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Triaging lower abdominal pain


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CE CENTER

Triaging lower abdominal pain

CE credit is no longer available for this article. (Expired December 2004)



Originally posted December 2002

Triaging lower abdominal pain

POLLY GERBER ZIMMERMANN, RN, MS, MBA, CEN

POLLY GERBER ZIMMERMANN is a nursing instructor at Harry S. Truman College in Chicago.

KEY WORDS: pelvic inflammatory disease, ectopic pregnancy, appendicitis, mittelschmerz, peritonitis, rebound tenderness, testicular torsion, epididymitis, epididymo-orchitis, dysuria, renal colic, diverticulitis

Appendicitis, pelvic inflammatory disease, and ectopic pregnancy have similar symptoms. So do other common lower abdominal problems. Here's how to tell them apart and ensure that the true emergencies get immediate care.

Jump to:

Denise, a 21-year-old, arrives in the ED complaining of sharp right lower quadrant (RLQ) pain that came on suddenly. She's weak and dizzy and says her last menstrual period was about six weeks ago, though she had some spotting today. Her symptoms, plus her history of pelvic inflammatory disease (PID) and a positive pregnancy test, suggest an ectopic pregnancy. You classify her as emergent.

Triaging a patient like Denise, who has lower abdominal pain, can be especially challenging. RLQ pain, for example, could signal appendicitis or the relatively benign mittelschmerz.

Adding to the challenge are the sheer numbers; lower abdominal pain is the third most common chief complaint that brings people to the ED.1 Patients seeking care could be in varying stages of an emergent condition that could be potentially fatal. Thus, your triaging must be accurate. There's much you must keep in mind, including systemic causes—everything from hematologic, endocrine, infectious, and inflammatory causes to those related to toxicities. We'll focus here on the classic signs and symptoms of some more common emergent conditions—such as peritonitis, ectopic pregnancy, and appendicitis—and several other common causes of lower abdominal pain.

Taking a history, assessing the pain

Triaging requires skill in rapid problem identification and prioritization.2 Before you can decide on an acuity level, you will of course need to gather key data (such as vital signs), as well as take a history, determine the pain characteristics, and perform a limited physical assessment.

With abdominal pain complaints, focus on prior medical and surgical histories, referred pain, associated symptoms such as GI bleeding, and current medications (including vitamins and herbal supplements).3 Query female patients about their menstrual and reproductive histories.

To help you take a history of the chief complaint—in this case, abdominal pain—consider using the PQRST mnemonic:2

Provokes—What provokes the pain?

Quality—What makes it better/worse? What does it feel like?

Radiation—Where is it? Where does it radiate?

Severity—Rate the pain on a scale of 1 – 10.

Time and Treatment—How long have you had it? What has been done already?

Pain is usually more serious if it has begun abruptly—the patient can recall the exact time it started or what she was doing when it started; it has reached maximum severity at its onset; or it awakened the patient from sleep.4 If a patient states that the pain intensity is a 10 but looks comfortable, ask about the worst pain the patient has previously experienced. By definition, pain anyone has for the first time is the "worst ever"—a "10" on a scale of 1 – 10.2

Recently I observed a 7-year-old literally rolling on the floor, crying about her "tummy hurting." This turned out to be her first remembered case of ordinary flatus. Patients who can't rate their pain but would be expected to have severe pain, such as a young child with a fracture, should be treated as though they have a score of 8 to 10.2

As you continue with your history, observe the patient's position. Patients in pain tend to seek the position that provides the most comfort. If the patient appears fairly comfortable and moves around at will, the problem is probably not severe.1,3 Positions of concern are holding oneself rigidly still, putting oneself into the fetal position, or writhing in pain.

As a general rule, cramping, intermittent, or sharp brief pains without any vital sign abnormalities are usually less serious. Visceral pain (constant ache, pressure, burning, squeezing) with associated symptoms (nausea/ vomiting, sweating, radiation of pain) and vital sign abnormalities are much more likely to be serious.4 Visceral pain alone is not always cause for alarm but requires further assessment.

Be cautious in applying these general rules to the elderly. Only about half of elderly patients with acute abdominal pain have "textbook" presentations.5 An older patient may have a blunted response or may not spike as high a fever as a middle-aged person because of age-related immune suppression.5

Focusing in on the abdomen

When you've observed the nature of the pain and taken the history, move on to assessing the patient's abdomen. Move directly from inspection to auscultation before performing percussion and palpation. That will avoid distortion of bowel sounds caused by pressing on the abdomen.6

With obese patients, distention may be difficult to determine by palpation. To make the distinction between a distended abdomen and an obese abdomen, roll the patient on her side, inspect the flank, and ask if her abdomen feels "tight." If distention is present, the abdomen will feel "tight," the patient's flank won't be bulging, and you'll notice increased tympany with percussion. In comparison, with obesity, the abdomen will not feel tight, the umbilicus will appear to be sunken, and there will be normal findings on percussion.7

As you continue, be on the alert for critical conditions that will need rapid care. Consider the most likely problem first. Keep this rule of thumb in mind: When you hear hoofbeats, think of horses, not zebras.

Start by ruling out peritonitis

The presence of peritonitis always signals an acutely ill patient. Inflammation of the peritoneum occurs when the greater omentum blocks leakage caused by a perforated organ, such as the appendix or diverticulum, or by a chemical or bacterial invasion. The loss of fluids into the peritoneal cavity leads to severe dehydration and electrolyte disturbances. If not treated promptly, sepsis and multisystemic failure occur rapidly.

Typically, peritonitis-related abdominal pain starts locally, at the site of the irritated organ, and then becomes more generalized as the peritoneal irritation spreads. If perforation occurs, there's usually an initial pain-free period followed by a gradually increasing generalized discomfort.1

Because of their pain, patients with peritonitis usually lie perfectly still or with their hips flexed. Either position is an instinctual effort to lessen muscle movement and tension. Other signs include a "board-like" abdomen (caused by spasms of the irritated muscles), high fever, nausea, and a rising tachycardia due to hypovolemia as a result of third spacing. You'll want to look for these signs as well:8

• Abdominal pain accompanied by left shoulder tip pain. This is referred to as Kehr's sign.

• Rebound tenderness, in which the pain is worse after a quick release of deeper palpation pressure. This is called Blumberg's sign.

• Pain in the RLQ following palpation of the left lower quadrant (LLQ). This sign, called Rovsing's sign, indicates that the irritation is spreading across the peritoneum.

If you suspect peritonitis, call a doctor immediately.

When you're assessing a female patient

When a female patient presents with lower abdominal pain, you'll need to be alert to the following conditions:

Ectopic pregnancy. This condition occurs in approximately 1 out of 60 pregnancies in the United States.9 It leads to shock in 10% of those patients, and it is the number one cause of maternal death in the first trimester.3

You must, therefore, consider ectopic pregnancy any time a woman with an early pregnancy has vaginal bleeding, pelvic pain, or syncope.10 When a patient has these symptoms, suspect a pregnancy—even if the patient does not think she's pregnant. As one teenager, who had irregular periods, said to me, "I know I'm not pregnant because I don't want to be." She was.

Use this rule of thumb from Great Britain's Manchester Triage Group: Until proven otherwise, any female who has reached puberty, whose normal menstruation has failed, and who is having unprotected sex should be considered potentially pregnant.11

Ectopic pregnancy causes unilateral abdominal pain. Most patients—at least 70%—will have minimal vaginal spotting.10 That was true for Denise, the patient in our opening scenario, who, among other things, experienced both unilateral pain and spotting. She was ultimately diagnosed with an ectopic pregnancy.

Other symptoms can include dizziness (present with at least one-third of ectopic pregnancies) or hormonal symptoms of pregnancy.10 The patient can often recall a late, missed, or recent period that was unusual in some subtle way. More than 50% have a history of PID.9

Pelvic inflammatory disease (PID). In almost all cases, this pelvic cavity infection is characterized by constant, dull, bilateral lower abdominal pain that's poorly localized and becomes worse with activity.12

Pain that's related to PID typically causes the patient to walk in the classic gait known as the "PID shuffle"—bending over at the waist and clutching the lower abdomen. If the pain is only on one side, promptly assess for an ectopic pregnancy.12

Other PID symptoms include burning or pain during urination, bleeding between menstrual periods, and thick vaginal discharge, which is present in more than 70% of cases.12 Keep in mind that only about 30% of patients with PID have all the textbook symptoms.13 However, patients with PID will appear sicker than patients with normal menstrual discomfort and their pain is usually more severe and lower in the abdomen than in other conditions such peritonitis or appendicitis (which I'll discuss later).

Risk factors for PID include a history of new or multiple sexual partners, frequent intercourse, recent insertion of an intrauterine device (IUD), lower socioeconomic status, younger age (15 – 19 years old), smoking, or a history of previous sexually transmitted disease.12

Mittelschmerz. This sudden onset of intense RLQ or LLQ pain occurs about halfway through the menstrual cycle, typically on days 12 to 16. The pain is generally attributed to local irritation caused by the release of blood, follicular fluid, and prostaglandins, as well as increased fallopian tube peristalsis during ovulation.

Sometimes other symptoms of hormonal changes may be present, such as breast tenderness or nausea.3 The pain resolves spontaneously. Knowing this, however, doesn't make it any less alarming to a young girl who is experiencing her first intense episode.

When you're assessing a male patient

The following conditions may be present in young and older male patients:

Testicular torsion. Young patients with testicle or scrotal pain require immediate evaluation. If your patient is a young male (newborn to age 20) presenting with unilateral testicular pain or tenderness, suspect testicular torsion—the twisting of a testis on its spermatic cord, cutting off the blood supply to the testicles.14

The condition results from a congenital abnormality, found in as many as 12% of males, that allows the testicle to twist spontaneously on the spermatic cord one or more times.15 About 30% of patients with these symptoms may have a history of recent, similar painful episodes that resolved spontaneously.

In most cases, the "twisting" pain usually starts suddenly during an activity and increases when the testicle is elevated. You might notice a bow-legged "saddle walk."14 These patients usually do not have pyuria. They may sometimes have referred lower abdominal pain or poorly localized scrotal pain. Other symptoms include nausea, vomiting, and fever.

If testicular torsion is suspected, care is needed immediately. If the torsion is corrected within six hours of the onset of pain, the testicle can likely be saved. But the testicle can be saved in only 20% of cases where treatment is delayed for 12 hours or more. 14

Epididymitis and epididymo-orchitis. Epididymitis is an inflammation of the epididymis—the coiled tube that lies above and behind the testicle and stores and transports spermatozoa from the testicle. Epididymo-orchitis is an inflammation of the epididymis and testes and can be a progression or complication of epididymitis.

Both of these conditions may be signaled initially by abdominal or flank pain, and both are characterized by a less severe gradual onset of testicular/scrotal pain.14

These conditions are usually seen in young, sexually active males.16 Sexually transmitted pathogens are the organisms most often responsible for epididymitis in patients younger than 35. Chlamydia trachomatis is responsible for more than 50% of epididymitis cases in men in that age group.16

The pain caused by epididymitis is often accompanied by dysuria, fever, and pyuria. While scrotal tenderness may be present, it's not as severe as in torsion, and elevation of the testicles usually helps decrease the pain. Don't overlook the possibility of epididymitis or epididymo-orchitis in the elderly—especially after a procedure with instrumentation, such as a cystoscopy.14

Some other conditions you'll need to watch for

As you assess patients of either gender, consider the following when the chief complaint is lower abdominal pain:

Acute appendicitis. The goal of triage in cases of appendicitis—an inflammation of the vermiform appendix—is to get treatment before rupture. Perforation occurs in up to 20% of patients and is reported to occur in 50% of patients younger than 3 and older than 50.17

Appendicitis can be difficult to identify because patients seek medical help at varying stages of this condition, which has a protracted course. More than 70% of patients have anorexia and, at the same time, diffuse periumbilical pain.12

The pain, which is caused by peritoneal irritation, localizes over a 12- to 48-hour period at McBurney's point (midway between the anterior superior iliac spine and the umbilicus in the RLQ). Coughing or walking can aggravate the pain.12 However, during this 12- to 48-hour period, the patient may be very still, with voluntary guarding, or stiffening of the muscles to avoid motion in the tender area.12

Nausea, vomiting, fever, and rebound tenderness are frequent symptoms. Cutaneous hyperesthesia—abnormally acute sensitivity to touch—can be present.12

To assess for cutaneous hyperesthesia, pick up a fold of skin between your thumb and index finger (without pinching it) at a series of points down the abdominal wall. Normally, this should not be painful; if it is, suspect appendicitis.7

Other physical assessment tests, if positive, can also indicate appendicitis:7,8

Iliopsoas muscle test. With the patient supine, raise his right leg while providing counter resistance. Resulting increased RLQ pain (known as the psoas sign) can indicate appendicitis.

Obturator muscle test. With the patient supine, flex his right leg, with the knee bent 90 degrees, and rotate the leg toward the left side of the body. The presence of hypogastric pain suggests appendicitis.

Aaron's sign. Palpate McBurney's point to detect pain developing by the heart or stomach.

Markle sign (heel jar/heel tap). Ask the patient to stand and raise both heels and allow them to hit the floor with a thump. If the patient cannot cooperate, tap on the heel instead. In each instance, RLQ pain could signal appendicitis.

Renal or ureteral colic. A classic case of renal colic—caused by renal calculi, or "kidney stones"—involves sudden onset of severe, unilateral, intermittent flank pain in a patient who had previously been feeling fine. The pain can last for more than 20 minutes at a time.11 There may also be severe pain in the abdomen (in the area of the obstructed ureter) or back, or it may radiate to the testicle or vulva. In addition the patient may have severe nausea and vomiting.3

Two common symptoms help distinguish renal colic from other abdominal-flank conditions: the patients' extreme restlessness—they writhe on the stretcher or pace the floor, unable to get comfortable—and extreme diaphoresis.3 The patient almost always has gross or microscopic hematuria.3

Renal colic occurs most often in men with a history of renal calculi (50% will have a recurrence) and a history of dehydration.3

Diverticulitis. Inflammation of the diverticula mucosa is often a disease of older adults and is one of the most common causes of acute abdominal pain in geriatric patients.18 By age 65, 50% of people in Western countries will have diverticulosis, small protruding sacs (diverticula) of the inner lining of the intestine.18

The condition is probably due in part to aging and a lifetime of inadequate bulk in the diet.18 Between 1% and 35% of patients with diverticulosis will have an episode of acute diverticulitis, and 15% – 30% of those will have a complication, such as perforation, peritonitis, or bowel obstruction.18,19

Patients with acute diverticulitis typically present with intermittent mild to moderate LLQ pain that is dull and aching. The pain is accompanied by local tenderness and fever. Less common symptoms include vomiting, bloating, and rectal bleeding.

Effective triaging involves careful listening, rapid but accurate history-taking, and thorough abdominal assessment. How well you triage can save lives and help seriously ill patients get the immediate treatment they need.

REFERENCES

1. Wright, J. (2001). Abdominal pain. In K. S. Oman, J. Koziol-McLain, & L. J. Scheetz, Emergency nursing secrets. (pp. 89 – 93). Philadelphia: Hanley & Belfus.

2. Zimmermann, P. G. (2002). Guiding principles at triage: Advice for new triage nurses. J Emerg Nurs, 28(1), 24.

3. Jenkins, J. L., & Braen, G. R. (2000). Manual of emergency medicine (4th ed.). Philadelphia: Lippincott Williams & Wilkins.

4. Canadian Association of Emergency Physicians. (1999). Canadian emergency department triage and acuity scale (CTAS). Implementation guidelines. Journal of the Canadian Association of Emergency Physicians, 1(3), S1.

5. Tripp, W., & Jackimczyk, K. C. (1999). Geriatric emergency medicine. In V. J. Markovchick & P. T. Pons (Eds.), Emergency medicine secrets (2nd ed.), (p. 26). Philadelphia: Hanley & Belfus.

6. Messner, R. L., & Wolfe, S. (1997). Pocket assessment guide—Quick, accurate evaluation of adult acute care patients. Montvale, NJ: Medical Economics.

7. Bates, B. (2002). A guide to physical examination (8th ed.). Philadelphia: J. B. Lippincott.

8. Seidel, H. M., Ball, J. W., et al. (1999). Mosby's physical examination handbook. St. Louis: Mosby.

9. Abbott, J. T. (1999). Ectopic pregnancy. In V. J. Markovchick and P. T. Pons (Eds.), Emergency medicine secrets (2nd ed.), (pp. 390 – 394). Philadelphia: Hanley & Belfus.

10. Ricketts, V. (1999). Vaginal bleeding. In M. A. Davis, S. R. Votey, & P. G. Greenough (Eds.), Signs and symptoms in emergency medicine. Literature-based approach to emergent conditions (pp. 479 – 480). St. Louis: Mosby.

11. Mackway-Jones, K. (Ed.). (1997). Emergency triage: Manchester triage group. London: BMJ Publishing Group.

12. Char, E., & Wong, J. (1999). Abdominal pain. In M. A. Davis, S. R. Votey, & P. Greenough (Eds.), Signs and symptoms in emergency medicine. Literature-based approach to emergent conditions. St. Louis: Mosby.

13. Trott, A. T. (1999). Pelvic inflammatory disease. In V. J. Markovchick & P. T. Pons (Eds.), Emergency medicine secrets (2nd ed.), (pp. 381 – 384). Philadelphia: Hanley & Belfus.

14. Miura, B. (1999). Scrotal pain. In M. Davis, S. R. Votey, & P. G. Greenough (Eds.), Signs and symptoms in emergency medicine. Literature-based approach to emergent conditions. St. Louis: Mosby.

15. Zwanger, M. "Testicular torsion." eMedicine: Instant access to the minds of medicine. 2001. www.emedicine.com/emerg/topic573.htm (16 Sept. 2002).

16. Brooks, M. G. "Epididymitis." eMedicine: Instant access to the minds of medicine. 2001. www.emedicine.com/EMERG/topic166.htm (16 Sept. 2002).

17. Liston, W. "Virtual Naval Hospital: General medical officer manual: Clinical section. Acute appendicitis." 1999. www.vnh.org/GMO/Clinical Section/22AcuteAppendicitis.html (16 Sept. 2002).

18. Hayes, K. S. (2000). Seniors. In K. S. Oman, J. Koziol-McLain, & L. J. Scheetz, Emergency nursing secrets (pp. 221 – 226). Philadelphia: Hanley & Belfus.

19. Stillman, D. L. (1999). Bowel disorders. In V. J. Markovchick and P. T. Pons (Eds.), Emergency medicine secrets (2nd ed.), (pp. 152 – 153). Philadelphia: Hanley & Belfus.


Test your triage skills

The following patients present in your ED with lower abdominal pain accompanied by other symptoms. As triage nurse, which would you rank as the most emergent?

Patient A is an 80-year-old female with a history of diverticulitis. The left lower quadrant (LLQ) pain that's typical of her condition got worse today but then subsided. Now she has a board-like abdomen with generalized abdominal pain, left shoulder pain, and positive rebound tenderness. Her vital signs are: Temp.,100.4° F (38° C); BP, 120/80; HR, 112; and RR, 22.

Patient B is a 45-year-old male with sharp intermittent LLQ abdominal pain and back pain. He doesn't have pain right now, but when it returns, he "cannot find a comfortable spot." His urine dip is positive for a large amount of blood. Vital signs are: Temp., 99º F (37.2º C); BP, 130/78; HR, 78; and RR, 18.

Patient C is a 17-year-old female who has a crampy periumbilical pain that has been slowly moving toward the right lower quadrant (RLQ) over the past two hours. She rates her pain a "3" on the pain scale. She vomited once. Her pregnancy test is negative. She walks with a slight limp. Her vital signs are: Temp., 99.5º F (37.5 C); BP, 112/74; HR, 100; and RR, 22.

Patient D is a 52-year-old male who complains of having some lower abdominal and scrotal pain that has gradually worsened in the last two days. He describes a "burning" sensation when he urinates. His vital signs are: Temp., 100.4 F (38° C); BP, 110/70; HR, 80; and RR, 16.

Who needs care most urgently? Patient B's renal calculi currently are not moving or obstructing urine flow. Patient C's appendicitis is at an early stage. And Patient D can safely wait for antibiotics to treat the epididymitis. In addition, further testing and care of these patients could be started in triage.

Patient A has the classic signs of peritonitis, probably secondary to perforation, and needs care right away. Her temperature is probably blunted as a result of immunosuppression due to aging. Her pulse is the most sensitive indicator of fluid volume deficit. Congratulations if you picked her.


 

Emil Vernarec, ed. Polly Zimmermann. Triaging lower abdominal pain. RN 2002;12:52.

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