abdominal pain Abstract: Abdominal pain is a common complaint encountered in primary care and in the ED. Varying levels of pain dictate the immediacy of the intervention. Time is vital when making the decision to initiate therapeutic interventions. A comprehensive assessment with physical exam and diagnostic studies is required. By Scott J. Saccomano, PhD, GNP-BC, RN and Lucille R. Ferrara, EdD, RN, MBA, FNP-BC
r. S is a 42-year-old male who presents to the ED with abdominal pain. His past medical history is significant for hypertension that is well controlled on hydrochlorothiazide 25 mg daily. He denies drinking, smoking, or taking illicit or recreational drugs. He states that the abdominal pain started around 3 a.m. accompanied by nausea
M
and vomiting. His last bowel movement was 2 days ago, which he describes as normal, and the present pain is 8/10 on a 0 to 10 pain scale. He vomited three times today, and each incidence was accompanied with green fluid. He also has not eaten today and is unable to keep oral fluids down. Mr. S denies recent travel, and his last meal was 2 days ago when he ate buffalo wings
Key words: abdomen assessment, abdominal pain, acute abdomen, acute abdominal pain, gastrointestinal pain
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Evaluation of acute
Evaluation of acute abdominal pain
and a burger at a party. His physical exam findings include the following: Vital signs (VSs): BP 160/100, pulse 102, respirations 18, temperature 101.2° F (38.4° C), weight 204 lbs (92.5 kg), height 72 in (182.9 cm) General: 42-year-old man in moderate distress, pale and diaphoretic Physical exam: • cardiac—normal S1S2; no murmurs, gallops, rubs • Pulmonary—bilateral breath sounds, clear to auscultation bilaterally • Abdominal—+ rebound, guarding, + psoas, + McBurney, hypoactive bowel sounds, distended. Lab and ECG results: • Complete blood cell (CBC) count: hemoglobin (Hb)— 14.2 g/dL; hematocrit (Hct)—37%; white blood cell (WBC) count: 22,000 cells/mm3 with a left shift • Chemistry (Chem): blood urea nitrogen—40 mg/dL, creatinine—1.0 mg/dL Amylase/lipase within normal limits (wnl) • Liver function test (LFT): wnl; urinalysis (U/A) wnl • ECG: normal sinus rhythm; no changes from last ECG dated May 2011 Mr. S was diagnosed with acute abdominal pain; rule out appendicitis. He was transferred from the ED to the radiology department for an abdominal computed tomography (CT) scan. The following is a guideline for assessing abdominal pain, specifically, acute abdominal pain. ■ Overview Abdominal pain is a common complaint encountered by both primary care and ED providers. Although common, varying levels in the severity of pain will dictate the immediacy of the intervention. Whether this patient is seen in the office or the ED, time is vital when making the decision to initiate therapeutic intervention efficiently. The key to initiating treatment lies in a comprehensive assessment not only from the physical exam but also from the studies that contribute to confirming diagnosis as well. ■ Epidemiology Abdominal pain accounts for approximately 4% to 5% of all ED visits.1 Approximately 14% of these patients have appendicitis, 5% will be diagnosed with cholecystitis, 20% with small bowel obstruction (SBO), and less than 1% with perforated peptic ulcer.1,2 Sixty percent of all SBOs are due to postsurgical adhesions.2 Finally, diverticulitis accounts for over 150,000 hospital admissions per year with increased incidence in patients over 80 years old.1 www.tnpj.com
■ Pathophysiology of common conditions of the acute abdomen Appendicitis Operative fi ndings classify appendicitis as one of three types: simple, gangrenous, or perforated. In simple appendicitis, the appendix is complete and viable. Necrosis of the appendiceal wall is characteristic of necrotic appendicitis. A disruption in the appendix is classified as perforated. Appendicitis is usually caused by a bacterial infection and results in obstruction of its orifice. Obstruction of the orifice leads to lymphoid hyperplasia secondary to dehydration and infection. Common causes of obstruction include mechanical obstruction, such as fecal matter, tumors, parasites, foreign bodies (fruit seeds), viral, and bacterial agents. Once the appendiceal lumen is obstructed, the mucosa continues to produce fluid. The mucosal fluid accumulation in the appendix produces a change in the intraluminal pressure greater than venous pressure, resulting in obstruction. The appendiceal obstruction causes hypoxia, which breaks down the appendiceal mucosa, creating a portal of entry for bacterial (colon bacilli and streptococci) and bowel flora. At this point, usually 24 to 36 hours later, the appendix is gangrenous, perforates, and the contents of the infected appendix are deposited in the peritoneal cavity.3-6 SBO SBO, occlusion, or paralysis of the bowel lumen causes fluid and gas to collect proximal to the occlusion. Gastric hydrochloric acid and chyme normally move through the bowel inhibiting bacterial growth. Intestinal dilation as a result of bowel obstruction increases capillary permeability, spilling fluid and electrolytes into the peritoneal cavity. Stasis accumulation of fluid, electrolytes, and abdominal distention leave the bowel predisposed to bacterial proliferation; the patient is at risk for bowel perforation and peritonitis. SBOs are classified into three categories: mechanical obstruction, nonmechanical obstruction, and pseudoobstruction. Surgical adhesions are the most common cause of mechanical obstruction followed by hernias and tumors. Colon cancer is the most common cause of large bowel obstruction. Nonmechanical causes include postoperative paralytic ileus, peritonitis, appendicitis, and spinal or thoracic fractures. Pseudoobstruction causes include neurologic and collagen vascular disorders.2,7 Diverticulitis Diverticula are herniated, pouch-like protrusions through the muscular wall of the small intestine or colon. Diverticula can occur throughout the colon, but the most common area is the sigmoid colon due to its small diameter. Increased The Nurse Practitioner • November 2013 47
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Evaluation of acute abdominal pain
bowel content causes intraluminal pressure to increase, causing the colon to hypertrophy. The hypertrophied colon wall becomes thick and rigid, herniation occurs at the weakest points of the submucosa and mucosa, and the diverticula become obstructed with localized abscess formation. The abscesses can perforate, causing peritonitis, further erosion of the intestinal wall with bleeding, and possible bowel obstruction.8,9 Peritonitis Peritonitis, an infection of the serous membrane of the peritoneal cavity, results from the hematogenous and lymphogenous spread of bacteria or fungi via an intact gut wall from the intestinal lumen. The peritoneum, a normally sterile environment, is infected through organ perforation. Bacteria or fungi enter the abdominal cavity causing an inflammatory response of vascular dilation, capillary permeability, and phagocytosis of invading organisms. If the inflammatory response is unsuccessful and the organism is not contained, fluid weeping into the peritoneal cavity causes inflammation, infection, and contamination. The fluid shifts into the peritoneal cavity, connective tissue, and vascular space, resulting in decreased circulatory volume. Organ and tissue perfusion that is severely diminished from the fluid shifts can potentially lead to renal failure and fluid/ electrolyte imbalances. Peritonitis can reduce or stop peristalsis, increasing bowel distention, and decreasing colon reabsorption, thus increasing intestinal reabsorption of toxins leading to bacteremia or septicemia.10-12 Abdominal aortic aneurysm The primary cause of an abdominal aortic aneurysm (AAA) is atherosclerosis secondary to a loss of elastin and collagen in the aorta, causing weakness of the vessel wall. Atherosclerotic plaques are deposited beneath the intima and cause degenerative changes in the media tunica. The mechanical stress to the vessels, with concurrent loss of muscle fibers and degradation of the media tunica, fills the cystic spaces with a metachromatic myxoid material. The mechanical stress causes weakness and decreased elasticity, which leads to increased vessel diameter and length.13,14 Cholecystitis Cholecystitis, acute bacterial inflammation of the gallbladder, is primarily a result of gallbladder outlet obstruction. Primary inflammation of the gallbladder is caused by continued blockage of the common bile duct or the cystic duct. Gallstones cause the majority of acute cholecystitis cases. The gallstones cause local irritation, distention, decreased blood supply, compromised lymphatic drainage, and symptoms of inflammation. Prostaglandins are 48 The Nurse Practitioner • Vol. 38, No. 11
released due to the inflammation, which reduces gallbladder contractility and motility leading to increased inflammation. Gangrene and perforation can result if inflammation is not treated.15,16 Ectopic pregnancy An ectopic pregnancy occurs when an ovum is implanted outside the confines of the uterine cavity, such as the fallopian tubes, cervix, or abdomen. The majority of ectopic pregnancies are located in the fallopian tube.17 The primary cause of ectopic pregnancy is thought to be alterations or destruction of the fallopian tubes. Alterations such as tubal length, diverticula, or kinking may make the ovum’s journey to the uterus longer. As the journey to the uterus is now longer, the ovum has time to multiply and grow, making its size more difficult to pass through the narrow tubes when it is ready for implantation. When implantation occurs, the tube stretches to its maximum size and ruptures, causing abdominal pain. Common causes of ectopic pregnancy include pelvic inflammatory disease, structural narrowing of the tubes, salphingitis, endometriosis, surgery with adhesions or scar tissue, intrauterine devices, and multiple abortions.17,18 ■ Assessment and associated clinical findings A comprehensive patient history will provide most of the information needed to arrive at a diagnosis. It is important to ascertain the history leading up to the current event or episode. Common, significant abdominal complaints in primary care include the following: nausea/vomiting, change in appetite, change in bowel habits, rectal bleeding, jaundice, abdominal distention, abdominal mass, and pain. Pain history is one of the most important components and should be thoroughly evaluated. Common questions regarding pain history should include the following: location—where is the pain and quality of pain—has the patient had this pain before? The location can suggest the cause of pathology; midline pain can be bowel related, where radiating pain may require more of a diagnostic workup; timing or onset of pain should be evaluated to assess the pain patterns over time; severity of pain, using the routine 0 to 10 pain scale (see Abdominal regions, reference planes, and quadrants). In terms of quality of pain, patients may not be able to accurately describe it but should be asked to point to the area of pain. Determine if the pain radiates; when radiation is present, it is usually helpful in the diagnostic evaluation with concurrent symptoms. Ask about aggravating and alleviating factors, last bowel movement (BM) or marked change in BM and the consistency of the BM, melana—presence of blood in the stool, hematemesis, oral intake, any nausea, vomiting, urological symptoms, and recent travel.19,20 www.tnpj.com
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Evaluation of acute abdominal pain
Abdominal regions, reference planes, and quardrants
Key Abdominal Regions: RH Right hypochondrium RL Right flank (lateral region) RI
Right inguinal (groin)
E
Epigastric
U Umbilical P Pubic LH Left hypochondriac LL Left flank (lateral region) LI Left inguinal (groin) Abdominal Quadrants:
RH
RL
E U
LH
RUQ
Right upper quadrant
LUQ
Left upper quadrant
RLQ
Right lower quadrant
LLQ
Left lower quadrant
LL
RUQ
LUQ
RLQ
LLQ
Median plane RI
P
LI
Transumbilical plane Anterior superior iliac spine (ASIS) Inguinal ligament
(A) Abdominal regions
(C) Abdominal quadrants
Jugular line Midclavicular line (MCL) Transpyloric plane Subcostal plane Transtubercular plane
Semilunar lines
L4 L5
Iliac tubercle Interspinous plane
Pubic symphysis
Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Liver: right lobe Gallbladder Stomach: pylorus Duodenum: parts 1-3 Pancreas: head Right suprarenal gland Right kidney Right colic (hepatic) flexure Ascending colon: superior part Transverse colon: right half
Liver: left lobe Spleen Stomach Jejunum and proximal ileum Pancreas: body and tail Left kidney Left suprarenal gland Left colic (splenic) flexure Transverse colon: left half Descending colon: superior part
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)
Cecum Appendix Most of ileum Ascending colon: inferior part Right ovary Right uterine tube Right ureter: abdominal part Right spermatic cord: abdominal part Uterus (if enlarged) Urinary bladder (if very full)
Sigmoid colon Descending colon: inferior part Left ovary Left uterine tube Left ureter: abdominal part Left spermatic cord: abdominal part Uterus (if enlarged) Urinary bladder (if very full)
(B) Abdominal reference planes
Source: Moore KL, Dalley AF, Agur, AM. Clinically Oriented Anatomy. 6th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2011:185.
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Evaluation of acute abdominal pain
reports pain over the area of inflammation once pressure is removed.20,21 Digital rectal exam (DRE) is indicated with lower abdominal/pelvic pain. DRE can reveal fecal impaction, hemorrhoids, or prostate enlargement. DRE is also necessary to receive a stool for occult bleeding.7 A pelvic exam can reveal vaginitis and cervical/adnexal tenderness, which may indicate ectopic pregnancy.24 Clinical manifestations of appendicitis vary, which make it difficult to diagnose. Patients with appendicitis present with continuous periumbilical pain, eventually shifting to the right at McBurney point. Tenderness is localized, muscle guarding and rebound tenderness are present, and the patient prefers to lie still with the right lower extremity flexed. A low-grade fever may or may not be present, Rovsing sign is positive, and coughing exaggerates the pain.18,22,23,25,26 Patients with SBO complain of vomiting, constipation, inability to pass gas, periumbilical abdominal pain, or tenderness and abdominal distention. Pain with SBO is reported as intermittent and cramping, usually in the periumbilical or epigastric areas. Initially, patients may present with diarrhea; however, once the distal bowel is emptied, constipation and the inability to pass gas are reported symptoms. Bowel sounds can The majority of AAAs are often be high pitched (in early obstruction) or absent (in late obstruction).2,24 asymptomatic and usually identified Diverticulitis is primarily asympon routine physical exam. tomatic; however, patients with symptoms tend to report abdominal pain with changes in bowel habits—usually constiupper quadrant (RUQ), and the patient feels pain in this area pation—and patients are without symptoms of infection. Pain and will have “inspiratory arrest.” A positive Rovsing sign is with diverticulitis is localized over the affected area of the elicited when the patient reports tenderness in the right lower colon, typically in the left lower abdomen. The pain may be quadrant (McBurney point tenderness) as the examiner perworse after eating and relieved with a bowel movement or forms deep palpation. In addition, other signs of peritoneal flatus. In addition, patients present with fever, leukocytosis, irritation include the psoas sign and the obturator sign. A bloating, nausea, vomiting, and positive occult blood in stool. positive psoas sign (irritation of the psoas muscle) is elicited A positive history of diverticulosis assists in making the diwhen the patient is supine and reports pain when asked to lift verticulitis diagnosis.8,27,28 The most common symptom of his or her thigh with the examiners hand placed just above peritonitis is abdominal pain, and the area involved is usually the knee; this may indicate that appendicitis may be present. tender. Other common signs of peritoneal irritation are reIn addition, the obturator sign can be positive in appendibound tenderness, muscular rigidity, and spasms. Respirations citis. With the patient in the supine position, the right hip cause abdominal pain, shallow respirations may be visible, and and knee are flexed while passively and internally rotating the the patient may lie still, as any movement such as jarring the right leg; right-sided abdominal pain indicates irritation of stretcher causes pain known as “shake tenderness.” Based on the obturator muscle.20,22,23 the severity of infection and the underlying cause of peritonitis, symptoms such as ascites, fever, tachycardia, nausea, Assessment for rebound tenderness is completed using vomiting, and change in bowel habits may be present.11,12,29 the fingertips and pressing the most painful area of the abdomen. This position is held until the pain diminishes The majority of AAAs are often asymptomatic and usuor the patient adapts to the pain, the examiner then quickally identified on routine physical exam. Physical exams also ly withdraws his or her hand, removing the pressure. reveal periumbilical abdominal pulsations and bruits. AAA Positive rebound tenderness is present when the patient can mimic symptoms of back pain or other abdominal
Assess VSs, paying particular attention to fever related to infection and orthostatic hypotension associated with complaints of dizziness. Tachycardia can indicate internal bleeding. In addition, orthostatic hypotension and tachycardia can be related to fluid volume depletion if vomiting or diarrhea is present. The general appearance of the patient should be assessed for signs and symptoms of pallor, restlessness, sweating, signs of peritonitis, and toxicity.20,21 Perform a complete abdominal exam, placing the patient in the supine position with the hips flexed. Inspect the contour of the abdomen, location of any scars, skin color, and skin texture. Auscultate for bowel sounds, and continue with percussion, palpation, and evaluation of extra-abdominal sources of abdominal pain. When percussing and palpating the abdomen, begin in a nonpainful region. It is important to determine the areas of localized tenderness, masses, liver span, and spleen size. Assess for abdominal rigidity, the presence of guarding, rebound tenderness, abdominal bruits, and assess for peritoneal irritation using Murphy sign if cholecystitis is suspected and Rovsing sign if appendicitis is suspected. Murphy sign can be elicited as the patient takes a deep breath, the examiner applies pressure in the area of the gallbladder, right
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Evaluation of acute abdominal pain
disorders, such as ureteral obstruction. Other clinical symptoms such as hypotension, atypical back, or abdominal pain may be present if the aneurysm is ruptured.13,21 Patients with cholecystitis present with colicky pain in the RUQ—usually with radiation to the flank and occasionally to the right shoulder—and are accompanied by nausea and vomiting. Biliary colic is localized to the midepigastric region and sometimes to the RUQ. Pain routinely occurs within 1 hour after a meal and persists for days with residual aching. Abdominal discomfort occurs following a highfat meal and may have associated symptoms of nausea, vomiting, anorexia, and fever. The patient may report a history of prior episodes, and Murphy sign is common.16,20,29 Patients with ectopic pregnancy report the initial signs of pregnancy, amenorrhea—a missed period, spotting, tender breasts, tiredness, urinary frequency, and fatigue. As the pregnancy develops, patients report increasing severe lower quadrant abdominal pain with movement, increased vaginal bleeding, and pain during intercourse. Peritoneal signs such as rebound tenderness and guarding with abdominal distention are present with a ruptured ectopic pregnancy. As the patient may be experiencing internal bleeding, signs and symptoms of dizziness, lightheadedness, or syncope may be present.17,18 ■ Testing The cost of acute abdominal pain is closely correlated to the type of testing and treatment rendered. Testing, especially imaging, can drive up cost, which is why choosing appropriate testing as an adjunct to physical exam is key. For example, the definitive imaging study that will provide the best information for diagnosing acute cholecystitis is ultrasound; however, CT is the imaging test of choice regarding the acute abdomen when appendicitis is suspected. Radiation exposure risk is always a concern, especially with the pediatric population.30 The exposure to radiation from CT scan of the abdomen and pelvis is 15 mSv. The average American receives approximately 3 mSv per year from radiation that naturally occurs in the surrounding environment. The increased risk of radiation exposure occurs with overuse of CT scan for diagnostic testing (for example, when performing multiple CT scans of the head for diagnosis related to headache or blunt trauma).30 When weighing the risk-to-benefit ratio, it is prudent to use a confirmatory test that will decrease the morbidity and mortality of patients suspected of having acute appendicitis. Quickly arriving at a diagnosis is critical, especially since delay in diagnosis (over 12 hours) of acute appendicitis can result in rupture,31 which may result in lifethreatening complications, such as peritonitis and sepsis. SBO is best diagnosed with flat and upright radiograph, especially in the absence of CT or if the patient is unable to tolerate CT www.tnpj.com
contrast.1,32-35 In addition to imaging, lab studies are essential in making or confirming diagnosis and initiating treatment. The most common labs that should be obtained for acute abdomen include CBC count, LFTs, Chem, amylase, lipase, U/A, beta-human chorionic gonadotropin (beta-hCG) for women of reproductive age, coagulation studies, and finally, a type and screen if surgical intervention is imminent. Other specialty lab tests would include blood cultures for febrile acute abdominal pain. Risk stratification should be determined for anesthesia administration as well as ECG, cardiac, and other testing for patients with comorbid states where they may be considered at high risk for surgical intervention. ■ Diagnostic findings Appendicitis As mentioned, acute appendicitis accounts for 14% of all acute abdominal pain presenting to the ED. In addition to the physical exam findings, CT findings for appendicitis typically show enlargement of the appendix greater than 6 mm. In a study conducted by Bondi et al., transvaginal ultrasound was used for diagnosis when the appendix was difficult to visualize on CT in female patients with suspected acute AP.36 Inflammatory markers such as a WBC count (specifically leukocytes) are usually elevated and are strong indicators of infection (peritonitis). Routine U/A will be normal or negative but should be performed in order to rule out renal calculi and pyelonephritis. SBO The gold standard test for SBO is the flat and upright radiograph. Findings consistent with SBO are dilated fluid-filled loops of bowel proximal to the obstruction. Leukocytosis may also be present in the presence of peritonitis, ischemic bowel, and infection. Liver enzymes will usually be normal, but electrolytes may be altered if the patient is dehydrated secondary to the obstruction and malabsorption. Diverticulosis/diverticulitis On CT, the study of choice for diverticulitis—typically bowel wall thickening—is the most common finding, but infiltration of pericolonic fat, abscess, and fluid or free air in the peritoneal cavity may also be present. Leukocytosis is commonly seen due to inflammation and infection. A decrease in Hb and Hct can occur in patients with chronic diverticulosis. AAA CT scan is the test of choice for diagnosing an AAA; however, ultrasound provides 98% accuracy for sizing the aneurysm.34 An aneurysm measuring greater than 5 cm indicates the need for surgical intervention. Anemia may be a finding in the presence of retroperitoneal bleeding. Renal The Nurse Practitioner • November 2013 51
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Evaluation of acute abdominal pain
■ Treatment The treatment for the acute abdomen is dependent upon the underlying cause or diagnosis (see Summary of diagnostic testing and treatment). Surgical intervention is most likely going to be the first-line treatment in the case of ruptured appendix, ruptured ectopic pregnancy, incarcerated hernia, Cholecystitis complete SBO, and perforated ulcer. Other treatment options Typical findings on ultrasound will demonstrate the presmay include antibiotic therapy, gut rest and decompression, ence of stones or calculi, gallbladder wall thickening, peripain management, hydration, and medical management for cholecystic fluid, and, on occasion, sonographic Murphy chronic conditions, such as diverticulitis and cholelithiasis. sign. Again, WBC count may be elevated in the presence Gut rest and decompression, for the most part, are basic, of infection or cholangitis. Asparate aminotransferase yet very effective treatments for certain diagnoses related to (AST), alanine aminotransferase (ALT), bilirubin, and acute abdominal pain, such as pancreatitis or diverticulialkaline phosphate (ALP) may be elevated; however, these tis.38,39 Antibiotic therapy is indicated when infection is presstudies may also be normal. Elevation in the serum total bilirubin and ALP concentrations may not be present but ent in cases, such as peritonitis, diverticulitis, pancreatitis, should not rule out cholecystitis. Clinical correlation, cholecystitis, and appendicitis.38,40-42 In a systematic review patient presentation, and physical exam findings must also conducted by Fitzmaurice and colleagues, antibiotic therapy be considered in the diagnosis of acute cholecystitis. as a standalone treatment for appendicitis failed as sole treatment but was considered an important “bridge therapy” for Ectopic pregnancy surgical intervention.42 Appendectomy still remains the gold In female patients of reproductive age, a serum beta-hCG standard of care for the treatment of acute appendicitis. is taken first, and if positive, it is followed by ultrasound Pain management for acute abdomen can be a challenge (transvaginal).37 If a live extrauterine pregnancy is seen, an for providers because of the belief that analgesia may mask or eliminate the very symptoms that aid in the diagnosis. absent intrauterine sac, free fluid, or blood in the peritoNonetheless, analgesia is necessary when pain is intolerable neum or pelvis, then the diagnosis of ectopic pregnancy is and severe. The findings of a randomized control trial conmade. ducted by Ravari and colleagues supported that proper administraSummary of diagnostic testing and treatment tion of analgesics did not interfere First-line lab testing for the following differential diagnoses include CBC count, with appropriate diagnosis related Chemistry, LFTs, amylase, lipase, U/A, coagulation studies, beta-hCG (if indicated), to acute abdominal pain.43 In fact, and type and screen. Imaging studies and treatment options are listed below. it was found that patients receiving analgesia had decreased delay from Differential Imaging Treatment diagnosis to surgical intervention. Appendicitis CT Surgery, antibiotics if indicated A final but most important SBO CT, or flat and Surgery if complete, otherwise therapy is hydration. In most cases, upright radiography watchful waiting, gut rest, patients presenting with acute abdecompression, hydration dominal pain may not be consumCholecystitis Ultrasound (U/S) Surgery if indicated, antibiotics if ing an adequate amount of fluids warranted, diet and medical due to nausea, vomiting, diarrhea, management and anorexia. It is essential to asPerforated ulcer CT Surgery, antibiotics if indicated sess for oral intake with regard to Ruptured U/S Surgery, antibiotics if indicated timing and amounts. Regardless of ectopic the diagnosis, patients presenting Diverticulitis CT Hydration, pain management, with acute abdominal pain should antibiotics, diet and medical management be receiving either I.V., oral hydration if tolerated, or both.44,45 AAA CT Surgery if aneurysm is greater than insufficiency may also be present depending on the level of the aneurysm in relation to kidney perfusion. Coagulation studies (prothrombin time [PT] and partial thromboplastin time [PTT]) may also be prolonged with aortic dissection.
5 cm (may vary depending upon patient risk comorbidity), otherwise medical management, watchful waiting
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Case discussion Mr. S was admitted to the surgical unit of the hospital after complewww.tnpj.com
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Evaluation of acute abdominal pain
tion of his abdominal CT scan. Based on clinical presentation, physical exam, and preliminary lab results, Mr. S was diagnosed with acute appendicitis, which was confirmed with the abdominal CT scan results. He was prescribed nothing by mouth and I.V. fluids were started. A type and screen and coagulation studies were drawn. A surgical consult was ordered and he underwent an uncomplicated appendectomy and had an uneventful hospital stay. He was discharged, given postoperative instructions, advised to continue his hydrochlorothiazide and pain medication as directed, and given a 1-week follow-up appointment with the surgeon. ■ Moving forward Abdominal pain accounts for 4% to 5% of ED visits, resulting in various diagnoses, some of which require surgical intervention. The outcome goals are to decrease morbidity and mortality by avoiding misdiagnosis, and most importantly, avoiding delay to treatment. These outcomes can be achieved through accurate assessment and diagnosis. Relying on physical assessment alone is not enough. Incorporating lab testing, disease-appropriate imaging, and correlating findings to clinical presentation will assist the NP in achieving these outcomes safely and efficiently. REFERENCES 1 Stoker J, van Randen A, Laméris W, Boermeester M. Imaging patients with acute abdominal pain. Radiology. 2009;253(1):31-46. 2. Nobie B. Small-bowel obstruction clinical presentation. The Medscape Reference Website. http://emedicine.medscape.com/article/774140-clinical. 3. Craig S. Appendicitis. The Medscape Reference Website. http://emedicine. medscape.com/article/773895-overview. 4. Cole E, Lynch A, Cugnoni H. Assessment of the patient with acute abdominal pain. Nurs Stand. 2006;20(39):67-75. 5. Incesu L. Appedicitis imaging. The Medscape Reference Website. http:// emedicine.medscape.com/article/363818-overview. 6. GE Healthcare. What is acute appendicitis. 2010. http://www.news-medical. net/health/What-is-Acute-Appendicitis.aspx 7. Trevino C. Small bowel obstruction: The art of management. AACN Adv Crit Care. 2010;21(2):187-194. 8. Nguyen MC. Diverticulitis. The Medscape Reference Website. http://emedicine. medscape.com/article/173388-overview. 9. Vermeulen J, van der Harst E, Lange JF. Pathophysiology and prevention of diverticulitis and perforation. Neth J Med. 2010;68(10):303-309. 10. Lopez N, Kobayashi L, Coimbra R. A comprehensive review of abdominal infections. World J Emerg Surg. 2011;6:7. 11. Alaniz C, Regal RE. Spontaneous bacterial peritonitis: A review of treatment options. P T. 2009;34(4):204-210. 12. Daley B. Peritonitis and abdominal sepsis. The Medscape Reference Website. http://emedicine.medscape.com/article/180234-overview#aw2aab6b2b6aa. 13. Pearce W. Abdominal aortic aneurysm. The Medscape Reference Website. http://emedicine.medscape.com/article/463354-overview#a0104. 14. Golledge J, Norman P. Atherosclerosis and abdominal aortic aneurysm: Causes, response or common risk factors. Arterioscler Thromb Vasc Biol. 2010;30(6):1075-1077.
18. Barnhart K. Ectopic pregnancy. N Engl J Med. 2009;361(4):379-387. 19. Higgins R. Abdominal assessment and diagnosis of appendicitis. Emerg Nurse; 2009;16(9):22-24. 20. Holcomb S. Acute abdomen: What a pain! Nursing. 2008;38(9):34-40. 21. Murphy P, Colwell C, Pineda G, Bryan, T. Abdominal pain. EMS World. http:// www.emsworld.com/article/10319892/abdominal-pain?page=4. 22. Zimmerman P. Is it appendicitis?. Am J Nurs. 2008;108(9):27-31. 23. Snyder JA, Gurevutz SL, Rush LS, McKeague LC, Houpt CG. Appendicitis review. Clin Rev. 2012;22(1):23-28. 24. Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008;77(7):971-978. 25. Vajnar J. Appendicitis: What helps to make the diagnosis? JAAPA. 2008;21(4):79-81. 26. Ebell MH. Diagnosis of appendicitis: Part I. History and physical exam. Am Fam Physician. 2008;77 (6):828-830. 27. O’Neill S, Ross P, McGarry P, Yalamarthi S. Latest diagnosis and management of diverticulitis. Br J Med Pract. 2011;4(4):a443. 28. National Digestive Diseases Information Clearing house (NDDIC). Diverticulosis and diverticulitis. July 2008. NIH Publication No. 08-1163. http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/. 29. Craig M, Infante S. Abdominal mysteries: Pain, peritonitis, pancreatitis, pseudocyst. Nephrol Nurs J. 2011;38(2):173-186. 30. Brenner, D., Hall E. Computed Tomography—An increasing source of radiation exposure, The New England Journal of Medicine, 2007, 357: 22772284, November 29, 2007 31. Busch M., Gutzwiller, F., Aellig, S., Kuettel, R., Metzger, U. (2011). In-hospital delay increases the risk of perforation in adults with appendicitis, Journal of Surgery, 37(7), 1626-1633 32. Panebianco NL, Jahnes K, Mills AM. Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin North Am. 2011;29:175-193. 33. Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study (MASS): Cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomized controlled trial. BMJ. 2002;325(7373):1135ProQuest Health & Medical Complete. 34. Horton K. Case of the month. Crit Rev Comput Tomogr. 2003;44(4):183-186. 35. Alobaidi M, Gupta R, Jafri SZ, Fink-Bennet DM. Current trends in imaging evaluation of acute cholecystitis. Emerg Radiol. 2004;10(5):256-258. 36. Bondi M, Miller R, Zbar A, Hazan Y, Appelman Z, Caspi B, Mavor E. Improving the diagnostic accuracy of ultrasonography in suspected acute appendicitis by the combined transabdominal and transvaginal approach. Am Surg. 2012;;78(1)ProQuest Health & Medical Complete:98-103. 37. Kadasne AR, Mirghani HM. The role of ultrasound in life-threatening situations in pregnancy. J Emerg Trauma Shock. 2011;4(4):508-511. 38. Mulder I and Vermeulen J. Treatment options for perforated colonic diverticular disease. CML Gastroenterol. 2011;30(3):77-84. 39. McCafferty MH, Roth L, Jorden J. Current management of diverticulitis. Am Surg. 2008;74(11):1041-1049. 40. Udgiri N, Curras E, Kella V, Nagpal K, Cosgrove J. Appendicitis, is it an emergency? Am Surg. 2011;77(7):898-901. 41. Hassan I, Cima RR, Larson DW, Dozois EJ, O’Byrne MM, Larson DR, Pemberton JH. The impact of uncomplicated and complicated diverticulitis on laparoscopic surgery conversion rates and patient outcomes. Surg Endosc. 2007;21(10):1690–1694. 42. Fitzmaurice GJ, McWilliams B, Hurreiz H, Epanomeritakis E. Antibiotics versus appendectomy in the management of acute appendicitis: A review of the current evidence. Can J Surg. 2011;54(5):307-314. 43. Ravari H, Ghaemi M, Vojdani A, Khashyar P. Does analgesia effect the diagnostic process in acute abdomen. Tehran Univ Med J. 2008;65(10):6-10. 44. Morse B, Smith B, Lawdahl R, Roettger R. Management of acute cholecystitis in critically ill patients: Contemporary role for cholecystostomy and cholecystecomy. Am Surg. 2010;76(7):708-712. 45. Oxentenko AS, Bundrick JB, Litin SC. Clinical pearls in gastroenterology 2011. Mayo Clin Proc. 2011;86(11):1104-1108.
15. Bloom A. Cholecystitis. The Medscape Reference Website. http://emedicine. medscape.com/article/171886-overview#a0104.
Scott J. Saccomano is an assistant professor at Herbert H Lehman College, Department of Nursing, Bronx, NY. Lucille R. Ferrara is an assistant professor, Director Family Nurse Practitioner Program at Pace University, College of Health Professions Pleasantville, NY.
16. Strasberg S. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804-2811.
The authors have disclosed that they have no financial relationships related to this article.
17. Sepillian V. Ectopic pregnancy. The Medscape Reference Website. http:// emedicine.medscape.com/article/258768-overview#a0104.
DOI-10.1097/01.NPR.0000433077.14775.f1
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r. S is a 42-year-old male who presents to the ED with abdominal pain. His past medical history is significant for hypertension that is well controlled on hydrochlorothiazide 25 mg daily. He denies drinking, smoking, or taking illicit or recreational drugs. He states that the abdominal pain started around 3 a.m. accompanied by nausea
M
and vomiting. His last bowel movement was 2 days ago, which he describes as normal, and the present pain is 8/10 on a 0 to 10 pain scale. He vomited three times today, and each incidence was accompanied with green fluid. He also has not eaten today and is unable to keep oral fluids down. Mr. S denies recent travel, and his last meal was 2 days ago when he ate buffalo wings
Key words: abdomen assessment, abdominal pain, acute abdomen, acute abdominal pain, gastrointestinal pain
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Evaluation of acute
Evaluation of acute abdominal pain
and a burger at a party. His physical exam findings include the following: Vital signs (VSs): BP 160/100, pulse 102, respirations 18, temperature 101.2° F (38.4° C), weight 204 lbs (92.5 kg), height 72 in (182.9 cm) General: 42-year-old man in moderate distress, pale and diaphoretic Physical exam: • cardiac—normal S1S2; no murmurs, gallops, rubs • Pulmonary—bilateral breath sounds, clear to auscultation bilaterally • Abdominal—+ rebound, guarding, + psoas, + McBurney, hypoactive bowel sounds, distended. Lab and ECG results: • Complete blood cell (CBC) count: hemoglobin (Hb)— 14.2 g/dL; hematocrit (Hct)—37%; white blood cell (WBC) count: 22,000 cells/mm3 with a left shift • Chemistry (Chem): blood urea nitrogen—40 mg/dL, creatinine—1.0 mg/dL Amylase/lipase within normal limits (wnl) • Liver function test (LFT): wnl; urinalysis (U/A) wnl • ECG: normal sinus rhythm; no changes from last ECG dated May 2011 Mr. S was diagnosed with acute abdominal pain; rule out appendicitis. He was transferred from the ED to the radiology department for an abdominal computed tomography (CT) scan. The following is a guideline for assessing abdominal pain, specifically, acute abdominal pain. ■ Overview Abdominal pain is a common complaint encountered by both primary care and ED providers. Although common, varying levels in the severity of pain will dictate the immediacy of the intervention. Whether this patient is seen in the office or the ED, time is vital when making the decision to initiate therapeutic intervention efficiently. The key to initiating treatment lies in a comprehensive assessment not only from the physical exam but also from the studies that contribute to confirming diagnosis as well. ■ Epidemiology Abdominal pain accounts for approximately 4% to 5% of all ED visits.1 Approximately 14% of these patients have appendicitis, 5% will be diagnosed with cholecystitis, 20% with small bowel obstruction (SBO), and less than 1% with perforated peptic ulcer.1,2 Sixty percent of all SBOs are due to postsurgical adhesions.2 Finally, diverticulitis accounts for over 150,000 hospital admissions per year with increased incidence in patients over 80 years old.1 www.tnpj.com
■ Pathophysiology of common conditions of the acute abdomen Appendicitis Operative fi ndings classify appendicitis as one of three types: simple, gangrenous, or perforated. In simple appendicitis, the appendix is complete and viable. Necrosis of the appendiceal wall is characteristic of necrotic appendicitis. A disruption in the appendix is classified as perforated. Appendicitis is usually caused by a bacterial infection and results in obstruction of its orifice. Obstruction of the orifice leads to lymphoid hyperplasia secondary to dehydration and infection. Common causes of obstruction include mechanical obstruction, such as fecal matter, tumors, parasites, foreign bodies (fruit seeds), viral, and bacterial agents. Once the appendiceal lumen is obstructed, the mucosa continues to produce fluid. The mucosal fluid accumulation in the appendix produces a change in the intraluminal pressure greater than venous pressure, resulting in obstruction. The appendiceal obstruction causes hypoxia, which breaks down the appendiceal mucosa, creating a portal of entry for bacterial (colon bacilli and streptococci) and bowel flora. At this point, usually 24 to 36 hours later, the appendix is gangrenous, perforates, and the contents of the infected appendix are deposited in the peritoneal cavity.3-6 SBO SBO, occlusion, or paralysis of the bowel lumen causes fluid and gas to collect proximal to the occlusion. Gastric hydrochloric acid and chyme normally move through the bowel inhibiting bacterial growth. Intestinal dilation as a result of bowel obstruction increases capillary permeability, spilling fluid and electrolytes into the peritoneal cavity. Stasis accumulation of fluid, electrolytes, and abdominal distention leave the bowel predisposed to bacterial proliferation; the patient is at risk for bowel perforation and peritonitis. SBOs are classified into three categories: mechanical obstruction, nonmechanical obstruction, and pseudoobstruction. Surgical adhesions are the most common cause of mechanical obstruction followed by hernias and tumors. Colon cancer is the most common cause of large bowel obstruction. Nonmechanical causes include postoperative paralytic ileus, peritonitis, appendicitis, and spinal or thoracic fractures. Pseudoobstruction causes include neurologic and collagen vascular disorders.2,7 Diverticulitis Diverticula are herniated, pouch-like protrusions through the muscular wall of the small intestine or colon. Diverticula can occur throughout the colon, but the most common area is the sigmoid colon due to its small diameter. Increased The Nurse Practitioner • November 2013 47
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Evaluation of acute abdominal pain
bowel content causes intraluminal pressure to increase, causing the colon to hypertrophy. The hypertrophied colon wall becomes thick and rigid, herniation occurs at the weakest points of the submucosa and mucosa, and the diverticula become obstructed with localized abscess formation. The abscesses can perforate, causing peritonitis, further erosion of the intestinal wall with bleeding, and possible bowel obstruction.8,9 Peritonitis Peritonitis, an infection of the serous membrane of the peritoneal cavity, results from the hematogenous and lymphogenous spread of bacteria or fungi via an intact gut wall from the intestinal lumen. The peritoneum, a normally sterile environment, is infected through organ perforation. Bacteria or fungi enter the abdominal cavity causing an inflammatory response of vascular dilation, capillary permeability, and phagocytosis of invading organisms. If the inflammatory response is unsuccessful and the organism is not contained, fluid weeping into the peritoneal cavity causes inflammation, infection, and contamination. The fluid shifts into the peritoneal cavity, connective tissue, and vascular space, resulting in decreased circulatory volume. Organ and tissue perfusion that is severely diminished from the fluid shifts can potentially lead to renal failure and fluid/ electrolyte imbalances. Peritonitis can reduce or stop peristalsis, increasing bowel distention, and decreasing colon reabsorption, thus increasing intestinal reabsorption of toxins leading to bacteremia or septicemia.10-12 Abdominal aortic aneurysm The primary cause of an abdominal aortic aneurysm (AAA) is atherosclerosis secondary to a loss of elastin and collagen in the aorta, causing weakness of the vessel wall. Atherosclerotic plaques are deposited beneath the intima and cause degenerative changes in the media tunica. The mechanical stress to the vessels, with concurrent loss of muscle fibers and degradation of the media tunica, fills the cystic spaces with a metachromatic myxoid material. The mechanical stress causes weakness and decreased elasticity, which leads to increased vessel diameter and length.13,14 Cholecystitis Cholecystitis, acute bacterial inflammation of the gallbladder, is primarily a result of gallbladder outlet obstruction. Primary inflammation of the gallbladder is caused by continued blockage of the common bile duct or the cystic duct. Gallstones cause the majority of acute cholecystitis cases. The gallstones cause local irritation, distention, decreased blood supply, compromised lymphatic drainage, and symptoms of inflammation. Prostaglandins are 48 The Nurse Practitioner • Vol. 38, No. 11
released due to the inflammation, which reduces gallbladder contractility and motility leading to increased inflammation. Gangrene and perforation can result if inflammation is not treated.15,16 Ectopic pregnancy An ectopic pregnancy occurs when an ovum is implanted outside the confines of the uterine cavity, such as the fallopian tubes, cervix, or abdomen. The majority of ectopic pregnancies are located in the fallopian tube.17 The primary cause of ectopic pregnancy is thought to be alterations or destruction of the fallopian tubes. Alterations such as tubal length, diverticula, or kinking may make the ovum’s journey to the uterus longer. As the journey to the uterus is now longer, the ovum has time to multiply and grow, making its size more difficult to pass through the narrow tubes when it is ready for implantation. When implantation occurs, the tube stretches to its maximum size and ruptures, causing abdominal pain. Common causes of ectopic pregnancy include pelvic inflammatory disease, structural narrowing of the tubes, salphingitis, endometriosis, surgery with adhesions or scar tissue, intrauterine devices, and multiple abortions.17,18 ■ Assessment and associated clinical findings A comprehensive patient history will provide most of the information needed to arrive at a diagnosis. It is important to ascertain the history leading up to the current event or episode. Common, significant abdominal complaints in primary care include the following: nausea/vomiting, change in appetite, change in bowel habits, rectal bleeding, jaundice, abdominal distention, abdominal mass, and pain. Pain history is one of the most important components and should be thoroughly evaluated. Common questions regarding pain history should include the following: location—where is the pain and quality of pain—has the patient had this pain before? The location can suggest the cause of pathology; midline pain can be bowel related, where radiating pain may require more of a diagnostic workup; timing or onset of pain should be evaluated to assess the pain patterns over time; severity of pain, using the routine 0 to 10 pain scale (see Abdominal regions, reference planes, and quadrants). In terms of quality of pain, patients may not be able to accurately describe it but should be asked to point to the area of pain. Determine if the pain radiates; when radiation is present, it is usually helpful in the diagnostic evaluation with concurrent symptoms. Ask about aggravating and alleviating factors, last bowel movement (BM) or marked change in BM and the consistency of the BM, melana—presence of blood in the stool, hematemesis, oral intake, any nausea, vomiting, urological symptoms, and recent travel.19,20 www.tnpj.com
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Evaluation of acute abdominal pain
Abdominal regions, reference planes, and quardrants
Key Abdominal Regions: RH Right hypochondrium RL Right flank (lateral region) RI
Right inguinal (groin)
E
Epigastric
U Umbilical P Pubic LH Left hypochondriac LL Left flank (lateral region) LI Left inguinal (groin) Abdominal Quadrants:
RH
RL
E U
LH
RUQ
Right upper quadrant
LUQ
Left upper quadrant
RLQ
Right lower quadrant
LLQ
Left lower quadrant
LL
RUQ
LUQ
RLQ
LLQ
Median plane RI
P
LI
Transumbilical plane Anterior superior iliac spine (ASIS) Inguinal ligament
(A) Abdominal regions
(C) Abdominal quadrants
Jugular line Midclavicular line (MCL) Transpyloric plane Subcostal plane Transtubercular plane
Semilunar lines
L4 L5
Iliac tubercle Interspinous plane
Pubic symphysis
Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Liver: right lobe Gallbladder Stomach: pylorus Duodenum: parts 1-3 Pancreas: head Right suprarenal gland Right kidney Right colic (hepatic) flexure Ascending colon: superior part Transverse colon: right half
Liver: left lobe Spleen Stomach Jejunum and proximal ileum Pancreas: body and tail Left kidney Left suprarenal gland Left colic (splenic) flexure Transverse colon: left half Descending colon: superior part
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)
Cecum Appendix Most of ileum Ascending colon: inferior part Right ovary Right uterine tube Right ureter: abdominal part Right spermatic cord: abdominal part Uterus (if enlarged) Urinary bladder (if very full)
Sigmoid colon Descending colon: inferior part Left ovary Left uterine tube Left ureter: abdominal part Left spermatic cord: abdominal part Uterus (if enlarged) Urinary bladder (if very full)
(B) Abdominal reference planes
Source: Moore KL, Dalley AF, Agur, AM. Clinically Oriented Anatomy. 6th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2011:185.
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Evaluation of acute abdominal pain
reports pain over the area of inflammation once pressure is removed.20,21 Digital rectal exam (DRE) is indicated with lower abdominal/pelvic pain. DRE can reveal fecal impaction, hemorrhoids, or prostate enlargement. DRE is also necessary to receive a stool for occult bleeding.7 A pelvic exam can reveal vaginitis and cervical/adnexal tenderness, which may indicate ectopic pregnancy.24 Clinical manifestations of appendicitis vary, which make it difficult to diagnose. Patients with appendicitis present with continuous periumbilical pain, eventually shifting to the right at McBurney point. Tenderness is localized, muscle guarding and rebound tenderness are present, and the patient prefers to lie still with the right lower extremity flexed. A low-grade fever may or may not be present, Rovsing sign is positive, and coughing exaggerates the pain.18,22,23,25,26 Patients with SBO complain of vomiting, constipation, inability to pass gas, periumbilical abdominal pain, or tenderness and abdominal distention. Pain with SBO is reported as intermittent and cramping, usually in the periumbilical or epigastric areas. Initially, patients may present with diarrhea; however, once the distal bowel is emptied, constipation and the inability to pass gas are reported symptoms. Bowel sounds can The majority of AAAs are often be high pitched (in early obstruction) or absent (in late obstruction).2,24 asymptomatic and usually identified Diverticulitis is primarily asympon routine physical exam. tomatic; however, patients with symptoms tend to report abdominal pain with changes in bowel habits—usually constiupper quadrant (RUQ), and the patient feels pain in this area pation—and patients are without symptoms of infection. Pain and will have “inspiratory arrest.” A positive Rovsing sign is with diverticulitis is localized over the affected area of the elicited when the patient reports tenderness in the right lower colon, typically in the left lower abdomen. The pain may be quadrant (McBurney point tenderness) as the examiner perworse after eating and relieved with a bowel movement or forms deep palpation. In addition, other signs of peritoneal flatus. In addition, patients present with fever, leukocytosis, irritation include the psoas sign and the obturator sign. A bloating, nausea, vomiting, and positive occult blood in stool. positive psoas sign (irritation of the psoas muscle) is elicited A positive history of diverticulosis assists in making the diwhen the patient is supine and reports pain when asked to lift verticulitis diagnosis.8,27,28 The most common symptom of his or her thigh with the examiners hand placed just above peritonitis is abdominal pain, and the area involved is usually the knee; this may indicate that appendicitis may be present. tender. Other common signs of peritoneal irritation are reIn addition, the obturator sign can be positive in appendibound tenderness, muscular rigidity, and spasms. Respirations citis. With the patient in the supine position, the right hip cause abdominal pain, shallow respirations may be visible, and and knee are flexed while passively and internally rotating the the patient may lie still, as any movement such as jarring the right leg; right-sided abdominal pain indicates irritation of stretcher causes pain known as “shake tenderness.” Based on the obturator muscle.20,22,23 the severity of infection and the underlying cause of peritonitis, symptoms such as ascites, fever, tachycardia, nausea, Assessment for rebound tenderness is completed using vomiting, and change in bowel habits may be present.11,12,29 the fingertips and pressing the most painful area of the abdomen. This position is held until the pain diminishes The majority of AAAs are often asymptomatic and usuor the patient adapts to the pain, the examiner then quickally identified on routine physical exam. Physical exams also ly withdraws his or her hand, removing the pressure. reveal periumbilical abdominal pulsations and bruits. AAA Positive rebound tenderness is present when the patient can mimic symptoms of back pain or other abdominal
Assess VSs, paying particular attention to fever related to infection and orthostatic hypotension associated with complaints of dizziness. Tachycardia can indicate internal bleeding. In addition, orthostatic hypotension and tachycardia can be related to fluid volume depletion if vomiting or diarrhea is present. The general appearance of the patient should be assessed for signs and symptoms of pallor, restlessness, sweating, signs of peritonitis, and toxicity.20,21 Perform a complete abdominal exam, placing the patient in the supine position with the hips flexed. Inspect the contour of the abdomen, location of any scars, skin color, and skin texture. Auscultate for bowel sounds, and continue with percussion, palpation, and evaluation of extra-abdominal sources of abdominal pain. When percussing and palpating the abdomen, begin in a nonpainful region. It is important to determine the areas of localized tenderness, masses, liver span, and spleen size. Assess for abdominal rigidity, the presence of guarding, rebound tenderness, abdominal bruits, and assess for peritoneal irritation using Murphy sign if cholecystitis is suspected and Rovsing sign if appendicitis is suspected. Murphy sign can be elicited as the patient takes a deep breath, the examiner applies pressure in the area of the gallbladder, right
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Evaluation of acute abdominal pain
disorders, such as ureteral obstruction. Other clinical symptoms such as hypotension, atypical back, or abdominal pain may be present if the aneurysm is ruptured.13,21 Patients with cholecystitis present with colicky pain in the RUQ—usually with radiation to the flank and occasionally to the right shoulder—and are accompanied by nausea and vomiting. Biliary colic is localized to the midepigastric region and sometimes to the RUQ. Pain routinely occurs within 1 hour after a meal and persists for days with residual aching. Abdominal discomfort occurs following a highfat meal and may have associated symptoms of nausea, vomiting, anorexia, and fever. The patient may report a history of prior episodes, and Murphy sign is common.16,20,29 Patients with ectopic pregnancy report the initial signs of pregnancy, amenorrhea—a missed period, spotting, tender breasts, tiredness, urinary frequency, and fatigue. As the pregnancy develops, patients report increasing severe lower quadrant abdominal pain with movement, increased vaginal bleeding, and pain during intercourse. Peritoneal signs such as rebound tenderness and guarding with abdominal distention are present with a ruptured ectopic pregnancy. As the patient may be experiencing internal bleeding, signs and symptoms of dizziness, lightheadedness, or syncope may be present.17,18 ■ Testing The cost of acute abdominal pain is closely correlated to the type of testing and treatment rendered. Testing, especially imaging, can drive up cost, which is why choosing appropriate testing as an adjunct to physical exam is key. For example, the definitive imaging study that will provide the best information for diagnosing acute cholecystitis is ultrasound; however, CT is the imaging test of choice regarding the acute abdomen when appendicitis is suspected. Radiation exposure risk is always a concern, especially with the pediatric population.30 The exposure to radiation from CT scan of the abdomen and pelvis is 15 mSv. The average American receives approximately 3 mSv per year from radiation that naturally occurs in the surrounding environment. The increased risk of radiation exposure occurs with overuse of CT scan for diagnostic testing (for example, when performing multiple CT scans of the head for diagnosis related to headache or blunt trauma).30 When weighing the risk-to-benefit ratio, it is prudent to use a confirmatory test that will decrease the morbidity and mortality of patients suspected of having acute appendicitis. Quickly arriving at a diagnosis is critical, especially since delay in diagnosis (over 12 hours) of acute appendicitis can result in rupture,31 which may result in lifethreatening complications, such as peritonitis and sepsis. SBO is best diagnosed with flat and upright radiograph, especially in the absence of CT or if the patient is unable to tolerate CT www.tnpj.com
contrast.1,32-35 In addition to imaging, lab studies are essential in making or confirming diagnosis and initiating treatment. The most common labs that should be obtained for acute abdomen include CBC count, LFTs, Chem, amylase, lipase, U/A, beta-human chorionic gonadotropin (beta-hCG) for women of reproductive age, coagulation studies, and finally, a type and screen if surgical intervention is imminent. Other specialty lab tests would include blood cultures for febrile acute abdominal pain. Risk stratification should be determined for anesthesia administration as well as ECG, cardiac, and other testing for patients with comorbid states where they may be considered at high risk for surgical intervention. ■ Diagnostic findings Appendicitis As mentioned, acute appendicitis accounts for 14% of all acute abdominal pain presenting to the ED. In addition to the physical exam findings, CT findings for appendicitis typically show enlargement of the appendix greater than 6 mm. In a study conducted by Bondi et al., transvaginal ultrasound was used for diagnosis when the appendix was difficult to visualize on CT in female patients with suspected acute AP.36 Inflammatory markers such as a WBC count (specifically leukocytes) are usually elevated and are strong indicators of infection (peritonitis). Routine U/A will be normal or negative but should be performed in order to rule out renal calculi and pyelonephritis. SBO The gold standard test for SBO is the flat and upright radiograph. Findings consistent with SBO are dilated fluid-filled loops of bowel proximal to the obstruction. Leukocytosis may also be present in the presence of peritonitis, ischemic bowel, and infection. Liver enzymes will usually be normal, but electrolytes may be altered if the patient is dehydrated secondary to the obstruction and malabsorption. Diverticulosis/diverticulitis On CT, the study of choice for diverticulitis—typically bowel wall thickening—is the most common finding, but infiltration of pericolonic fat, abscess, and fluid or free air in the peritoneal cavity may also be present. Leukocytosis is commonly seen due to inflammation and infection. A decrease in Hb and Hct can occur in patients with chronic diverticulosis. AAA CT scan is the test of choice for diagnosing an AAA; however, ultrasound provides 98% accuracy for sizing the aneurysm.34 An aneurysm measuring greater than 5 cm indicates the need for surgical intervention. Anemia may be a finding in the presence of retroperitoneal bleeding. Renal The Nurse Practitioner • November 2013 51
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Evaluation of acute abdominal pain
■ Treatment The treatment for the acute abdomen is dependent upon the underlying cause or diagnosis (see Summary of diagnostic testing and treatment). Surgical intervention is most likely going to be the first-line treatment in the case of ruptured appendix, ruptured ectopic pregnancy, incarcerated hernia, Cholecystitis complete SBO, and perforated ulcer. Other treatment options Typical findings on ultrasound will demonstrate the presmay include antibiotic therapy, gut rest and decompression, ence of stones or calculi, gallbladder wall thickening, peripain management, hydration, and medical management for cholecystic fluid, and, on occasion, sonographic Murphy chronic conditions, such as diverticulitis and cholelithiasis. sign. Again, WBC count may be elevated in the presence Gut rest and decompression, for the most part, are basic, of infection or cholangitis. Asparate aminotransferase yet very effective treatments for certain diagnoses related to (AST), alanine aminotransferase (ALT), bilirubin, and acute abdominal pain, such as pancreatitis or diverticulialkaline phosphate (ALP) may be elevated; however, these tis.38,39 Antibiotic therapy is indicated when infection is presstudies may also be normal. Elevation in the serum total bilirubin and ALP concentrations may not be present but ent in cases, such as peritonitis, diverticulitis, pancreatitis, should not rule out cholecystitis. Clinical correlation, cholecystitis, and appendicitis.38,40-42 In a systematic review patient presentation, and physical exam findings must also conducted by Fitzmaurice and colleagues, antibiotic therapy be considered in the diagnosis of acute cholecystitis. as a standalone treatment for appendicitis failed as sole treatment but was considered an important “bridge therapy” for Ectopic pregnancy surgical intervention.42 Appendectomy still remains the gold In female patients of reproductive age, a serum beta-hCG standard of care for the treatment of acute appendicitis. is taken first, and if positive, it is followed by ultrasound Pain management for acute abdomen can be a challenge (transvaginal).37 If a live extrauterine pregnancy is seen, an for providers because of the belief that analgesia may mask or eliminate the very symptoms that aid in the diagnosis. absent intrauterine sac, free fluid, or blood in the peritoNonetheless, analgesia is necessary when pain is intolerable neum or pelvis, then the diagnosis of ectopic pregnancy is and severe. The findings of a randomized control trial conmade. ducted by Ravari and colleagues supported that proper administraSummary of diagnostic testing and treatment tion of analgesics did not interfere First-line lab testing for the following differential diagnoses include CBC count, with appropriate diagnosis related Chemistry, LFTs, amylase, lipase, U/A, coagulation studies, beta-hCG (if indicated), to acute abdominal pain.43 In fact, and type and screen. Imaging studies and treatment options are listed below. it was found that patients receiving analgesia had decreased delay from Differential Imaging Treatment diagnosis to surgical intervention. Appendicitis CT Surgery, antibiotics if indicated A final but most important SBO CT, or flat and Surgery if complete, otherwise therapy is hydration. In most cases, upright radiography watchful waiting, gut rest, patients presenting with acute abdecompression, hydration dominal pain may not be consumCholecystitis Ultrasound (U/S) Surgery if indicated, antibiotics if ing an adequate amount of fluids warranted, diet and medical due to nausea, vomiting, diarrhea, management and anorexia. It is essential to asPerforated ulcer CT Surgery, antibiotics if indicated sess for oral intake with regard to Ruptured U/S Surgery, antibiotics if indicated timing and amounts. Regardless of ectopic the diagnosis, patients presenting Diverticulitis CT Hydration, pain management, with acute abdominal pain should antibiotics, diet and medical management be receiving either I.V., oral hydration if tolerated, or both.44,45 AAA CT Surgery if aneurysm is greater than insufficiency may also be present depending on the level of the aneurysm in relation to kidney perfusion. Coagulation studies (prothrombin time [PT] and partial thromboplastin time [PTT]) may also be prolonged with aortic dissection.
5 cm (may vary depending upon patient risk comorbidity), otherwise medical management, watchful waiting
52 The Nurse Practitioner • Vol. 38, No. 11
Case discussion Mr. S was admitted to the surgical unit of the hospital after complewww.tnpj.com
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Evaluation of acute abdominal pain
tion of his abdominal CT scan. Based on clinical presentation, physical exam, and preliminary lab results, Mr. S was diagnosed with acute appendicitis, which was confirmed with the abdominal CT scan results. He was prescribed nothing by mouth and I.V. fluids were started. A type and screen and coagulation studies were drawn. A surgical consult was ordered and he underwent an uncomplicated appendectomy and had an uneventful hospital stay. He was discharged, given postoperative instructions, advised to continue his hydrochlorothiazide and pain medication as directed, and given a 1-week follow-up appointment with the surgeon. ■ Moving forward Abdominal pain accounts for 4% to 5% of ED visits, resulting in various diagnoses, some of which require surgical intervention. The outcome goals are to decrease morbidity and mortality by avoiding misdiagnosis, and most importantly, avoiding delay to treatment. These outcomes can be achieved through accurate assessment and diagnosis. Relying on physical assessment alone is not enough. Incorporating lab testing, disease-appropriate imaging, and correlating findings to clinical presentation will assist the NP in achieving these outcomes safely and efficiently. REFERENCES 1 Stoker J, van Randen A, Laméris W, Boermeester M. Imaging patients with acute abdominal pain. Radiology. 2009;253(1):31-46. 2. Nobie B. Small-bowel obstruction clinical presentation. The Medscape Reference Website. http://emedicine.medscape.com/article/774140-clinical. 3. Craig S. Appendicitis. The Medscape Reference Website. http://emedicine. medscape.com/article/773895-overview. 4. Cole E, Lynch A, Cugnoni H. Assessment of the patient with acute abdominal pain. Nurs Stand. 2006;20(39):67-75. 5. Incesu L. Appedicitis imaging. The Medscape Reference Website. http:// emedicine.medscape.com/article/363818-overview. 6. GE Healthcare. What is acute appendicitis. 2010. http://www.news-medical. net/health/What-is-Acute-Appendicitis.aspx 7. Trevino C. Small bowel obstruction: The art of management. AACN Adv Crit Care. 2010;21(2):187-194. 8. Nguyen MC. Diverticulitis. The Medscape Reference Website. http://emedicine. medscape.com/article/173388-overview. 9. Vermeulen J, van der Harst E, Lange JF. Pathophysiology and prevention of diverticulitis and perforation. Neth J Med. 2010;68(10):303-309. 10. Lopez N, Kobayashi L, Coimbra R. A comprehensive review of abdominal infections. World J Emerg Surg. 2011;6:7. 11. Alaniz C, Regal RE. Spontaneous bacterial peritonitis: A review of treatment options. P T. 2009;34(4):204-210. 12. Daley B. Peritonitis and abdominal sepsis. The Medscape Reference Website. http://emedicine.medscape.com/article/180234-overview#aw2aab6b2b6aa. 13. Pearce W. Abdominal aortic aneurysm. The Medscape Reference Website. http://emedicine.medscape.com/article/463354-overview#a0104. 14. Golledge J, Norman P. Atherosclerosis and abdominal aortic aneurysm: Causes, response or common risk factors. Arterioscler Thromb Vasc Biol. 2010;30(6):1075-1077.
18. Barnhart K. Ectopic pregnancy. N Engl J Med. 2009;361(4):379-387. 19. Higgins R. Abdominal assessment and diagnosis of appendicitis. Emerg Nurse; 2009;16(9):22-24. 20. Holcomb S. Acute abdomen: What a pain! Nursing. 2008;38(9):34-40. 21. Murphy P, Colwell C, Pineda G, Bryan, T. Abdominal pain. EMS World. http:// www.emsworld.com/article/10319892/abdominal-pain?page=4. 22. Zimmerman P. Is it appendicitis?. Am J Nurs. 2008;108(9):27-31. 23. Snyder JA, Gurevutz SL, Rush LS, McKeague LC, Houpt CG. Appendicitis review. Clin Rev. 2012;22(1):23-28. 24. Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008;77(7):971-978. 25. Vajnar J. Appendicitis: What helps to make the diagnosis? JAAPA. 2008;21(4):79-81. 26. Ebell MH. Diagnosis of appendicitis: Part I. History and physical exam. Am Fam Physician. 2008;77 (6):828-830. 27. O’Neill S, Ross P, McGarry P, Yalamarthi S. Latest diagnosis and management of diverticulitis. Br J Med Pract. 2011;4(4):a443. 28. National Digestive Diseases Information Clearing house (NDDIC). Diverticulosis and diverticulitis. July 2008. NIH Publication No. 08-1163. http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/. 29. Craig M, Infante S. Abdominal mysteries: Pain, peritonitis, pancreatitis, pseudocyst. Nephrol Nurs J. 2011;38(2):173-186. 30. Brenner, D., Hall E. Computed Tomography—An increasing source of radiation exposure, The New England Journal of Medicine, 2007, 357: 22772284, November 29, 2007 31. Busch M., Gutzwiller, F., Aellig, S., Kuettel, R., Metzger, U. (2011). In-hospital delay increases the risk of perforation in adults with appendicitis, Journal of Surgery, 37(7), 1626-1633 32. Panebianco NL, Jahnes K, Mills AM. Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin North Am. 2011;29:175-193. 33. Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study (MASS): Cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomized controlled trial. BMJ. 2002;325(7373):1135ProQuest Health & Medical Complete. 34. Horton K. Case of the month. Crit Rev Comput Tomogr. 2003;44(4):183-186. 35. Alobaidi M, Gupta R, Jafri SZ, Fink-Bennet DM. Current trends in imaging evaluation of acute cholecystitis. Emerg Radiol. 2004;10(5):256-258. 36. Bondi M, Miller R, Zbar A, Hazan Y, Appelman Z, Caspi B, Mavor E. Improving the diagnostic accuracy of ultrasonography in suspected acute appendicitis by the combined transabdominal and transvaginal approach. Am Surg. 2012;;78(1)ProQuest Health & Medical Complete:98-103. 37. Kadasne AR, Mirghani HM. The role of ultrasound in life-threatening situations in pregnancy. J Emerg Trauma Shock. 2011;4(4):508-511. 38. Mulder I and Vermeulen J. Treatment options for perforated colonic diverticular disease. CML Gastroenterol. 2011;30(3):77-84. 39. McCafferty MH, Roth L, Jorden J. Current management of diverticulitis. Am Surg. 2008;74(11):1041-1049. 40. Udgiri N, Curras E, Kella V, Nagpal K, Cosgrove J. Appendicitis, is it an emergency? Am Surg. 2011;77(7):898-901. 41. Hassan I, Cima RR, Larson DW, Dozois EJ, O’Byrne MM, Larson DR, Pemberton JH. The impact of uncomplicated and complicated diverticulitis on laparoscopic surgery conversion rates and patient outcomes. Surg Endosc. 2007;21(10):1690–1694. 42. Fitzmaurice GJ, McWilliams B, Hurreiz H, Epanomeritakis E. Antibiotics versus appendectomy in the management of acute appendicitis: A review of the current evidence. Can J Surg. 2011;54(5):307-314. 43. Ravari H, Ghaemi M, Vojdani A, Khashyar P. Does analgesia effect the diagnostic process in acute abdomen. Tehran Univ Med J. 2008;65(10):6-10. 44. Morse B, Smith B, Lawdahl R, Roettger R. Management of acute cholecystitis in critically ill patients: Contemporary role for cholecystostomy and cholecystecomy. Am Surg. 2010;76(7):708-712. 45. Oxentenko AS, Bundrick JB, Litin SC. Clinical pearls in gastroenterology 2011. Mayo Clin Proc. 2011;86(11):1104-1108.
15. Bloom A. Cholecystitis. The Medscape Reference Website. http://emedicine. medscape.com/article/171886-overview#a0104.
Scott J. Saccomano is an assistant professor at Herbert H Lehman College, Department of Nursing, Bronx, NY. Lucille R. Ferrara is an assistant professor, Director Family Nurse Practitioner Program at Pace University, College of Health Professions Pleasantville, NY.
16. Strasberg S. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804-2811.
The authors have disclosed that they have no financial relationships related to this article.
17. Sepillian V. Ectopic pregnancy. The Medscape Reference Website. http:// emedicine.medscape.com/article/258768-overview#a0104.
DOI-10.1097/01.NPR.0000433077.14775.f1
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