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What's causing that gut pain?


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CE credit is no longer available for this article. (Expired July 2008)


 

Originally posted July 2006

By Maureen Movius, RN, MN, CS

MAUREEN MOVIUS is a clinical nurse specialist at UCI medical Center in Orange, CA. The author has no financial relationships to disclose.

Appendicitis? Diverticulitis? Constipation? MI? When a patient presents with acute GI pain, a targeted nursing assessment will help you cut through the confusion.

Abdominal pain is a common complaint and a leading cause of ED visits.1 Despite its frequency, however, it presents a perplexing dilemma for clinicians. Part of the problem is determining whether the pain and associated signs of distress are evidence of a gastrointestinal disorder or secondary to an MI or other, non-GI condition.

Given this diagnostic challenge, it's easy to see why the ability to do a thorough abdominal assessment is a vital nursing skill. The information you gather will go a long way toward cutting through the confusion, laying the foundation for an accurate diagnosis and treatment plan.


Assessing abdominal pain

Learn all you can about the pain

Determining whether your patient is in urgent need of treatment is an essential first step. A strangulating obstruction or arterial embolus, for example, demands immediate intervention to prevent gangrene or perforation of the gut, which can occur in as little as six hours after the onset.2

As always, start with the ABCs, then do a rapid pain assessment. Severe pain, tachycardia, sweating, and pallor, often accompanied by fever, are among the signs and symptoms that signal a need for emergency medical or surgical intervention.3

In most cases, the physician will order lab work, and often, abdominal X-rays, ultrasound, and endoscopic procedures. These, too, often have limited success in determining the cause of the pain—another reason a targeted assessment is key.

You'll want to find out as much as possible about the pain and document what you learn. Ask the patient to describe the pain, helping him along with targeted questions that cover its severity and location, precipitating or aggravating factors, duration, and "character."


To determine the severity, ask the patient to rate the pain on a scale of 1 – 10, with 10 representing the worst possible pain. Then, have him point to the place where it hurts the most. Find out, too, whether the pain is localized or diffuse and whether it radiates.

Inquire about precipitating or aggravating factors as well as anything that ameliorates the pain. Does eating, moving, or lying down, for example, make it worse or better? Knowing what helps or hurts may provide clues to the cause of the pain.

Gastric ulcer pain typically gets worse after eating, for instance, while pain associated with a duodenal ulcer tends to subside. Gastroesophageal reflux disease (GERD) is often linked to alcohol, caffeine, or chocolate and may be exacerbated by lying flat shortly after eating.4

Ask him, too, to tell you everything he has had to eat and drink—including alcoholic beverages—in the last 24 hours and to provide a chronological sequence of events. Pin down the pain's duration by asking him when he first developed GI symptoms, whether the pain began gradually or suddenly, if it occurs intermittently or continually, and what time he last ate.5 And find out whether and when he developed any of the other cardinal symptoms of GI distress: diarrhea, nausea and vomiting, and anorexia.

Take this opportunity to ask about related symptoms. Has the patient recently had an unexplained weight loss? Constipation or a change in bowel habits? What about jaundice, hematuria, or mucus or blood in the stool? Has he suffered any recent abdominal trauma?

To learn as much as possible about the character—or type—of pain, ask him to tell you what it feels like. If necessary, provide your patient with adjectives he can use to describe the pain, such as sharp, dull, throbbing, aching, burning, cramping, or stabbing. (See the table below on  "Commonly misdiagnosed conditions.")

Broaden the search for a cause

Continue to gather information and clues with more targeted questions, starting with a medication history. Ask the patient to name every prescription drug and OTC product he's taking, including herbal remedies. Inquire about the dosage, route, and frequency, and when it was last taken. (If he took something for GI distress before seeking medical care, include that in the medication history, as well.)

Some meds—potassium tablets, for example—are highly irritating to the intestine and may be the culprit behind gut perforation and peritonitis. Immunosuppressive drugs increase the risk of perforation, as well.2 And nonsteroidal anti-inflammatory drugs, including aspirin, taken frequently, can cause gastric irritation and bleeding.

Find out, too, whether the patient has any drug or food allergies; if so, has he ever had GI pain associated with an allergic reaction? Finally, ask about illicit or recreational drug use.

If your patient is female and between the ages of 12 and 50, take a reproductive health history. When did her last menstrual period begin? Are her menses normal? If she's sexually active, find out whether she uses birth control and if so, what kind.

Ask the female patient whether she has recently had vaginal discharge, swelling, itching, redness, or pain. If she reports any abnormal vaginal bleeding, ask her to estimate the extent of the blood loss. Finally, take a pregnancy history, including the possibility that she's pregnant now.3

Once you've completed the recent history, move on to previous GI problems. Has the patient ever had gastroesophageal reflux disease, gallstones, kidney stones, or diverticular disease, for example? If so, was he treated successfully? Has he ever had abdominal surgery and if so, for what?2

Conclude this phase of your assessment with a family GI history. Certain conditions—polyps and colorectal cancer, for example—have a familial component, while others, such as a relative's recent bout of vomiting and diarrhea, point to gastroenteritis as a possible cause of your patient's pain.2

Pay attention to the visual cues

As you prepare for the physical assessment, remember that with an abdominal assessment, auscultation precedes percussion and palpation. This will insure that intestinal activity and bowel sounds are not disturbed before they're fully assessed.4,6 But first, you'll need to do a visual inspection.

Have the patient lie on his back, arms at his sides, with knees flexed to relax the abdomen as you study its contour. The abdomen should be flat. It's important to note any distention or protrusion, which could be caused by a hernia, tumor, bowel obstruction, or enlarged organs.6

Closely observe for pulsations, peristalsis, or bulging, as well. A slight pulsation of the aorta at the epigastrium is normal. But visible peristaltic movement could indicate an intestinal obstruction, in which case you'll detect a peristaltic wave above the obstructed area.6

Inspect the skin, checking for scars, bruising, and petechiae. Scars from previous abdominal surgeries should alert you to the possibility of painful internal adhesions.5

Reddish-blue or purple striae may be a sign of liver disease or Cushing's syndrome. Cullen's sign—periumbilical ecchymosis—may indicate intraperitoneal bleeding. And Grey Turner's sign—flank ecchymosis—is often associated with acute hemorrhagic pancreatitis. If the patient has a stoma, inspect it carefully. It should protrude slightly from the abdomen and be free of redness and irritation.

You'll want to closely observe your patient's movements or posture for additional clues. Those with peritonitis typically lie completely, almost morbidly, still, for instance, while patients with kidney stones often writhe in pain, unable to find a comfortable position.6

Now, picture your patient's abdomen in four quadrants as you attempt to pinpoint the source of the pain. Pain in the right upper quadrant is likely to be related to biliary or hepatic disease. Consider acute MI as the cause of pain that's high in the epigastrium, although crampy, diffuse abdominal pain is sometimes its only presenting symptom.4

Appendicitis is the classic cause of pain in the right lower quadrant, but it could also be associated with right lower lobe pneumonia. And, if your patient is a woman, pain in either the right or left lower quadrant could also be caused by an ectopic pregnancy or a ruptured ovarian cyst. Similarly, pain in the suprapubic or lower abdomen could be the result of a urinary tract infection, mittelschmerz (ovulation pain), or pelvic inflammatory disease.4

Regardless of the patient's gender, diverticulitis is a possible cause of lower left quadrant pain. If the pain comes from the left upper quadrant, possibilities include acute pancreatitis, gastritis, and injury or inflammation of the spleen.

Listen and feel for abnormalities

Prepare for the next step—auscultation—by pre-warming your stethoscope, then placing it over one quadrant at a time. Listen closely for bowel sounds, which are produced by peristalsis, noting their tone and frequency. Borborygmi—loud, prolonged rumbling noises associated with the movement of gas, similar to the sound of the stomach growling—may be an early sign of bowel obstruction.

If you don't hear bowel sounds, listen for one to three minutes over various parts of the abdomen before concluding that they're absent.4 Hypoactive or no bowel sounds may be the result of peritonitis, paralytic ileus, mesenteric thrombosis, narcotic overdose, bowel ischemia, or hypokalemia.4

Listen for vascular sounds over the abdominal aorta and the right and left renal arteries, located near the epigastrium in the right and left upper quadrants. In the lower quadrants, auscultate the iliac and femoral arteries. If the patient has an abdominal aneurysm, you may hear a bruit—the swishing sound of turbulent blood flow. If so, do not percuss or palpate the abdomen; either activity could cause an aneurysm to rupture. Instead, report your findings at once.

At the right and left upper quadrants, listen for friction rubs over the liver and spleen. These grating sounds may indicate a hepatic tumor, splenic infarct, or inflammation of the peritoneum.

As you move on to percussion, keep in mind that there are two basic sounds that you can elicit: tympany, a high-pitched, hollow sound like a drum beat, and dullness, a medium-pitched sound like a thud. You should hear tympany over most of the abdominal cavity. Unusual dullness may be an indication of an abdominal mass. If percussion produces sharp pain, there may be underlying inflammation, such as peritonitis, which would be supported by other findings in the history and exam.6

To check for ascites, percuss the areas of dullness and note whether they shift with changes in patient position. Include percussion of the flanks for costovertebral angle tenderness, which suggests pyelonephritis—inflammation of the kidney and upper urinary tract caused by bacterial infection.4

When you move on to palpation, start lightly. Apply slow, steady pressure, avoiding rapid or sharp movements that are likely to startle the patient or cause additional discomfort. Again, examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel.6

After the initial palpation, examine each quadrant again, but press more deeply this time. If an organ is palpable, note its size, shape, tenderness, and consistency. If you locate a mass, evaluate its qualities as well, including its mobility and whether it moves when the patient inhales and exhales.

Determine the area of greatest tenderness, judging either by what the patient says or his nonverbal response to your touch. Watch for guarding—a reflex contraction of the abdominal musculature, often because of peritonitis or simply to protect the intra-abdominal organs—and rigidity, an abnormal muscle tension or inflexibility. Rebound tenderness, or pain that occurs immediately following palpation, is suggestive of peritonitis, as well.4

Wrap up your abdominal assessment with a digital rectal examination, which will help you to detect an abnormal growth. Be sure to check the stool for occult blood; if the stool is hard and impacted, it could be a sign of severe constipation or, possibly, an obstruction.

Once you're through, review your notes, searching for patterns and areas that warrant a closer look. Then report your findings to the patient's physician, confident that your detective work has provided valuable clues to the cause—and ultimately, the treatment—of your patient's pain.

REFERENCES

1. McCraig, L. F., & Burt, C. W. (2005). National hospital ambulatory medical care survey: 2003 emergency department summary. Advance data from vital and health statistics (No. 358, May 26, 2005). Atlanta: Centers for Disease Control and Prevention.

2. The Merck Manual of Diagnosis and Therapy. "Abdominal pain." 2005. www.merck.com/mrkshared/mmanual/section3 /chapter25/25a.jsp (13 Apr. 2006).

3. Bemis, P. A. "Abdominal pain and abdominal emergency." 2005. www.nursingceu.com/courses/1/index_nceu.html (12 Apr. 2006).

4. White, M. J., & Counselman, F. L. "Troubleshooting acute abdominal pain." 2002. www.emedmag.com/html/pre/cov/covers/011502.asp (13 Apr. 2006).

5. Cook, K. (2005). Evaluating acute abdominal pain in adults. JAAPA, 18(3), 22.

6. Goldberg, C. "A practical guide to clinical medicine." 2005. medicine.ucsd.edu/clinicalmed/abdomen.htm (12 Apr. 2006).


Commonly misdiagnosed conditions

When patients come to the ED with abdominal pain, serious conditions can easily go undetected. Here's a look at four life-threatening conditions that are commonly missed, and ways to improve their identification:


Commonly misdiagnosed conditions

Sources: 1. American College of Emergency Physicians. "Clinical policy: Critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain." 2000. www.acep.org/NR/rdonlyres/8D206F7F-A564-4920-8EF6-584D15305E48/0/cp402130.pdf (13 April 2006). 2. Flasar, M. H., & Goldberg, E. (2006). Acute abdominal pain. Med Clin North Am, 90(3), 481. 3. White, M. J., & Counselman, F. L. "Troubleshooting acute abdominal pain." 2002. www.emedmag.com/html/pre/cov/covers/011502.asp (13 April 2006).


Web Exclusive: What type of pain is it?

There are three main categories of pain: visceral, somatic, and referred. Each has distinguishing characteristics that may provide clues to the source of your patient's abdominal pain.

Visceral pain is poorly localized and dull, cramping, burning, deep, or aching. It originates from internal organs and the peritoneum and is typically the result of stretching, inflammation, or ischemia. Appendicitis, pancreatitis, and peptic ulcer disease are among the conditions that produce visceral pain.

Somatic pain comes from nerve endings, so it's sharper and more localized. It's often an indication of tissue damage and may originate from the abdominal wall or parietal peritoneum. Cuts, contusions, and muscle spasm are among the conditions that produce somatic pain.

Referred pain describes pain that's felt in a part of the body far from the source because of shared nerve pathways to the spinal cord and brain. Liver or gallbladder disease, for example, may cause pain in the right shoulder, while damage to the heart from a myocardial infarction may cause abdominal pain.

Sources: 1. Flasar, M. H., & Goldberg, E. (2006). Acute abdominal pain. Med Clin North Am, 90(3), 481. 2. White, M. J., & Counselman, F. L. "Troubleshooting acute abdominal pain." 2002. www.emedmag.com/html/pre/cov/covers/011502.asp (13 April 2006).


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