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Abdominal Pain Part III
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.
ABSTRACT
Abdominal pain is one of the most common complaints that patients make to medical professionals, and it has a wide array of causes, ranging from very simple to complex. Although many cases of abdominal pain turn out to be minor constipation or gastroenteritis, there are more serious causes that need to be ruled out. An accurate patient medical history, family medical history, laboratory work and imaging are important to make an accurate diagnosis. Initial assessment and diagnostic testing will provide an early indication of cause and the possible treatment options, which are discussed.
Continuing Nursing Education Course Director & Planners
William A. Cook, PhD, Director, Douglas Lawrence, MS, Webmaster,
Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner
Accreditation Statement
This activity has been planned and implemented in accordance with the policies of and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.
Statement of Need
Health professionals in acute and non-acute health settings need to be able to recognize overt and subtle signs of conditions associated with abdominal pain in order to properly treat and/or refer to a specialist.
Course Purpose
To provide nurses with knowledge of the causes and treatments of acute and chronic abdominal pain.
Learning Objectives
1. Identify common laboratory testing for abdominal pain.
2. Describe how a pregnancy test can be used as a diagnostic tool for abdominal pain.
3. Identify common causes of abdominal pain that can be diagnosed using radiology techniques.
4. Explain various therapies used as treatment for abdominal pain.
5. Describe the relationship between electrolyte imbalance and abdominal pain.
Target Audience
Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates
Course Author & Director Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence,
Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support:
There is no commercial support for this course.
Activity Review Information:
Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC
Release Date: 12/10/2014 Termination Date: 12/10/2017
|Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a |
|self-assessment of knowledge learned will be provided at the end of the course |
1. The following is true of the CBC white blood cell (WBC) count:
a. Normal WBC count is between 4,500 and 11,000 mm3
b. Neutrophils are the most common type of WBC
c. When the WBC count is elevated neutrophils become elevated and infection can be suspected
d. All of the above
2. The complete metabolic profile (CMP) tests the patient’s:
a. CMV, hemoglobin and hematocrit
b. Electrolytes and kidney function
c. Total protein and liver enzymes
d. Answers b and c above
3. True or False. Ischemic conditions may reveal metabolic alkalosis due to lack of adequate oxygen to the abdominal tissues.
a. True
b. False
4. Classic symptoms of an ectopic pregnancy include:
a. Back pain radiating to the flank
b. Burning sensation in the suprapubic region
c. Abdominal pain with abnormal vaginal bleeding after amenorrhea
d. Answers a and b above
5. H-pylori is an infectious agent associated with:
a. Gastritis and peptic ulcer disease
b. Infection of the gut spread through fecal-oral transmission
c. 40 % affected individuals in the United States
d. All of the above
6. CT scan for appendicitis is performed to identify:
a. An abnormally shaped or enlarged appendix
b. Thinning of the wall of the appendix
c. A softened texture to the bowel mucosa
d. None of the above
7. True or False. Thrombolytic medications used to manage emboli of the mesenteric arteries include streptokinase or urokinase.
a. True
b. False
8. Fluid maintenance is important in the treatment of pancreatitis for prevention of:
a. Infection
b. Necrosis
c. Organ failure
d. All of the above
9. Pain management techniques considered by the clinician must:
a. Include a review of more than one form of treatment
b. Include a review of the best single method of treatment
c. Factor in patient differences and responses to pain
d. Answers a and c above
10. True or False. Patients with abdominal pain often experience a worsening of symptoms because they are type A personalities and cling to a feeling of being in control.
a. True
b. False
Introduction
Generalized abdominal pain can include a myriad of possible conditions that may make it difficult to identify a specific diagnosis through information provided solely through the patient history and physical examination. The potential causes of abdominal pain can be extensive and can result in quite a list of possibilities. The information gained through the patient’s history and through the physical examination can help to limit the possible causes of pain, and can guide the clinician toward the types of diagnostic tests necessary to isolate a diagnosis. Once the clinician reaches the point where the abdominal condition has been narrowed down to a few possible causes, diagnostic testing can then be ordered to rule out some conditions and to determine a final diagnosis.
Abdominal Pain And Diagnostic Testing
The type of diagnostic testing to perform for abdominal pain depends on the results of the patient’s examination, their description of the pain, and the information from the patient medical and family histories. When there is potential for more than one cause of the abdominal pain, diagnostic testing helps to pinpoint a diagnosis and rules out other potential causes of the abdominal pain. The clinician should consider all factors carefully before ordering diagnostic tests. While some amount of testing is necessary, ordering diagnostic tests without careful thought and planning may result in unnecessary tests that are costly both financially and in terms of the patient’s time.
There are certain diagnostic tests that can be ordered to help identify some general physical conditions, such as blood oxygenation, blood cell counts, and detection of infection. Furthermore, some imaging studies are relatively common and are necessary for viewing the abdominal organs and structures. Such tests can be ordered and are often performed quickly when the patient’s condition suggests the need to do so.
Laboratory Testing
Laboratory testing is an important component of the diagnostic process and should be obtained on any patient who presents with an acutely painful abdomen. However, in some cases, laboratory test results can be non-specific or may be completely normal, despite the presence of an active disease process. An example of when this can happen is with ischemic bowel disease; often, despite checking a complete blood count, electrolyte panel, and liver function tests, the results can be non-specific.15 Nonetheless, it is important to run laboratory tests as part of the medical management of abdominal pain to help identify or at least narrow down a potential diagnosis of the abdominal pain through a review and comparison of the test results.
Complete blood count
The complete blood count (CBC) is a common type of blood test that measures the cell components of blood. According to Lokwani in The ABC of CBC: Interpretation of Complete Blood Count and Histograms, “the complete blood count (CBC) is one of the most informative single investigation, expressing the health and disease status of the body, in the whole menu of laboratory medicine.”47 The CBC measures a number of different elements that can suggest disease or infectious processes within the body, based on the response of the cells. The CBC measures such items as blood cell counts, including white blood cells, red blood cells, and platelets; hemoglobin, which determines the amount of oxygen available to the body’s tissues; hematocrit, which is the percentage of red blood cells within whole blood; the different types of white blood cells available and their percentages (known as the differential), as well as any blood cell abnormalities.
Beyond identification of infection or inflammation, the CBC is useful for determining other conditions, particularly those that impact the bone marrow, where the blood cells are created. The CBC can be drawn to look for such conditions as anemia, thrombocytopenia, nutritional deficiencies, hemoglobinopathies, and certain forms of cancer, such as leukemia.47 It is relatively inexpensive to perform and most healthcare facilities that treat patients presenting for help with abdominal pain should have access to a facility to check blood for results. The results can be gathered quickly and while they may not always give a clear identification of the patient’s condition, they can point the provider toward further testing that will clarify a diagnosis.
If the patient’s condition suggests infection as a cause of the pain, a CBC with differential is warranted. A complete blood count should also be ordered when the patient may have an underlying condition that causes changes in blood cell function, such as anemia or a bleeding disorder.
The white blood cell count is often elevated in cases where abdominal pain is caused by an infectious or inflammatory process. Among patients with appendicitis, for example, the white count is typically elevated early on in the illness.20 Inflammatory conditions often cause an increase in white blood cells when leukocytes and plasma rush to the site of injury during the inflammatory response process. The body continues to produce more leukocytes, as it is aware of the infectious process that is taking place. A white blood cell count of 11,000 mm3 or more is classified as leukocytosis. Patients who are in an immunocompromised state, such as post-transplant patients or those diagnosed with cancer may not necessarily have an elevated white blood cell count in the presence of infection.45
A normal white blood cell count runs between 4,500 and 11,000 mm3 for both men and women. The differential is the breakdown of the various types of white blood cells and is listed as a percentage of the total amount of white blood cells. Neutrophils, which are the most common type, comprise up to 70 % of the total amount of white blood cells. Neutrophils are important for immunity and are often the first type of cell to arrive at the site of infection. When the white blood cell count is elevated and there are a large percentage of neutrophils, the provider can suspect that the patient has an infection.
Lymphocytes are the next most common form of white blood cell; a normal amount of lymphocytes make up between 25 and 35 % of the total amount of white blood cells.47 These cells are also responsible for protecting the body against infection and they develop specific responses to pathogens that have invaded the body in order to produce antibodies. Lymphocytes are also a main component of lymph fluid and lymph nodes.
The monocytes are the largest of all of the white blood cells and account for 4 to 6 % of the total amount. Monocytes work by destroying dead tissue and by protecting against certain types of cancer. When an infection develops, monocytes move into the affected area and turn into macrophages, which ingest foreign substances. Increased serum monocytes may indicate a chronic disease state, cancer, or an autoimmune disease.
Eosinophils are more often activated in response to allergen exposure and certain types of infections. They are types of cells known as granulocytes and they make up 1 to 3 % of the total white blood cell count. Basophils, another type of granulocyte, are activated in response to allergens and to other foreign pathogens, such as parasitic infections. Finally, band cells are immature forms of neutrophils that make up the earliest response to an infection. Bands make up between 3 and 5 % of the total white blood cell count.47
Red blood cells, called erythrocytes when they have reached maturity, are created in the bone marrow. The kidneys regulate erythrocyte production through erythropoietin, which stimulates the bone marrow to make more cells. Red blood cells are notable in that they contain hemoglobin, which is a substance that binds to oxygen molecules for transport. Therefore, the most significant function of the red blood cell is to transport oxygen molecules to various tissues by circulating through the bloodstream. Red blood cells have a lifespan of approximately 120 days and their number may be lessened as a result of various factors, including age, sex, kidney function, amount of exercise, and other lifestyle factors, such as tobacco or drug use.47
The impaired production of red blood cells results in various forms of anemia. Low red blood cell counts can also result from blood loss through hemorrhage. Some people have medical conditions that cause abnormalities in the red blood cells such that, although their cell counts may be normal, cell function is impaired. For example, a patient with sickle cell disease will have abnormally shaped red blood cells that have a shorter lifespan and that do not flow through the bloodstream well, and instead become stuck or clumped in certain areas of the bloodstream. These types of red blood cells do not perform normally and actually contribute to pain for the patient when cell clumping causes vessel occlusion, decreased oxygenation, and tissue ischemia.
The normal red blood cell count is approximately 4.6 to 6 million/mm3 for adult men and 4.2 to 5 million/mm3 for adult women.47 High levels of red blood cells can occur due to such conditions as heart or lung disease, polycythemia vera, or dehydration. Patients who smoke or those who live at high altitudes may also demonstrate increased red blood cell counts.
Coinciding with the red blood cell count is the hemoglobin level, also measured with the CBC. Hemoglobin is the portion of the red blood cell that carries oxygen; and, measuring this element in the CBC determines the body’s ability to bring oxygen to the organs and to tissues. Hemoglobin levels tend to be higher in men than in women. The normal range of hemoglobin for men is 13.3 to 16.2 g/dL, while the normal range of hemoglobin for women is 12.0 to 15.8 g/dL.47
Hemoglobin levels are decreased in conditions that result in blood loss, such as through hemorrhage from ulcerative colitis or gastrointestinal bleeding; and, may also be low with red blood cell deficiency as well as other conditions such as gastrointestinal inflammation. Alternatively, a patient may have elevated levels of hemoglobin. Although hemoglobin is important for oxygen transport, elevated levels typically do not indicate a positive occurrence. Instead, hemoglobin levels may be elevated in such conditions as polycythemia, respiratory disease such as with COPD, deficiency of folic acid or vitamin B12, and supplementation of certain hormones such as testosterone.
Slightly immature red blood cells are reticulocytes. The number of reticulocytes is measured to determine how rapidly they are being produced in the bone marrow. When a cell reaches the reticulocyte stage, it is one stage removed from being a fully mature red blood cell. A normal reticulocyte count ranges between 0.5 and 1.5 %. When the reticulocyte count is elevated, the patient may be anemic or could have some form of internal bleeding, which could be causing abdominal pain. Increased levels indicate that the bone marrow is working harder to create more red blood cells, possibly because of trying to make up for red cell destruction or loss. Decreased levels of reticulocyte counts are associated with bone marrow disease, liver cirrhosis, and kidney disease.47
The hematocrit, which is a measure of the percent of red blood cells within a volume of whole blood, is included as part of the CBC and determines the differentiation of red blood cells. The hematocrit may also be referred to as the packed cell volume or PCV. If the patient is suspected of being anemic, the hematocrit serves to determine not whether anemia is present, but rather the degree of severity of anemia. Normal hematocrit levels differ between adult men and women; for men, normal levels range between 38 and 46 percent, while the normal range for women is between 35 and 44 percent.47 High hematocrit levels may be due to dehydration, polycythemia, or heart disease; alternatively, low levels of hematocrit tend to be seen with bone marrow disease, hemorrhage, kidney or autoimmune diseases, and certain types of cancer, such as lymphoma.
Platelet counts determine the body’s ability to produce enough platelets to prevent bleeding and whether there are potentially pathological processes occurring that are causing the destruction of platelets. Platelets are essential for blood clotting and congregate at the site of an injury to combine with other clotting factors and close off a wound to prevent excessive bleeding. A normal platelet count is between 150,000 and 400,000 platelets/mcL.
Other elements of the CBC that may be checked include the mean corpuscular volume (MCV), which is the average volume of the red blood cell; the mean corpuscular hemoglobin (MCH), which identifies the amount of hemoglobin within a red blood cell; the mean corpuscular hemoglobin concentration (MCHC), which indicates the average amount of hemoglobin within a certain volume of red blood cells; and, the red cell distribution width (RDW), which measures the size variability of red blood cells.47 Together, these tests are known as red cell indices.
While the CBC is useful in determining whether a disease process is occurring within the body, it is a systemic test and, as such, has its limitations. The clinician may review the results of the CBC and determine that some element of disease process is going on within the patient, but the CBC does not necessarily allow the clinician to isolate the affected area. Despite this potential limitation, the CBC is one of the most commonly ordered tests among patients who present for care with acute abdominal pain.48 This and other forms of systemic laboratory tests provide important clinical information about the patient and support which direction the provider is taking toward diagnosis.
Cultures may also be required as part of diagnosis when infection is the potential cause of the abdominal pain. If the patient has indications of infection as noted from the CBC, a sample culture may then be performed if the area of infection can be isolated. Cultures can be taken from various sources, including blood, urine, sputum, abdominal fluid, or other tissue samples. If the patient needs antibiotics for treatment of an infection that is causing the pain, the culture identifies the specific offending organism, and the provider can use the information gained from the culture to prescribe antibiotics that can specifically target the infection-causing bacteria.
Complete metabolic profile
The metabolic profile checks the patient’s electrolyte levels and should be drawn to test for fluid status and kidney function.37 The complete metabolic profile (CMP) tests a group of various electrolyte and protein levels, all collected together into one test. The main components of the CMP include levels of electrolytes, such as sodium, potassium, and chloride, as well as total protein, alkaline phosphatase, albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin.
The CMP can be collected in a routine manner through a blood draw. The collected blood is then sent to the laboratory for analysis and the clinician can receive the results in a relatively short timeframe. The metabolic profile is a test of serum components, even though elements such as electrolytes are distributed between both the blood and the intracellular fluid in the body. It is important to note that intracellular levels of these metabolic elements may differ from serum levels, although it is not possible to test the intracellular levels. Abnormalities on the CMP indicate alterations in electrolyte levels, problems with liver or kidney function, and acid-base imbalances.
A number of conditions that cause abdominal pain may reveal abnormalities associated with the CMP. Because abdominal pain may be caused by numerous conditions, and since there are many different components of the CMP, laboratory test results and the outcome will vary depending on the cause and extent of the patient’s condition. Inflammatory conditions may cause alterations in electrolytes and protein levels. For example, a patient with inflammatory bowel disease may have low levels of albumin or changes in levels of potassium. Conditions that affect the liver and that cause abdominal pain may reveal alterations in normal levels of AST, ALT, or bilirubin on the CMP test.
Ischemic conditions may reveal acidosis because of the lack of adequate oxygen to the abdominal tissues. One component of the CMP is a measurement of CO2, which can detect acidosis if the results are low. Metabolic acidosis occurs from a variety of conditions, some of which are associated with decreased oxygenation. When an ischemic condition is present in the abdomen that is causing pain, such as ischemic bowel disease, the CMP may reveal acidosis as part of the results. Determining that acidosis is present from the CMP results can better help the clinician to narrow down a possible diagnosis when used with information gained from the patient history and physical examination.
Other specific conditions may also be isolated according to the CMP results. The AST and ALT are tests associated with liver function. If liver cells are damaged, they leak enzymes into the bloodstream that can cause the liver function tests of the CMP to become elevated.52 Liver disease, such as cirrhosis or hepatitis may cause pain for the patient and may increase the risk of such conditions as abdominal compartment syndrome or cholecystitis. The damage that occurs to the liver with these disease processes may then cause increases in AST, ALT, or bilirubin levels.
Electrolyte levels may also be altered if the patient has abdominal pain associated with gastrointestinal illness that causes nausea or vomiting. Increased nausea and vomiting can lead to dehydration and alterations in serum electrolytes, such as sodium levels. Consistent vomiting causes loss of gastric substances and fluid that contains electrolytes and can alter their serum concentrations if the body attempts to move electrolytes between the intra- and extracellular spaces to make up for the loss.
Alterations in protein levels may also show up on the CMP. These changes can occur in response to disease processes that cause abdominal pain. The blood urea nitrogen (BUN) test is part of the CMP, and it tests for urea nitrogen levels, which is a by-product of protein breakdown. Elevated levels of BUN have been associated with severe disease processes, including gastrointestinal bleeding, kidney disease, an obstruction in the urinary tract, or shock. The creatinine level is associated with the BUN; and, the creatinine level measures kidney function and may also be elevated on the CMP when kidney problems are present. Other protein-associated components of the test, such as albumin levels, may also be altered with certain disease processes, resulting in either too high or too low of levels.
The metabolic profile is an important lab test that is often included as part of diagnostic testing for abdominal pain. Because fluid and electrolyte levels require a complex balance between the intracellular and extracellular spaces, alterations in metabolic elements can cause significant symptoms. Recognizing and identifying these symptoms helps the provider to narrow down the underlying cause or disease process associated with the patient’s abdominal pain.
Stool sample
An analysis of a stool sample can also provide some clues to internal processes that are causing abdominal pain. A stool sample involves a collection of feces, which can be tested for a number of variances. When abdominal pain is present, a stool sample may be checked for such elements as the presence of occult blood, pathogens, such as parasites or bacterial infection, food residue, and fat content, as well as overall consistency and color of the fecal sample.53
One of the most commonly performed tests of stool is for fecal occult blood, which refers to specific testing for the presence of blood in the stool, even if it can be outwardly seen. Conditions that can cause gastrointestinal bleeding may result in a positive test for fecal occult blood; and, such conditions may include ulcerative colitis, Crohn’s disease, peptic ulcers, and gastroesophageal reflux disease, all of which also cause abdominal pain.53 If the quality of the patient’s abdominal pain and the presence of other symptoms suggest a gastrointestinal disease process that may lead to bleeding within the digestive tract, a fecal occult blood sample may be helpful.
Unfortunately, the fecal occult blood test may lead to false positive results if the patient eats certain foods or has other conditions that can cause a small amount of bleeding from the rectum. Ingestion of red meat, turnips, or horseradish, as well as the presence of hemorrhoids and recent aspirin or NSAID use have all been associated with positive fecal occult blood test results.53 The test may need to be restricted based on the patient’s history. Additionally, a positive result should be combined with a thorough patient history to discuss if any of the above factors are present that could be causing a false positive.
Other tests of stool sample that also look for occult blood include the fecal immunochemical test or the stool DNA test. These tests are more involved than a simple fecal occult blood test but they do not have food or drug restrictions. The immunochemical stool test checks for the presence of blood in the stool and is often used to check for signs of tissue changes in the large intestine, such as with colon polyps. The stool DNA test looks for cellular changes that can indicate the presence of certain disease processes, such as colon polyps or colorectal cancer.
Because some patients present with abdominal pain that is related to gastrointestinal disease, a stool sample is often warranted to rule out certain conditions while simultaneously including others. When needed, the stool test can be performed as an early part of the physical examination and may then lead to further testing to support its results.
Urinalysis
The urinalysis is a common and simply performed examination of the urine. The standard urinalysis test identifies various components within the urine that can indicate the presence of a disease process or injury that is causing the abdominal pain. The main components of the urinalysis include assessment of the urine color, such as whether it is clear, cloudy, dark, or pale, the specific gravity of the urine, which is a measure of its dilution, and the urine chemistry and microscopic appearance. The urine chemistry and microscopic examination components of the urinalysis detect the presence of various elements typically found in trace amounts, such as sodium, potassium, and phosphates, as well as types and amounts of other elements, such as protein, blood cells, glucose, or ketones.
A patient with flank pain or costovertebral angle tenderness may need a urinalysis as part of diagnostic testing to determine the cause of the pain. Common causes of this type of pain can include disease processes affecting the kidneys, such as pyelonephritis, kidney stones, or renal abscess. All of these conditions can lead to abdominal pain and pain that is referred to the groin. When disease or injury impacts the kidneys and causes pain, the effects are likely to show up with testing through urinalysis.
Because the kidneys act as a filtering system for the body and excess wastes are excreted in the urine, changes in the consistency of urine or increased levels of waste products can indicate that the kidneys are not working appropriately. For example, a patient may have pain from a kidney infection, which causes the kidneys to filter wastes inappropriately. Upon urinalysis, excess waste products may then appear in the urine; the person may also have greater levels of electrolytes and other products in the urine that may not have been managed appropriately by the kidneys and were instead excreted in the waste.
A person with a bladder infection may also have pain that radiates into the abdomen. When the history and clinical examination suggest a bladder or urinary tract infection because of painful urination or low back pain, a urinalysis is often done to detect changes in appearance and concentration. Additionally, the presence of bacteria or protein in the urine is detected that can indicate an infection.
A urinalysis test has pre-set parameters that guide the clinician to normal results and what they mean. When the results are outside of these parameters, the clinician can better determine the cause of the problem. Increased blood cells in the urine, such as excess white blood cells, may indicate that the body has an elevated white blood cell count because of infection. Increased glucose in the bloodstream from poorly managed diabetes may end up spilling over into the urine, and elevated levels of glucose will appear on the urinalysis test. By understanding the meaning of each of the components of the urinalysis, and what levels outside of the indicated parameters mean, the clinician can better narrow down a potential diagnosis for the cause of abdominal pain and use the urinalysis results to make decisions for other types of testing that may be needed as well.
Pregnancy test
All women of childbearing age who present with abdominal pain should have a pregnancy test to rule out the possibility of pregnancy or its associated complications. At times, the discomforts of pregnancy may cause abdominal pain and may actually be confused with other emergent conditions. For example, a woman who experiences stretching of the uterine ligaments during pregnancy may have severe pain that could be confused with appendicitis. Confirming or ruling out pregnancy is necessary in cases when there is a question of whether it is present.
A pregnancy test can be performed quickly in the healthcare environment. The most common methods of determining pregnancy are through a blood test or urine test. The urine pregnancy test can provide rapid results to detect pregnancy; and, if it is positive, the provider can then order further comprehensive tests. The healthcare provider may also perform a blood test. The blood test confirms the pregnancy by checking the levels of human chorionic gonadotropin (hCG) in the blood, which elevate exponentially when following implantation of the fertilized egg. The blood test is useful for better determining viability of the pregnancy, as well as its presence, based on the amount of hCG in the blood. Low levels of hCG may indicate that a pregnancy exists, but its viability may not be as strong when compared to a pregnancy that produces much higher levels of hCG.
A pregnancy test can also be used to indicate the presence of an ectopic pregnancy; although the pregnancy is not viable in this case, an ectopic pregnancy will still provide a positive pregnancy test result that can be further investigated. An ectopic pregnancy occurs when the fertilized egg has implanted in an area other than the uterus. The zygote may implant in a number of areas outside of the uterine lining, including on the ovary, the cervix, or even within the abdominal cavity. The most common location of an ectopic pregnancy, however, is within the fallopian tube. As the fertilized egg grows in the abnormal location, it places pressure on the surrounding tissues, which are not meant to house the fertilized ovum. The woman may experience severe abdominal or pelvic pain as a result.
A woman is more likely to have an ectopic pregnancy if she has a history of pelvic infections, such as pelvic inflammatory disease; the condition seems to develop more commonly among women who have used assistive technology to achieve pregnancy.56 An ectopic pregnancy typically causes symptoms of abdominal pain, combined with abnormal vaginal bleeding after a period of amenorrhea. These symptoms are described as a “classic” presentation, meaning they may be some of the most common symptoms seen when ectopic pregnancy occurs. However, many women may have other symptoms in addition to or in place of classic symptoms, such as heavy vaginal bleeding, and symptoms of pelvic infection or hypovolemia. In some situations, no symptoms develop and the condition is found on routine exam.56
An ectopic pregnancy can progress to a life-threatening situation for the mother. If the surrounding tissue stretches and then ruptures, excessive internal bleeding can result. The pregnancy itself is not viable but the mother may need rapid treatment through surgical removal of the products of conception and the damaged tissues, as well as methods to control bleeding for the mother or even loss of life.
An ovarian cyst may also develop within the pelvic cavity, causing abdominal or pelvic pain, particularly when it ruptures or hemorrhages. An ovarian cyst is a collection of fluid that forms in a sac on one or both of the ovaries. An ovarian cyst may cause few or no symptoms in some women and they may not be noticed until a routine examination or during testing for infertility, which may be caused by the presence of a cyst.
An ovarian cyst can become painful when it ruptures and fluid leaks into the surrounding cavity. At times, the cyst may also hemorrhage into itself, or torsion may develop, which occurs when the tissue stretches and twists onto itself. Either case can cause severe pain. An ovarian cyst may be present in a woman who is pregnant as well as in a woman who is not pregnant. Symptoms of a ruptured cyst are often sharp and intense pain followed by a dull and constant ache in the abdomen and pelvis. If the bleeding is extensive and reaches the diaphragm, the pain may also be referred to the shoulder.56 When a case of an ovarian cyst occurs, the clinician should perform a pregnancy test to determine if pregnancy is also present. The inclusion of pregnancy may affect how treatment is performed. Treatment of an ovarian cyst requires pain management and supportive care. With significant fluid loss and pain, the patient may require laparoscopic surgery to remove the tissue and to control bleeding and pain.
Up to 20 % of pregnancies may end in miscarriage, the loss of a pregnancy before the gestational age of viability, which is approximately 24 weeks. A patient who is experiencing a miscarriage may develop vaginal bleeding prior to abdominal pain. Alternatively, an ectopic pregnancy, which also results in loss of the fetus, typically causes abdominal pain before vaginal bleeding.56
The probability of a miscarriage is based on the patient’s history, the physical examination, and the presenting symptoms. Management of the condition may vary, depending on the woman’s condition, such as whether she is experiencing significant pain and bleeding. In these cases, surgical intervention may be necessary to relieve suffering and prevent excess blood loss through hemorrhage. Alternatively, some women experience miscarriages that, despite causing some pain and bleeding, may require little further management beyond comfort measures. The affected patient is monitored during the loss of the fetus.
A miscarriage can be very emotionally painful for the patient and her family. The physical pain is sometimes considered minor when compared to the emotional pain associated with loss of the fetus. A patient who experiences a miscarriage should receive extra time from the health provider to assess for sources of support or to provide referrals if needed. The loss of pregnancy can be such an emotionally charged time that the provider and the nurse will need to utilize extra forms of comfort and support in this situation.
Helicobacter pylori test
Helicobacter pylori (H-pylori) are infectious agents that are associated with gastrointestinal pain, gastritis, and peptic ulcer disease. H. pylori are a type of gram-negative bacteria that infect the gut; and, are spread through fecal-oral transmission. Up to 40 % of people in the United States and other industrialized countries and approximately 70 % of people in developing countries are affected by H. pylori, although not all people with the infection have symptoms. In fact, most cases of infection are asymptomatic.85
Chronic infection with Helicobacter pylori has been shown to cause pain and gastrointestinal disease. Eradication of H. pylori therefore has also been shown to improve some conditions and their associated pain, including such conditions as dyspepsia and peptic ulcer disease.56 People who do develop symptoms associated with H. pylori infection may feel burning or gnawing pain in the abdomen and epigastric area. Infection also causes nausea, vomiting, anorexia, bloating, and gastrointestinal bleeding for some patients.
When infection with H. pylori causes symptoms, it is usually because the bacteria have moved into the protective lining of the stomach and released toxins that alter the cells of the stomach and the duodenum. This ultimately leads to chronic inflammation of the tissue and makes it more prone to damage from digestive juices, such as hydrochloric acid in the stomach. In rare cases, the cellular changes associated with H. pylori infection can cause stomach cancer. Although this is considered a rare cause of stomach cancer, because so many people throughout the world have H. pylori infection, the sheer number of infected persons automatically increases the risk based on volume of cases.86
Tests for H. pylori include blood or stool tests as well as breath tests. Blood tests determine if the body is producing an immune response to H. pylori infection by detecting the presence of antibodies that are specific to the bacteria. Stool tests are relatively simple and check for the presence of H. pylori bacteria in a stool sample. Additionally, the breath test can be performed, which involves giving the patient a liquid solution that he or she drinks. The H. pylori bacteria then break down the solution when it enters the digestive tract. The breakdown of solution causes urea as a by-product, which can then be detected on the patient’s breath by using the breath test.86
In most cases, patients with stomach or duodenal ulcers that cause symptoms should be tested for H. pylori. Not all ulcers are caused by the bacteria, but isolating it as a cause leads to more successful treatment and resolution of symptoms. The test is not recommended for people who do not have symptoms or who have no history of peptic ulcer disease.86 For those who do have the bacteria and symptoms associated with its infection, it can be treated with medications such as antibiotics and proton pump inhibitors. Antibiotics kill the bacteria and treat the infection, while proton pump inhibitors control stomach acid to allow for better healing of ulcerated areas without further irritation and tissue breakdown from stomach acid. Some of the more common proton pump inhibitors used are lansoprazole (Prevacid®) and omeprazole (Prilosec®).
Amylase and lipase levels
Amylase and lipase are two types of enzymes produced by the pancreas that support food digestion. Amylase is used for digestion of carbohydrates; it is actually secreted both by the pancreas and in the saliva. Lipase is an enzyme secreted by the pancreas that is used for fat absorption. When levels of these two enzymes are tested and they appear in the bloodstream, it generally means that some form of damage to the pancreas has occurred.
Inflammatory pancreatic disease can cause changes in amylase and lipase levels. Often, these levels are elevated three times the normal amount when testing a patient with acute pancreatitis.18 The amylase level tends to increase after the patient develops pain from the pancreatitis and the levels remain elevated for several days. The patient may also develop a condition called macroamylasemia, in which amylase particles abnormally bind to protein and the particles are not easily cleared from the body. The result is consistently high levels of amylase in the bloodstream.
Lipase levels are typically elevated in patients with acute pancreatitis. Although lipase and amylase levels tend to increase with pancreatitis, continual monitoring of amylase and lipase does not necessarily indicate progression or resolution of the disease. In other words, while checking amylase and lipase levels may be initially indicated as part of diagnosing inflammatory pancreatic disease, it is not necessary to continue to monitor these levels on a routine basis to determine if they are changing during recovery.
Lactate level
If the patient has a potential bowel obstruction or other condition causing ischemia, lactate levels may also be drawn. The test of lactate determines the presence of lactic acidosis, which can disturb the acid-base balance of the blood. Lactic acid is a by-product of cell metabolism; if the cells do not get enough oxygen, lactic acid can accumulate, resulting in lactic acidosis.49 Consequently, if lactic acid levels are elevated, the patient may have some form of ischemia due to lack of oxygen reaching the cells and tissues.
Lactic acid levels are also often drawn for potential cases of sepsis. Sepsis can develop as a complication from a number of disease processes that cause abdominal pain and is associated with high levels of morbidity and mortality. When sepsis is suspected, high levels of serum lactic acid can indicate the need for rapid treatment. A test of lactic acid may also be used to confirm the presence of other disease processes that are not related to decreased oxygenation, such as liver or kidney disease. However, additional analysis with other lab tests is often indicated to isolate a diagnosis.49
Sexually transmitted disease test
Abdominal pain that occurs in conjunction with other symptoms or risk factors outlined in the patient’s history warrants the need for testing of sexually transmitted diseases (STDs). If the patient presents not only with abdominal pain, but also with other symptoms that can indicate genitourinary infection, such as pelvic pain, vaginal or penile discharge, abnormal vaginal bleeding, or pain with urination, sexual transmission of infection should be considered. Other factors, such as a history of drug use, multiple sex partners, or other high-risk activities, should also warrant STD testing as part of the diagnostic work-up.
When a patient tests positive for a specific sexually transmitted disease when ruling out causes of abdominal pain, the clinician should test for the presence of other types of STDs as well, whether or not they cause abdominal pain. If a person has been exposed to one type of sexually transmitted infection, he or she is at risk of having other types of infections as well. Although other conditions such as herpes or human immunodeficiency virus (HIV) may not directly cause abdominal pain, these tests should be conducted as part of STD testing, particularly if the patient has tested positive in other areas.
Pelvic inflammatory disease (PID) is one of the most common causes of pelvic or abdominal pain as a result of sexually transmitted infections. PID is not a sexually transmitted disease itself; instead, it develops when other types of sexually transmitted diseases are not treated. PID affects only women and can be caused by other conditions that are not transmitted through sexual contact. Women who are sexually active with more than one sexual partner, those with a history of untreated sexually transmitted infections, women who douche regularly and those who use an intrauterine device for birth control are more likely to develop pelvic inflammatory disease.54
There is not a specific test to diagnose PID, but diagnosis is made when a patient presents with symptoms of the condition and the history and physical examination suggests further testing. Diagnosis can be made after testing for other sexually transmitted diseases, urinalysis, blood tests for CBC and CRP, and a pelvic exam. Symptoms of PID include abdominal or pelvic pain, pain with intercourse, fever, abnormal vaginal discharge, and bleeding between menstrual periods. Pelvic inflammatory disease may cause very few symptoms among some women; alternatively, some patients who develop the condition may have severe and debilitating pain.
Without proper management, PID can cause chronic abdominal or pelvic pain, as well as pelvic or abdominal adhesions, in which scar tissue develops between organs and tissues and causes them to stick together. These adhesions may also cause significant abdominal pain, which usually must be treated with surgical intervention to remove the scar tissue. Approximately 20 % of women with PID can develop these adhesions, or a condition known as Fitz-Hugh-Curtis syndrome, in which adhesions and inflammation extend to the peritoneum, the liver, and the diaphragm.56
Trichomoniasis is another type of sexually transmitted infection. It is caused by transmission of the organism Trichomonas vaginalis. Although the main symptoms of trichomoniasis are vaginal discharge, burning with urination, and pain with intercourse, some patients may develop abdominal pain in the lower part of the abdomen. Some other common forms of sexually transmitted infections, such as chlamydia, gonorrhea, or syphilis may not directly cause abdominal pain with the initial infection but, if left untreated, can lead to scarring and prolonged pelvic infection that can be very painful. These types of diseases still cause symptoms that are uncomfortable and painful, such as burning with urination, pain with intercourse, abnormal genital discharge, bleeding between menstrual periods, and genital itching.
Radiographic Imaging
Radiographic images are useful for diagnosing specific conditions that cause abdominal pain. There are a number of different types of images available, from the basic flat plate X-ray to the more extensive CT scan. Depending on the patient’s presentation with abdominal pain, the type of radiographic test to consider varies. Imaging tests allow the health provider to get a clear picture of the internal structures and to look for the sometimes subtle signs of disease.
Computed tomography scan
A computed tomography (CT) scan, also known as computed axial tomography scan (CAT scan), is effective in identifying problems contributing to abdominal pain and determining if factors are present that are causing complications or that would inhibit treatment of the pain. The CT scan can provide much more detailed results when compared to an abdominal X-ray. The CT scan is a specialized type of X-ray system that takes multiple images of the patient’s body and places them in an order that appears as slices, where each “slice” is a small region of internal organs, tissues, or other areas in the patient’s body.
To perform a CT scan, the patient must lie on an X-ray table. The table is then moved into an imaging system that takes a number of scans by rotating around the patient. With each rotation, the machine takes an X-ray through a section of the body. As the table moves, each image is taken, one by one, throughout the area to be examined, with each image collected as a cross-section. The images are then reconstructed and viewed together as a system.33 The CT scan is usually only used to scan a specific body system, such as the abdomen, as part of a diagnostic process. It is generally not used to scan the entire body.
A computed tomography scan can provide rapid identification of a disease process occurring in the abdomen that is causing the pain. For some suspected conditions, a CT scan is the foremost choice or the gold standard for pinpointing a diagnosis. For example, in cases of appendicitis, a CT scan may be performed after an abdominal assessment and after identifying positive obturator or Rovsing’s signs. The abdominal CT can also identify appendicitis in cases where there is atypical presentation or when other diagnostic tests, such as an ultrasound, have been unable to accurately confirm or rule out the condition.
When performing a CT scan for appendicitis, the radiologist looks for signs of an abnormally shaped appendix or one that is enlarged, thickening of the wall of the appendix, and areas of calcification in the bowel, which all indicate appendicitis that is causing pain but the appendix has not ruptured yet.20 Abscess formation in the nearby tissue can indicate that the appendix has ruptured and is advancing to peritonitis.
In cases such as appendicitis, the CT scan is extremely useful for identifying the situation clearly so that further treatment can be started. The accuracy of the CT prevents unnecessary treatment measures from being ordered because the clinician can clearly identify the cause of the condition. Appendicitis is an example of a condition that may be inaccurately treated. The appendix may have no exact known cause of inflammation; however, when inflamed, significant pain ensues that can be relieved with its removal.
Because a person can live without an appendix, it can be removed before it ruptures when it becomes inflamed. Even if appendicitis is not actually present, the appendix can still be removed with few long-term consequences for the patient, although this procedure may be inaccurately performed when it is not needed. For example, if a patient complains of abdominal pain and has positive signs of appendicitis, surgery may be warranted to remove the inflamed appendix. Karul, et al., noted in the journal Fortschr Röntgenstr that unnecessary appendectomies are increased when patients do not undergo radiologic imaging prior to the procedure and the surgery is based on clinical symptoms alone. An unnecessary appendectomy results in expense, time, and unnecessary medications and pain for the patient that could be avoided. Use of a CT scan as a radiologic technique in cases of suspected appendicitis is more likely to definitively diagnose the condition or identify other potential causes of the pain, thereby avoiding costly and unnecessary surgery to remove the appendix that is not inflamed.20
If a patient has a history of a bowel disease that also causes extra-intestinal symptoms, the CT scan is useful for identifying other affected areas as well, which may or may not contribute to the abdominal pain. For example, a patient with Crohn’s disease may have abdominal pain from the inflammatory process that is taking place within the bowel, but may also be suffering from gallstones, which are a known extra-intestinal complication associated with Crohn’s disease.23 The CT scan can identify other problematic areas in which symptoms have developed that are also causing symptoms in the patient.
Early in the disease process, a CT scan may not identify a condition that causes ischemia and some disease processes may not cause any changes in a CT scan when attempting to diagnose bowel ischemia. A CT can identify some areas of damage that have occurred due to ischemia in the gut, such as thickening of the bowel wall. Additionally, a CT scan may determine if vessel occlusion is present and a potential cause of ischemia.
When diagnosing an ischemic condition, CT with contrast may be ordered, depending on the patient’s condition and the area to observe. For example, CT with contrast can better identify occlusions in the mesenteric vessels when identifying ischemic bowel disease. Contrast, also referred to as dye, makes certain organs and blood vessels stand out more during the imaging. Contrast may be given intravenously or orally, depending on the area being viewed. For instance, if the clinician is looking for signs of decreased blood flow and ischemia, contrast should be administered intravenously, where the dye can flow through the blood vessels and make areas of decreased blood flow stand out. Alternatively, when looking for other sources of abdominal pain in the gut, such as an obstruction or other problems in the gastrointestinal tract, the patient may need to consume an oral contrast and the clinician can then monitor the contrast dye in the gastrointestinal tract on the CT scan. The healthcare provider orders the type and amount of contrast needed, typically when working in conjunction with the radiologist, who may ultimately read the scans.
Ultrasound
Ultrasound is a quick and non-invasive diagnostic tool that can identify disease processes that have developed in the abdomen and can rule out other conditions and abnormalities. Aside from abdominal pain that the patient is experiencing, the ultrasound itself is not a painful procedure and typically does not contribute to further pain for the patient. It can be repeated relatively easily, if necessary.
An abdominal ultrasound is performed to evaluate the solid organs within the abdomen as well as their sizes and positions. It can be done to assess for other problems as well, including an abdominal aortic aneurysm, the size and function of certain blood vessels, or the location and amount of ascites present in the abdomen. The ultrasound uses high-frequency sound waves sent through a transducer when it is moved over the surface of the abdomen. The sound waves are then sent back to the transducer and are converted into energy where they can be displayed on a monitor for the clinician to view the internal structures of the abdomen.
Most patients can tolerate an abdominal ultrasound, as it is not an invasive procedure and does not cause pain. The feeling of the transducer pressing on the skin may cause increased pain for some patients. Additionally, the ultrasound often requires the patient to lie supine on the exam table and some people may have such pain that this position is not well tolerated. The ultrasound is otherwise a valuable diagnostic technique that can locate abnormalities within the abdomen that are contributing to the pain. If biopsy or tube placement is required, the ultrasound can be used to guide the instruments internally. For example, some patients may receive pain medication through a nerve block; the appropriate nerves can be located through ultrasound and monitored continuously while the physician finds and injects the nerve with medication. For cases of peritonitis that require fluid removal for testing, the clinician can be guided through ultrasound when inserting the needle during a paracentesis procedure.
Normally, the ultrasound should show standard size and position of the abdominal organs, no excess fluid or abscesses in the abdominal cavity, and the absence of problems that can contribute to abdominal pain, such as gallstones, a tumor, or an aortic aneurysm.34 In some conditions, an abdominal ultrasound is the preferred initial test to use for a diagnosis. For example, in the case of a patient who presents with symptoms of gallstones, abdominal ultrasound is often used as a first-line diagnostic test to visualize the gallstones and to formulate a diagnosis if they are present. Abdominal ultrasound is often one of the first tests performed when diagnosing other conditions associated with disease of the gallbladder.
In the case of inflammatory conditions such as acute pancreatitis, ultrasound is an appropriate diagnostic tool to identify the structure of the pancreas and to better determine if it is enlarged or if there is an obstruction that could be contributing to autodigestion. Ultrasound is useful for identifying sludge in the gallbladder associated with cholecystitis. The method is also appropriate in diagnosing appendicitis and is used relatively early in the diagnostic process, just after completing the physical examination. In cases of appendicitis as the cause of abdominal pain, ultrasound can identify an enlarged or ruptured appendix; however, if the patient is significantly overweight with excess fat tissue in the abdomen or if the appendix is in a slightly different position than normal, an ultrasound may not be the most accurate test to diagnose appendicitis.
Its important to realize that an ultrasound can be limited in cases of severe pain in a patient who may have little tolerance for the procedure. A patient who has a significant amount of bowel gas or abdominal distention, or when attempting to assess for fluid but which there is very little present, may not result in a successful diagnosis through abdominal ultrasound. Another potential disadvantage is that the results of the ultrasound are dependent on the expertise of the technician performing the test. Without a skilled clinician, there is high potential for error, which can affect the capacity for diagnosis.
Abdominal x-ray
An abdominal X-ray takes a picture of the internal organs and structures in the abdominal cavity; it is most often used to visualize organs such as the intestines, the spleen, or the stomach. The X-ray uses electromagnetic radiation and sends particles through the body to form a picture of internal structures. X-rays can be taken throughout the body to visualize internal structures of various areas. An X-ray of the abdomen is typically ordered as an abdominal X-ray, while an X-ray taken in the lower abdomen or the pelvis is known as a KUB as it views the kidneys, ureters, and bladder. Not all patients who present with abdominal pain require an X-ray, but if the patient’s condition suggests a possible disease process that requires further testing, in many cases, an X-ray can often identify the cause.
At one time, a plain X-ray of the abdomen was the imaging study of choice for its ease of use, convenience, and relatively rapid timeframe for results. However, as other types of imaging studies are becoming more common and easily accessible, a plain x-ray is often much more limited in its ability to provide enough information to formulate a diagnosis in a patient with abdominal pain. A study by Panebianco, et al., in the journal Emergency Medicine Clinics of North America showed that among patients who had normal results with an abdominal X-ray as an initial diagnostic exam, 81 % had positive findings when later tested through CT or ultrasound.48 However, the abdominal X-ray does provide support for the clinical examination when formulating a diagnosis; it is often more useful when more than one view is taken of the abdomen to observe the affected area from several angles.
An X-ray of the abdomen may be taken from several views, depending on the imaging area and the patient’s condition. A supine abdominal X-ray, sometimes called a flat plate, is taken when the patient lies flat in a supine position on a table or bed and the picture is taken from above. The X-ray image may also be taken from the side of the abdomen while the patient is still lying on his or her back; this view is known as a cross-table lateral view.
Another technique that may be used when the patient is unable to stand upright or stretch out is the lateral decubitus. This type of X-ray is taken when the patient lies on his or her side and the image is taken horizontally. Often, a background must be placed behind the patient, which is moved right behind the back. When more than one abdominal X-ray is ordered for the patient, such as a flat plate abdominal X-ray and a left lateral decubitus, the order is said to be an abdominal series. When a patient presents with abdominal pain, performing an abdominal series — more than one X-ray taken at different angles —may provide the most comprehensive results for a disease process occurring within the abdomen.
A standard abdominal X-ray is useful to diagnose certain conditions while ruling out others. In the case of a patient with an ischemic bowel, for example, the abdominal X-ray does not necessarily identify ischemia, but it can determine if there were disease processes present that would contribute to the ischemia, such as a small bowel obstruction. The same case can be said for acute pancreatitis when identification and diagnosis requires an X-ray. A plain film does not necessarily identify acute pancreatitis, but it does rule out other causes of abdominal pain.
The clinician may order X-rays to aid in the diagnosis of many other conditions that could also be causing abdominal pain, such as with the presence of a foreign body or a bowel obstruction. Solid organs or masses show up as white areas on the X-ray image. Other abnormalities may also be apparent when a disease process is present, such as free air in the abdomen or up under the diaphragm, which may occur if part of the small intestine becomes perforated. The X-ray is more commonly performed before other procedures that may require contrast, such as a CT scan. An abdominal X-ray or series is typically performed without causing pain for the patient and it is non-invasive. Furthermore, the results can be viewed quickly. Normal X-ray results would show the abdominal organs in their appropriate locations and of regular size; and the absence of stones, perforation, obstructions, or other masses in the abdomen.
Another imaging technique that may be used in addition to the CT scan or X-ray is angiography, a system of visualizing the blood vessels through radiographic images. If the clinician believes that the patient has abdominal pain because of abnormality in the blood vessels, angiography can identify issues associated with circulation. For example, angiography is used to locate areas of occlusion or vasoconstriction that lead to decreased blood flow and tissue ischemia in cases of ischemic abdominal pain. When vessel occlusion is the suspected cause of ischemic bowel disease, angiography can be used to identify involved vessels.
The process is most successful when used to locate an embolus or a thrombus that is occluding a mesenteric vessel; it can also identify a non-occlusive state of vasoconstriction of the mesenteric arteries or veins that could be causing ischemia as well. Alternatively, in cases of ischemic bowel disease that is caused by non-occlusive factors, angiography does not necessarily pinpoint the causes, such as in the case of hypotension.17 It can rule out possibilities, however, and narrow the facts to better isolate a cause.
Other types of imaging techniques may also be needed, depending on the patient’s presenting condition, description of pain, and other associated symptoms. Magnetic resonance imaging (MRI) may be necessary in some cases of abdominal pain, particularly if other forms of testing have failed to identify the condition causing the pain. For instance, MRI can locate very small lesions or areas of abnormality that are caused from a disease process and that are causing pain. MRI is useful in terms of isolating problems associated with liver or pancreatic lesions; it also can be used in evaluating ischemic bowel disease. Although it may not be the first choice of diagnostic testing, the MRI is appropriate and effective for determining areas of damage inside the body that may otherwise be difficult to see with a CT scan or X-ray.
The MRI works by sending radio frequency waves to the body. The patient lies on a table, which is moved into a magnetic field. Protons found inside molecules in the body are sensitive to the magnetism and radio frequency waves. The machine is able to manipulate the protons to form a picture of the internal structures of the body. The image formed has enough detail that the picture of the internal organs shows more features that can depict areas of damage that may be harder to see with conventional testing.
When compared to a CT scan, MRI is safer for some patients because of lower levels of radiation. For this reason, it may be a better diagnostic test for some patients such as pregnant women and children. The contrast medium used with MRI has also been shown to be less toxic for the kidneys when compared to the dye used for contrast with CT scans. This makes MRI a better diagnostic choice for some patients with kidney disease who need abdominal evaluation.37
Pain Management
When considering pain management techniques, it is important for the clinician to review several different forms of treatments with the patient that may be available. Because each patient is different and will present with varying symptoms and responses to abdominal pain, the clinician should have several options available to consider for treatment. In this method, if one form of pain management is not successful, there may be other alternatives that would work instead.
Relying solely on one or two methods of pain management and expecting them to be successful for all patients does a disservice to some patients. It leaves out other options for pain control for them to consider that could otherwise be implemented successfully.
Positioning
A patient’s position of comfort may depend on the type of abdominal pain he or she is experiencing. Some people may squirm and have a difficult time finding a comfortable position; alternatively, some people curl up in a comfortable position and try to move as little as possible. The nurse should try to help the patient to find as comfortable of a position as possible by assisting with positioning or moving with repositioning when needed.
Proper body alignment is important to avoid placing too much pressure on certain areas of the body and to support circulation. The patient can be assisted to move into a certain position and the nurse may use pillows or blankets for support of the extremities. Some people with abdominal pain feel more comfortable with the legs bent. If a person is lying on his or her back, bending at the hips and the knees may place less pressure on the abdomen; and, the muscles are not stretched tightly across the abdomen while lying in this position.
Some patients find more comfort with lying on one side, bending the knees and hips, and curling the legs up toward the chest. In this situation, the nurse can help the patient to turn onto his or her side and position the arms and legs with a pillow behind the back and one between the legs for support. The nurse should place important items within reach of the patient so that if he or she needs to reach the call light or the remote, these items are close enough that no movement is needed by the patient to reach them.
Touch Therapy
The power of touch cannot be underestimated. Throughout the world, the use of touch to provide comfort through massage, back rubs, or holding has benefitted people for thousands of years. Massage and the comfort of touch have been used to promote healing, reduce pain, communicate, provide protection, or to improve overall health.80
Back rub
The action of providing a back rub does more than provide a calming effect for the patient. The act of massaging the muscles improves circulation by promoting vasodilation to increase blood and lymph flow. Therapeutic touch can also increase levels of neurotransmitters, improve flexibility and range of motion, decrease levels of substance P (neurotransmitter peptide); and improve personal interactions, relationships, and a sense of trust. The Touch Research Institutes have conducted a number of studies that have proven various effects of touch as not only a method of comfort, but in managing some forms of chronic disease. According to Braun in Introduction to Massage Therapy, Touch Research Institutes have found that the use of touch has diminished pain, decreased autoimmune symptoms, improved immune function, improved sleep, decreased anxiety and depression, and improved glucose levels and white blood cell counts.80
Back rubs have been shown to be beneficial through touch and comfort. The patient may derive more benefit of pain relief from having their backed rubbed. Although it is a natural response to rub a body part that feels painful, rubbing the abdomen when the patient has abdominal pain, particularly when a disease process or injury is present, is not necessarily effective and may actually cause more damage. Alternatively, allowing the patient to lie in a position of comfort and providing a back rub is typically more therapeutic and sends a comforting message. Providing comfort through massages, such as a back rub, is a small way a nurse can comfort the patient, even if the abdominal pain is not immediately resolved.
Heat Therapy
Heat therapy has been shown to be beneficial among some patients with abdominal pain. Use of heat has traditionally been used as a comfort measure with pain through such items as heating pads, whirlpool baths, or moist hot packs. The clinician may encourage the use of a heating pad for the patient to help with pain control and to support comfort during treatment for abdominal pain.
Heat therapy is used to increase circulation to affected tissues by causing vasodilation, which increases blood flow to the affected area. Heat therapy typically affects superficial areas, such as the skin, joints, and subcutaneous tissues, but using a heating pad or other device as a topical application will not reach deeper tissues. Yet superficial heat therapy still has its benefits; the warmth provided is comforting and relaxing and the patient may feel calmer after sitting with a heating pad for a few minutes. The calm and stress relief may help to lessen some of the pain. The increased blood flow — even when it reaches the superficial layers of tissue — can still support movement, relax muscles, and decrease tension.
A heating pad produces dry heat through conduction, in which the heat is transferred from the pad to the skin with direct contact. For outpatient treatment, a heating pad can be purchased at a drugstore or medical supply store for use in the home. Many patients may already have heating pads in the home or can devise a similar item, such as by warming a towel. The nurse should caution the client when using a heating pad, as inappropriate use has caused severe burns in some people. It should be used on a low or medium setting and not for longer than 30 minutes at a time.
It may seem obvious, but heating pads should also not be used when there are open injuries to the abdomen, such as lacerations. Similarly, if a patient has had surgery to the abdomen, a heating pad should not be placed over the incision site. The heat from the pad, while it may be comforting, can cause tissue changes that affect healing and the site may heal slowly or may not heal properly.
Some types of heating pads use a moist heat by adding a hot water component. In general, moist heat is typically more therapeutic when compared to dry heat from a heating pad. If the heating pad has a moisture element, it should be used for greater benefit of heat therapy. Moist heat is often more comfortable for the patient and the effects of the heat tend to reach deeper into the tissues when compared to dry heat. Often, in places where heat is used for treatment and pain management, moist heat is preferred over dry.55
Health Management
Once an abdominal examination and diagnostic testing have been performed, health management measures are implemented to treat the cause of the abdominal pain and to prevent the condition from worsening. Typically, treatment of the condition causing the pain tends to resolve much of the pain itself. However, in some cases, abdominal pain can and should be treated separately from the cause. The reason for the pain and the presence of other symptoms necessitate separate pain control, although management of both pain and the principle disease process is at the heart of comprehensive health management.
Fluid and Electrolyte Balance
Many patients with abdominal pain require some form of fluid maintenance or repletion. Fluids administered through an intravenous route for a patient who is currently an inpatient or who will become one because of symptoms are typically used to instill larger volumes for fluid correction. Intravenous placement also facilitates faster administration of pain medications when needed, as well as other measures for treatment of conditions causing the abdominal pain, such as antibiotics, electrolytes, or imaging contrast.
For those patients who need intravenous fluid replacement because of their conditions, crystalloid solutions are typically the first choice. These types of fluids are cheaper and easier to access when compared to colloid solutions. They provide volume replacement in situations where hypovolemia has developed, such as in cases of gastrointestinal bleeding or sepsis, and they can be mixed with electrolytes to add to the circulatory system when the patient is depleted of certain minerals.
Gastrointestinal issues such as nausea or vomiting can cause dehydration that requires fluid replacement as part of treatment. Excess vomiting and diarrhea, if present, also lead to electrolyte abnormalities that often need correction with intravenous fluids. Hypokalemia and hyponatremia are two of the most common forms of electrolyte imbalances associated with excess nausea and vomiting, although alterations in other electrolyte levels can also develop from prolonged vomiting or diarrhea.
If hyponatremia is present, the patient may need fluid replacement with a hypotonic solution such as 0.45% sodium chloride. Hypotonic solutions are typically administered to expand the amount of fluid in the intracellular space and to replace fluid lost through such mechanisms as excess vomiting or diarrhea. This particular type of solution can replace some of the sodium lost and is beneficial if the patient has developed hyponatremia. Alternatively, isotonic solutions can also be useful; because these solutions contain the same concentration as plasma, they are used for replacing fluid loss as well as expanding intravascular volume. Lactated Ringer’s solution is a type of isotonic fluid that may be given to expand volume but that is also beneficial because it contains a solution of electrolytes that can be used for replacement when some electrolyte levels have been altered.
Other situations, such as volume loss through internal bleeding — as in the case of damaged tissue from an ectopic pregnancy — or because of complex conditions that cause third spacing, such as during abdominal compartment syndrome, require fluid and electrolytes for replacement as well. At times, rapid fluid replacement is needed to prevent hemodynamic collapse and severe illness or even death.
Fluid maintenance is important in the treatment of pancreatitis to prevent infection, necrosis, and organ failure. Patients with acute pancreatitis often require high fluid requirements, as progression of pancreatitis and decreased fluid volume can lead to shock from hypotension and renal failure.18 Some patients with severe acute pancreatitis retain significant amounts of fluid within the retroperitoneal space, which is not useful for maintaining circulation. It is therefore imperative in these situations to administer large volumes of fluid to maintain circulation, requiring up to 350 mL/hour at times, even if the patient is sequestering some of the fluid in the body.
If a patient has abdominal pain as a result of ischemic disease caused by a vessel occlusion, treatment with thrombolytic therapy may be necessary to break up a clot causing the occlusion. An embolus in the mesenteric artery that restricts blood flow to the gut requires the administration of thrombolytics infused in close proximity to the affected area, which then breaks up the clot and can restore normal blood flow. Some types of thrombolytic medications used to manage emboli of the mesenteric arteries include streptokinase or urokinase. When the embolus has disintegrated and blood flow is restored, the patient will most likely experience a reduction in abdominal pain.15
Fluid management and resolution of vasoconstriction may also be required following lysis of an embolism in the mesenteric artery. Despite destruction of the clot that causes an occlusion, the body may continue to hamper blood flow through vasoconstriction around the affected site. If this occurs, administration of vasodilators is required to restore proper blood flow to the bowel. Papaverine is an example of a drug that is used as a vasodilator that can improve blood flow.16 Papaverine is used to treat spasms of smooth muscle tissue, such as that of the blood vessels when they remain constricted after an occlusive event. Administration of this medication has been shown to improve mortality in patients affected by ischemic bowel disease.15 Papaverine may also be administered to other patients who have ischemic bowel disease caused by venous thrombosis or other conditions that cause vasoconstriction but that are not related to vessel occlusion.
Administration of antibiotics is necessary in many cases of abdominal pain, particularly in those patients that have developed pain from an infectious process. Antibiotics are also warranted in some situations to prevent infection developing as a complication to a disease process. For example, a patient with acute pancreatitis requires prophylactic antibiotics to prevent infection of the pancreas, which would be more likely to develop with a blockage in the pancreatic duct and subsequent inflammation from digestive enzymes.18
Antibiotics are also necessary in other inflammatory conditions that cause abdominal pain. If the patient needs to be hospitalized for the condition, antibiotics may most likely be given intravenously. Peritonitis is another situation of an inflammatory condition that causes severe abdominal pain. Antibiotics are part of the line of treatment because of the infection of the peritoneal membrane. Both broad-spectrum and single preparations designed to target specific organisms have been used to successfully treat inflammatory conditions. Typically, a broad-spectrum antibiotic may be used for treating an uncomplicated case of infection or inflammation. An example might be acute cholecystitis in which the gallbladder is inflamed due to gallstones. Without other complications, a standard, broad-spectrum antibiotic can be used to treat the condition and it can be done on an outpatient basis.
Emotional Support
Pain can be debilitating for the affected patient not only because the pain may make movement and activities difficult, but also because pain can take an emotional toll. One of the most important components of nursing care is to provide emotional support to the patient who is in pain while he or she waits and goes through the processes of assessment, diagnostic testing, and treatments to lessen the pain and to manage the cause of the pain.
A patient’s abdominal pain is influenced by a number of factors, including previous experience with pain, cognitive response to the pain, and cultural influences associated with pain management.27 Each person develops a cognitive response to pain, which is a perception of the factors associated with the pain and the amount of focus the person has on the pain. For example, two people may experience abdominal pain caused by food poisoning, with pain and discomfort located in the same area of the abdomen. One person assumes the pain is from food poisoning and takes steps to manage the condition by resting and increasing fluid intake. The other person wonders where the pain comes from and considers all other potential causes, including some that are life threatening. The person experiencing pain may spend a significant amount of time focusing on the pain and possible outcomes, depending on the diagnosis and may go to the hospital for treatment. The amount of pain a person experiences is directly affected by his or her cognitive perceptions of the pain.
A patient’s perception of pain is also impacted by previous experiences with pain. If a patient has a history of severe pain in the past, he or she may be anxious or feel threatened when pain occurs again. For instance, a patient who suffers from bouts of inflammatory bowel disease may have severe abdominal pain when symptoms are triggered, even though in between periods of flare-ups there are relatively comfortable moments. When the next flare is triggered and the patient starts to experience pain again, he or she may be highly anxious and apprehensive about dealing with the recurring pain, remembering the last flare and severe abdominal pain at that time.
Furthermore, a patient’s cultural background can impact how pain is managed. Some patients are quite stoic about the amount of pain they are experiencing, even if it is significant. Their cultural backgrounds naturally compel them to respond to pain in this way. Alternatively, some patients are naturally vocal about their pain and may respond to pain by crying, screaming, or yelling about minor or significant pain. In order to provide emotional support and to best help the patient cope with the situation, the clinician must try to understand the client’s cultural background and recognize that verbal responses are not always a direct indication of the amount of pain the patient is experiencing.
Some patients require emergent treatment for acute abdominal pain because the cause is related to a disease process that is not only very painful, but can lead to debilitating complications. In certain situations, the abdominal pain is a symptom of a condition that can quickly become life threatening. When this occurs, the nurse often needs to provide emotional support to the patient and to the family in addition to providing physical care of the patient.
The emotional component associated with pain causes suffering, which is a state of distress that is associated with loss.81 Often, a patient not only seeks help for abdominal discomfort because of pain, but is also suffering and experiencing an emotional response that can lead to a feeling of being out of control. Providing support and comfort and pain relief is key to also alleviating the suffering that the patient is experiencing.
The clinician can know how to best provide emotional support to the patient by understanding his or her background, history, and factors affecting the pain. In some situations, an abbreviated discussion with the patient may outline his or her most important needs; in other care situations, the nurse may be the one with more time to get to know the patient. For instance, some people want to talk about their medical backgrounds and their current pain condition. Talking about and discussing the situation through with the patient may help them feel better if they believe that someone is listening and providing support. Alternatively, some people would rather be comforted through other measures instead of talking. The nurse should determine what activities most signify care and comfort to the patient.
Emotional support may be provided through caring words and responses to what the patient says. Responses such as “I know you must be hurting right now,” or “I’m sorry this is so difficult for you,” can convey caring and understanding so that the patient does not feel alone. Listening to the patient and showing empathy, allowing the patient to cry, and avoiding interruptions are all other methods of showing compassion and providing emotional support when the patient is feeling pain.
When family is present, the nurse may need to provide support by talking with family members or facilitating discussion between the patient and the family. It is important to remember that each person has his or her own methods of coping and family relationships can be a source of support or could cause tension. Just because a person comes to the facility accompanied by a family member does not necessarily mean that the family is supportive or helpful. Some patients may want family near for comfort and help; others may feel better if family members are not in the room. The nurse should ask the patient what he or she wants and what would make the situation most comfortable, and avoiding further strain in the situation caused by unnecessary tension.
Sometimes, the only thing the nurse can do to be supportive is to sit with the patient and be present. Despite medical technologies that provide diagnostic expertise, the availability of multiple types of medications that can supply pain relief, and medical procedures that grant pain relief in a relatively rapid manner, the patient may still need to wait for pain relief. At times, when all other measures have been exhausted and the patient must wait for his or her time to undergo a medical procedure or wait while medication takes effect, the nurse can be a source of support by staying with the patient and being a comforting presence during a time of uncertainty.
Summary
Abdominal pain is one of the most common reasons why patients seek treatment and help for pain, largely because the causes of abdominal pain can be extremely varied. The clinician holds a large amount of responsibility for understanding not only the types of underlying disease processes that lead to specific kinds of abdominal pain, but also the varied techniques for narrowing down a possible diagnosis. Through focused examinations and available forms of diagnostic testing, the healthcare provider can successfully identify and manage abdominal pain when a patient seeks help and treatment.
Health management measures are important to implement following diagnostic testing to treat the cause of the abdominal pain and to prevent complications. The cause of abdominal pain and corresponding pain must be treated concurrently or separately. While the patient may wait for a painful condition to be treated, such as while undergoing diagnostic testing or awaiting a surgical procedure, the nurse may utilize comforting techniques to lessen the painful experience and to help the patient not feel alone in their difficult circumstance. While this course has addressed diagnostic measures to isolate the cause of pain for appropriate treatment, the role of the health provider and nurse to listen and show sensitivity to the patient’s experience of pain is underscored to help lessen patient anxiety and to effectively cope with abdominal pain. Abdominal pain can signify a dangerous situation, which requires rapid assessment and intervention. Yet, its important for clinicians to recognize that pain does not always signal an immediate danger to the patient and very often requires an extended assessment and skill to treat correlating stressors and responses to pain. Future studies on the treatment of abdominal pain and enhanced guidelines for clinicians to support safe and appropriate interventions to treat the patient with one or several causes of abdominal pain are needed. Nurses, in particular, are encouraged to learn from their patients and to continuously engage in research and education on possible medical and other prominent causes of abdominal pain.
Please take time to help the course planners evaluate nursing knowledge needs met following completion of this course by completing the self-assessment Knowledge Questions after reading the article. Correct Answers, page 59.
1. The following is true of the CBC white blood cell (WBC) count:
a. Normal WBC count is between 4,500 and 11,000 mm3
b. Neutrophils are the most common type of WBC
c. When the WBC count is elevated neutrophils become elevated and infection can be suspected
d. All of the above
2. The complete metabolic profile (CMP) tests the patient’s:
a. CMV, hemoglobin and hematocrit
b. Electrolytes and kidney function
c. Total protein and liver enzymes
d. Answers b and c above
3. True or False. Ischemic conditions may reveal metabolic alkalosis due to lack of adequate oxygen to the abdominal tissues.
a. True
b. False
4. Classic symptoms of an ectopic pregnancy include:
a. Back pain radiating to the flank
b. Burning sensation in the suprapubic region
c. Abdominal pain with abnormal vaginal bleeding after amenorrhea
d. Answers a and b above
5. H-pylori is an infectious agent associated with:
a. Gastritis and peptic ulcer disease
b. Infection of the gut spread through fecal-oral transmission
c. 40 % affected individuals in the United States
d. All of the above
6. CT scan for appendicitis is performed to identify:
a. An abnormally shaped or enlarged appendix
b. Thinning of the wall of the appendix
c. A softened texture to the bowel mucosa
d. None of the above
7. True or False. Thrombolytic medications used to manage emboli of the mesenteric arteries include streptokinase or urokinase.
a. True
b. False
8. Fluid maintenance is important in the treatment of pancreatitis for prevention of:
a. Infection
b. Necrosis
c. Organ failure
d. All of the above
9. Pain management techniques considered by the clinician must:
a. Include a review of more than one form of treatment
b. Include a review of the best single method of treatment
c. Factor in patient differences and responses to pain
d. Answers a and c above
10. True or False. Patients with abdominal pain often experience a worsening of symptoms because they are type A personalities and cling to a feeling of being in control.
a. True
b. False
Correct Answers:
1. d
2. d
3. b
4. c
5. d
6. a
7. a
8. d
9. d
10. b
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Red blood cells, as seen on microscopy.
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Common sites of ectopic pregnancy.
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CT scan showing an abdominal aortic aneurysm.
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Ascites development, as seen on ultrasound.
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Gallstones seen on an x-ray.
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