14: The Acute Abdomen

1. Define the term “acute abdomen.”

2. Identify the signs and symptoms of the acute abdomen and the necessity for immediate transport of patients with these symptoms.

3. Define the concept of “referred pain.”

Cognitive Objectives (1 of 2)

4. Describe areas of pain or referred pain seen with the common causes of the acute abdomen.

5. Explain that pain in the abdomen can arise from other body systems.

Cognitive Objectives (2 of 2)

Psychomotor Objectives

6. Perform a rapid, gentle assessment of the abdomen.

• There are no affective objectives for this chapter.

Abdominal Pain

• Common complaint• Cause is often difficult to identify; not necessary to

determine cause• Need to recognize life-threatening problems and

act swiftly

Physiology of the Abdomen (1 of 2)

• Peritonitis– Irritation of the peritoneum

• Peritoneum– Thin membrane lining the entire abdomen

• Acute abdomen– Sudden onset of abdominal pain– Can be fatal

Physiology of the Abdomen (2 of 2)

• Pain usually interpreted as colic; a severe, intermittent cramping pain.

• Referred pain

– Perceived pain at a distant point of the body caused by irritation of the visceral peritoneum

Causes of Acute Abdomen (1 of 2)

• Nearly every kind of abdominal problem can cause an acute abdomen.

• Substances lying in or adjacent to the abdominal cavity

Causes of Acute Abdomen (2 of 2)

• Perforation of an ulcer• Gallstones that lead to inflammation (cholecystitis)

• Inflammation of the pancreas (pancreatitis)

• Inflammation or infection of appendix

• Inflammation of pouches in large intestine (diverticulitis)

Urinary System

• Kidneys can be affected by stones that form from materials normally passed in the urine.

• Kidney infections can cause severe pain.• Patients are often quite ill, with a high fever.• Bladder infection (cystitis) more common,

especially in women. • Patients usually have lower abdominal pain.

Uterus and Ovaries

• Always consider a gynecologic problem with women having abdominal pain.

• Causes of pain– Menstrual cycle– Pelvic inflammatory disease– Ectopic pregnancy

Other Organ Systems

• Aneurysm– Weakness in aorta

• Pneumonia– May cause ileus and abdominal pain

• Hernia– Protrusion through a hole in the body wall

Signs and Symptoms of Acute Abdomen (1 of 2)

• Ileus– Paralysis of muscular contractions in the

intestine– Causes abdominal distention

• Nothing can pass normally out of stomach or bowel.

• Stomach can only empty through vomiting.• Almost always associated with nausea and

vomiting

Signs and Symptoms of Acute Abdomen (2 of 2)

• Distention • Anorexia• Loss of body fluid into peritoneal cavity• Fever may or may not be present.• Tenseness of abdominal muscles over irritated

area

You are the Provider

• You and your EMT-I partner are assigned to a high-school football game. 

• After a tackle, one player remains on the ground with his knees pulled to his chest. 

• You await evaluation by the team’s trainers. After a few moments, the player gets up and walks to the bench with assistance.

• A few minutes later, the trainer motions you to come over. 

You are the Provider continued

• What sorts of injuries can occur to the abdomen during contact sports such as football?

Scene Size-up

• Ensure that the scene is safe.• Acute abdomen can be result of violence.• Consider ALS back-up.• Observe the scene closely for clues.

You are the provider continued• The patient explains that the wind was knocked out

of him during the tackle when another player’s helmet “hit him in the gut.”

• He now feels pain in his stomach, nausea. • Given his description of the events and trainer’s

comments, you believe this is an isolated injury to the abdomen.

You are the provider continued

• What could be causing his pain and what other signs and symptoms could you expect the patient to have?

Initial Assessment

• Ascertain chief complaint.• Note patient’s LOC using AVPU scale.• Check for adequate airway and treat appropriately.• Administer oxygen. • Assess for major bleeding.• Pulse and skin condition may indicate shock.• If evidence of shock exists, elevate patient’s legs 6˝

to 12˝ or to position of comfort.

Transport Decision

• Transport gently.• Do not delay transport if patient has:

– Life threat– Suspected internal bleeding– Poor general impression

• Do not delay transport of pediatric or geriatric patients.

You are the provider continued (1 of 2)

• The patient has been involved in recent physical activity, so observing his skin is not useful.

• Pulse is regular, full, 130 beats/min. • You carefully assist him to the cot and suggest that he

lay down in a position of comfort.• He tells you that his left shoulder is beginning to hurt. • You begin transport immediately. 

You are the provider continued (2 of 2)• What other conditions might have made his injury more likely to occur?

Focused History and Physical Exam

• Local or diffuse abdominal pain/tenderness

• Patient position• Rapid and shallow

breathing• Referred (distant) pain• Anorexia, nausea,

vomiting

• Tense, distended abdomen

• Constipation, bloody diarrhea

• Tachycardia• Hypotension• Fever• Rebound tenderness

SAMPLE History

• Use OPQRST to ask the patient what makes the pain better or worse.

• Do not give the patient anything by mouth.

Focused Physical Exam (1 of 2)

• Explain what you are about to do.• If no trauma, place patient supine with legs drawn

up and flexed at knees.• Determine if motion causes pain and if distention is

present.• Palpate the four quadrants of the patient’s

abdomen gently.

Focused Physical Exam (2 of 2)

• Determine whether patient can relax abdomen on command.

• Determine whether abdomen is tender when palpated.

• Palpate gently—rough palpation could cause further damage.

Baseline Vital Signs

• Monitor for adequate ventilation.• Beware that changes in vital signs may be as a

result of septic or hypovolemic shock.

Interventions

• Based on assessment findings.• Anticipate vomiting.• Nausea is frequently lessened by low-flow oxygen.• If the patient exhibits signs of shock, place in

Trendelenburg position.

You are the Provider continued

• You ask the patient whether he has recently had mononucleosis. He seems surprised and confirms a recent history of “mono.” 

• He did not tell his coach because he was afraid he wouldn’t be allowed to play.    

• You apply high-flow oxygen and obtain a blood pressure while your partner initiates two large-bore IVs.

Detailed Physical Exam

• You will not be able to make a diagnosis.• This exam may help provide more information. • Do not delay transport to perform this.

You are the Provider continued• Vital signs:

– BP 96/64 mm Hg– Respirations 36 breaths/min– Pulse oximetry 95% receiving 15 L/min via

nonrebreathing mask. • He complains of feeling dizzy. • You place him in the shock position and cover him

with a blanket. • He remains awake and alert during transport;

complains of severe abdominal pain throughout the call.

Ongoing Assessment

• Patient’s condition may rapidly change.• Reassess ABCs.• Anticipate development of shock; treat even if there

are no obvious signs.• Communication and documentation

– Relay information as soon as possible so that appropriate resources are made available.

– Include pertinent physical findings.

Emergency Medical Care

• Take steps to provide comfort and lessen effects of shock; reassure patient.

• Position patients who are vomiting to maintain airway.

• Be sure to use BSI.• Clean ambulance and equipment once patient is

delivered.

Review

1. MOST patients with an acute abdomen present with:

A. dyspnea.

B. diarrhea.

C. hypotension.

D. tachycardia.

Review

Answer: D

Rationale: Tachycardia (heart rate >100 beats/min) is commonly seen in patient’s with an acute abdomen; it is usually the result of severe pain. Hypotension is not seen in all patients with an acute abdomen; if the patient is hypotensive, you should suspect internal bleeding or a severe infection (sepsis). Many patients with an acute abdomen have increased respirations (tachypnea); however, dyspnea (a feeling of shortness of breath) is not common.

Review

1. MOST patients with an acute abdomen present with:

A. dyspnea.

Rationale: Some patients may have increased respirations, but typically do not have difficulty breathing.

B. diarrhea.

Rationale: Diarrhea may be a symptom of some abdominal problems, but not in most patients.

C. hypotension.

Rationale: Hypotension is not seen in most patients and should be suspected when shock is present.

D. tachycardia.

Rationale: Correct answer

Review

2. The ___________ lies in the retroperitoneal space.

A. liver

B. pancreas

C. stomach

D. small intestine

Review

Answer: B

Rationale: The pancreas, kidneys, and ovaries lie in the retroperitoneal space, which is behind the peritoneum, and are often the cause of acute abdominal pain. The liver, stomach, and small intestine are all found within the true (anterior) abdomen.

Review

2. The ___________ lies in the retroperitoneal space.

A. Liver

Rationale: The liver is found in anterior abdomen.

B. Pancreas

Rationale: Correct answer

C. Stomach

Rationale: The stomach is found in anterior abdomen.

D. small intestine

Rationale: The small intestine is found in anterior abdomen.

Review

3. A 34-year-old woman with a recent history of pelvic inflammatory disease presents with acute severe abdominal pain. Her abdomen is distended and diffusely tender to palpation. Based on your findings thus far, you should suspect:

A. peritonitis.

B. pancreatitis.

C. appendicitis.

D. cholecystitis.

Review

Answer: A

Rationale: Peritonitis—an inflammation of the thin membrane that lines the abdominal cavity—typically presents with acute abdominal pain. Causes of peritonitis include infection and blunt or penetrating abdominal trauma. The pain caused by peritonitis is typically diffuse (widespread), whereas appendicitis, pancreatitis, and cholecystitis (inflammation of the gallbladder) typically present with pain that is localized to a particular area.

Review3. A 34-year-old woman with a recent history of pelvic inflammatory

disease presents with acute severe abdominal pain. Her abdomen is distended and diffusely tender to palpation. Based on your findings thus far, you should suspect:

A. peritonitis. Rationale: Correct answerB. pancreatitis. Rationale: Pancreatitis is usually a localized pain (in one specific

area).C. appendicitis. Rationale: Appendicitis is usually a localized pain (in one specific

area).D. cholecystitis. Rationale: Cholecystitis is usually a localized pain (in one specific

area).

Review

4. In which position do most patients with acute abdominal pain prefer to be transported?

A. Sitting with head elevated 45°

B. Supine with their legs elevated 12”

C. On their side with their knees flexed.

D. Fowler’s position with their legs straight

Review

Answer: C

Rationale: Most patients with acute abdominal pain prefer to lie on their side with their knees flexed (and usually drawn up into their abdomen). This position takes pressure of the abdominal muscles and may afford them pain relief.

Review

4. In which position do most patients with acute abdominal pain prefer to be transported?

A. Sitting with head elevated 45°

Rationale: This is also know as the semi-Fowler’s position.

B. Supine with their legs elevated 12”

Rationale: This is usually done in patients with hypotension.

C. On their side with their knees flexed.

Rationale: Correct answer

D. Fowler’s position with their legs straight

Rationale: This is when the patient is sitting straight up.

Review

5. A condition in which a person experiences a loss of appetite is called:

A. ileus.

B. colic.

C. emesis.

D. anorexia.

Review

Answer: D

Rationale: Anorexia is defined as a loss of appetite. It is a non-specific symptom, but is often associated with gastrointestinal diseases and abdominal pain.

Review

5. A condition in which a person experiences a loss of appetite is called:

A. ileus.

Rationale: This is the paralysis of the muscular contractions that normally propel material through the intestine.

B. colic.

Rationale: This is a severe, intermittent cramping pain.

C. emesis.

Rationale: This is also know as vomiting.

D. anorexia.

Rationale: Correct answer

Review

6. If a hernia is incarcerated and the contents are so greatly compressed that circulation is compromised, the hernia is said to be:

A. reduced.

B. ruptured.

C. strangulated.

D. hypoxemic.

Review

Answer: C

Rationale: A strangulated hernia occurs when a hernia is incarcerated and compressed by the surrounding tissues. It is a serious medical emergency and requires immediate surgery to repair the hernia, remove dead tissue, and return oxygen to the tissues.

Review6. If a hernia is incarcerated and the contents are so greatly

compressed that circulation is compromised, the hernia is said to be:

A. reduced.Rationale: This is a mass or lump that will disappear back into

the body cavity in which it belongs.B. ruptured.Rationale: This is a mass or lump that bursts from internal

pressure.C. strangulated.Rationale: Correct answerD. hypoxemic.Rationale: This is a decrease in arterial oxygen levels.

Review

7. Which of the following signs or symptoms would you be the LEAST likely to find in a patient with an acute abdomen?

A. Rapid, shallow breathing

B. Soft, nondistended abdomen

C. Tachycardia and restlessness

D. Constipation or diarrhea

Review

Answer: B

Rationale: Signs and symptoms of an acute abdomen include, but are not limited to, rapid and shallow breathing, a tense and distended abdomen, tachycardia, restlessness, and constipation or diarrhea.

Review

7. Which of the following signs or symptoms would you be the LEAST likely to find in a patient with an acute abdomen?

A. Rapid, shallow breathingRationale: This is a common sign of an acute abdomen.B. Soft, nondistended abdomenRationale: Correct answerC. Tachycardia and restlessnessRationale: These are common signs of an acute abdomen. D. Constipation or diarrheaRationale: These are common signs of an acute abdomen.

Review

8. Which of the following is NOT a solid organ?

A. Liver

B. Kidney

C. Spleen

D. Gallbladder

Review

Answer: D

Rationale: The gallbladder is a hollow organ that concentrates and stores bile, which is produced by the liver. Other hollow organs include the stomach and intestines. The liver, spleen, and kidney are all solid organs.

Review

8. Which of the following is NOT a solid organ?

A. Liver

Rationale: The liver is a solid organ.

B. Kidney

Rationale: The kidney is a solid organ.

C. Spleen

Rationale: The spleen is a solid organ.

D. Gallbladder

Rationale: Correct answer

Review

9. A 70-year-old man presents with an acute onset of severe, tearing abdominal pain that radiates to his back. His BP is 88/66 mm Hg, pulse rate is 120 beats/min, and respirations are 26 breaths/min. Treatment for this patient should include:

A. rapid transport to the hospital.

B. firm palpation of the abdomen.

C. placing him in a sitting position.

D. oxygen at 4 L/min via nasal cannula.

Review

Answer: A

Rationale: Severe, tearing abdominal pain that radiates to the back is typical of an abdominal aortic aneurysm (AAA); it commonly occurs in older patients—especially those with hypertension. Treatment includes high-flow oxygen and rapid transport. If the patient has signs of shock, place him or her supine and elevate the legs 6” to 12”. Do not vigorously palpate the patient’s abdomen; doing so may cause the aneurysm to rupture.

Review (1 of 2)

9. A 70-year-old man presents with an acute onset of severe, tearing abdominal pain that radiates to his back. His BP is 88/66 mm Hg, pulse rate is 120 beats/min, and respirations are 26 breaths/min. Treatment for this patient should include:

A. rapid transport to the hospital.Rationale: Correct answerB. firm palpation of the abdomen.Rationale: A firm or vigorous palpation is contraindicated in

patients with severe and sudden onset abdominal pain.

Review (2 of 2)

9. A 70-year-old man presents with an acute onset of severe, tearing abdominal pain that radiates to his back. His BP is 88/66 mm Hg, pulse rate is 120 beats/min, and respirations are 26 breaths/min. Treatment for this patient should include:

C. placing him in a sitting position.Rationale: Hypotension is treated by elevating the patient’s legs

into the shock position. D. oxygen at 4 L/min via nasal cannula.Rationale: High flow oxygen is indicated in the treatment of

shock.

Review

10. The medical term for inflammation of the urinary bladder is:

A. cystitis.

B. nephritis.

C. cholecystitis.

D. diverticulitis.

Review

Answer: A

Rationale: Cystitis is the medical term for inflammation of the urinary bladder. Nephritis is inflammation of the kidney. Inflammation of the gallbladder is called cholecystitis. Diverticulitis is a condition in which small pouches in the colon (large intestine) become inflamed.

Review

10. The medical term for inflammation of the urinary bladder is:

A. cystitis.

Rationale: Correct answer

B. nephritis.

Rationale: Nephritis is the inflammation of the kidney.

C. cholecystitis.

Rationale: Cholecystitis is the inflammation of the gallbladder.

D. diverticulitis.

Rationale: Diverticulitis is the inflammation of part of the large intestine.