weight change
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(continued)
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Abdominal pain: Causes and associated findings (continued)
Major associated signs and symptoms
Common
causes
Hepatic abscess
Hepatic amebiasis
Hepatitis
Herpes zoster
Insect toxins
Intestinal
obstruction
Irritable bowel
syndrome
Listeriosis
Mesenteric artery
ischemia
Myocardial
infarction
Norovirus infection
Ovarian cyst
Pancreatitis
Pelvic inflammatory
disease
Perforated ulcer
Peritonitis
Pleurisy
Pneumonia
Pneumothorax
Prostatitis
Abdominal
distention
Abdominal mass
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Abdominal rigidity
Abdominal
tenderness
Amenorrhea
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Anorexia
Bowel sounds,
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absent
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Bowel sounds,
hyperactive
Bowel sounds,
hypoactive
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Breath odor, fruity
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Chest pain
Constipation
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Costovertebral
angle tenderness
Cough
Diarrhea
Dyspnea
Fever
Kussmaul’s
respirations
Nausea
Oliguria or anuria
Skin lesions
Skin mottling
ABDOMINAL PAIN 17
Tachycardia
Tachypnea
Urinary frequency
Vomiting
Weakness
Weight change
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(continued)
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Abdominal pain: Causes and associated findings (continued)
Major associated signs and symptoms
Common
causes
Pyelonephritis
(acute)
Renal calculi
Sickle cell crisis
Smallpox
(variola major)
Splenic infarction
Systemic lupus
erythematosus
Ulcerative colitis
Uremia
with guarding, and possibly a palpable mass in
a lower quadrant. Abdominal pain is commonly
relieved by defecation. Milder chronic signs and
symptoms include right-lower-quadrant pain
with diarrhea, steatorrhea, and weight loss.
Complications include perirectal or vaginal fistulas.
◆ Cystitis. Abdominal pain and tenderness
usually occur in the suprapubic region. Associated signs and symptoms include malaise, flank
pain, low back pain, nausea, vomiting, urinary
frequency and urgency, nocturia, dysuria, fever,
and chills.
◆ Diabetic ketoacidosis. Rarely, severe,
sharp, shooting, and girdling pain may persist
for several days. Fruity breath odor, a weak and
rapid pulse, Kussmaul’s respirations, poor skin
turgor, polyuria, polydipsia, nocturia, hypotension, decreased bowel sounds, and confusion
also occur.
◆ Diverticulitis. Mild cases usually produce
intermittent, diffuse left-lower-quadrant pain,
which may be relieved by defecation or passage of flatus and worsened by eating. Other
signs and symptoms include nausea, constipa-
Abdominal
distention
Abdominal mass
Abdominal rigidity
Abdominal
tenderness
Amenorrhea
Anorexia
Bowel sounds,
absent
Bowel sounds,
hyperactive
Bowel sounds,
hypoactive
•
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tion or diarrhea, low-grade fever and, in many
cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left-lower-quadrant pain, abdominal
rigidity, and possibly signs and symptoms of
sepsis and shock (high fever, chills, and hypotension).
◆ Duodenal ulcer. Localized abdominal
pain—described as steady, gnawing, burning,
aching, or hungerlike—may occur high in the
midepigastrium, slightly off center, usually on
the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically
begins 2 to 4 hours after a meal and may
cause nocturnal awakening. Ingestion of food
or antacids brings relief until the cycle starts
again. Other symptoms include changes in
bowel habits and heartburn or retrosternal
burning.
◆ Ectopic pregnancy. Lower abdominal pain
may be sharp, dull, or cramping and constant
or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur along
with urinary frequency, a tender adnexal mass,
Breath odor, fruity
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Chest pain
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Constipation
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Costovertebral
angle tenderness
Cough
Diarrhea
Dyspnea
Fever
Kussmaul’s
respirations
Nausea
Oliguria or anuria
Skin lesions
Skin mottling
ABDOMINAL PAIN
Tachycardia
Tachypnea
Urinary frequency
Vomiting
Weakness
19
Weight change
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and a 1- to 2-month history of amenorrhea.
Rupture of the fallopian tube produces sharp
lower abdominal pain, which may radiate to
the shoulders and neck and become extreme
with cervical or adnexal palpation. Signs of
shock (such as pallor, tachycardia, and hypotension) may also appear.
◆ Endometriosis. Constant, severe pain in the
lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated
by defecation. Depending on the location of the
ectopic tissue, abdominal pain may be accompanied by abdominal tenderness, constipation,
dysmenorrhea, dyspareunia, and deep sacral
pain.
◆ Escherichia coli O157:H7. E. coli O157:H7
is an aerobic, gram-negative bacillus that causes food-borne illness. Most strains of E. coli are
harmless and are part of the normal intestinal
flora of healthy humans and animals. E. coli
O157:H7, one of hundreds of strains of the bacterium, is capable of producing a powerful toxin
and can cause severe illness. Eating undercooked beef or other foods contaminated with
the bacterium causes the disease. Signs and
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symptoms include watery or bloody diarrhea,
nausea, vomiting, fever, and abdominal cramps.
In children younger than age 5 and the elderly,
hemolytic uremic syndrome may develop and
ultimately lead to acute renal failure.
◆ Gastric ulcer. Diffuse, gnawing, burning
pain in the left upper quadrant or epigastric
area commonly occurs 1 to 2 hours after meals
and may be relieved by ingestion of food or
antacids. Vague bloating and nausea after eating are common. Indigestion, weight change,
anorexia, and episodes of GI bleeding also
occur.
◆ Gastritis. With acute gastritis, the patient ex-
periences rapid onset of abdominal pain that
can range from mild epigastric discomfort to
burning pain in the left upper quadrant. Other
typical features include belching, fever, malaise,
anorexia, nausea, bloody or coffee-ground
vomitus, and melena. However, significant
bleeding is unusual, unless the patient has hemorrhagic gastritis.
◆ Gastroenteritis. Cramping or colicky ab-
dominal pain, which can be diffuse, originates
in the left upper quadrant and radiates or
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migrates to the other quadrants, usually in a
peristaltic manner. It’s accompanied by diarrhea,
hyperactive bowel sounds, headache, myalgia,
nausea, and vomiting.
◆ Heart failure. Right-upper-quadrant pain
commonly accompanies heart failure’s hallmarks: jugular vein distention, dyspnea,
tachycardia, and peripheral edema. Other
findings include nausea, vomiting, ascites,
productive cough, crackles, cool extremities,
and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the
disease and amount of cardiovascular impairment.
◆ Hepatic abscess. Steady, severe abdominal
pain in the right upper quadrant or midepigastrium commonly accompanies hepatic abscess—a rare disorder—but right-upper-quadrant tenderness is the most important finding.
Other signs and symptoms are anorexia, diarrhea, nausea, fever, diaphoresis, elevated right
hemidiaphragm and, rarely, vomiting.
◆ Hepatic amebiasis. Rare in the United
States, hepatic amebiasis causes relatively severe right-upper-quadrant pain and tenderness
over the liver and possibly the right shoulder.
Accompanying signs and symptoms include
fever, weakness, weight loss, chills, diaphoresis,
and jaundiced or brownish skin.
◆ Hepatitis. Liver enlargement from any type
of hepatitis causes discomfort or dull pain and
tenderness in the right upper quadrant. Associated signs and symptoms may include dark
urine, clay-colored stools, nausea, vomiting,
anorexia, jaundice, malaise, and pruritus.
◆ Herpes zoster. Herpes zoster of the tho-
racic, lumbar, or sacral nerves can cause localized abdominal and chest pain in the areas
served by these nerves. Pain, tenderness, and
fever can precede or accompany erythematous
papules, which rapidly evolve into grouped
vesicles.
◆ Intestinal obstruction. Short episodes of
intense, colicky, cramping pain alternate with
pain-free intervals in intestinal obstruction, a
life-threatening disorder. Accompanying signs
and symptoms may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive bowel sounds proximal to the
obstruction and hypoactive or absent sounds
distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal
small- or large-bowel obstruction, nausea and
vomiting are commonly feculent. Complete
obstruction produces absent bowel sounds.
Late-stage obstruction produces signs of
hypovolemic shock, such as hypotension and
tachycardia.
◆ Irritable bowel syndrome. Lower abdomi-
nal cramping or pain is aggravated by ingestion
of coarse or raw foods and may be alleviated by
defecation or passage of flatus. Related findings
include abdominal tenderness, diurnal diarrhea
alternating with constipation or normal bowel
function, and small stools with visible mucus.
Dyspepsia, nausea, and abdominal distention
with a feeling of incomplete evacuation may
also occur. Stress, anxiety, and emotional lability intensify the symptoms.
◆ Listeriosis. Listeriosis is a serious infection
that’s caused by eating food contaminated with
the bacterium Listeria monocytogenes. This foodborne illness primarily affects pregnant women,
neonates, and those with weakened immune
systems. Signs and symptoms include fever,
myalgia, abdominal pain, nausea, vomiting, and
diarrhea. If the infection spreads to the nervous
system, it may cause meningitis, characterized
by fever, headache, nuchal rigidity, and altered
level of consciousness (LOC).
GENDER CUE Listeriosis infection during
pregnancy may lead to premature delivery,
infection of the neonate, or stillbirth.
◆ Mesenteric artery ischemia. Always sus-
pect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmias, cardiovascular infarct, or
hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel
sounds. Associated findings include vomiting,
anorexia, alternating periods of diarrhea and
constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia,
tachypnea, absent bowel sounds, and cool,
clammy skin.
◆ Myocardial infarction (MI). In MI—a life-
threatening disorder—substernal chest pain
may radiate to the abdomen. Associated signs
and symptoms include weakness, diaphoresis,
nausea, vomiting, anxiety, syncope, jugular vein
distention, and dyspnea.
◆ Norovirus infection. Abdominal pain or
cramping is a symptom commonly associated
with noroviruses. Transmitted by the fecal-oral
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