CE Article: Getting the Most From Your History and Physical Part 4: The Acute Abdomen

Objectives:

• Review chief complaints for abdominal pain; 
• Discuss assessment of the location of abdominal pain;
• Review a detailed physical exam;
• Review identification of the most common and deadly illnesses causing abdominal pain. 

This is the fourth and final installment in this year’s series on the history and physical. Previous articles:

• Part 1, chest pain: www.emsworld.com/12149999;

• Part 2, neurological patients, www.emsworld.com/12171904;

• Part 3, respiratory patients, www.emsworld.com/12197828.

You and your crew arrive at the home of a 30-year-old female complaining of severe lower abdominal pain. As you park your vehicle and put on your personal protective equipment, your mind begins to sort out the possible causes.

As with our previous articles, this fourth installment will review the appropriate steps for the paramedic to perform to make a logical prehospital diagnosis. Patients presenting with the chief complaint of abdominal pain represent a very diverse group of potential diagnoses ranging from minor ailments to acute life threats. Navigating the prehospital history and physical exam in a logical, efficient manner will assist the paramedic in arriving at the correct prehospital diagnosis. It is important to recognize the patterns of presentation of the most common and dangerous clinical problems; doing so enables rapid lifesaving treatment and correct transport destination decisions. 

An acute abdomen is defined as the sudden onset of severe abdominal pain for less then 24 hours without a known cause. Pain associated with an acute abdomen can have many etiologies involving several different body systems, including the digestive, urinary, reproductive and cardiovascular systems, making abdominal pain challenging to correctly diagnose.

As with all prehospital emergencies, it is imperative to rule out life-threatening conditions first. Two of the most immediately life-threatening that paramedics must be adept at discovering include a ruptured abdominal aortic aneurysm and ruptured ectopic pregnancy. In addition, many other causes of abdominal pain can similarly result in life-threatening hemorrhage or infection. Conducting a systematic focused history and physical exam will help determine the correct prehospital differential diagnosis.

Because there are so many different etiologies for abdominal pain, there can be a tendency to conduct lengthy histories and physical exams to determine the cause. One of the main goals of prehospital medicine is rapid stabilization and transport to the appropriate facility for definitive care. Stable patients do not require lengthy histories and physical exams, and unstable patients cannot afford transport delays. Any patient complaining of severe abdominal pain, fever and/or signs of shock should be transported without delay, with the investigation for the underlying cause taking place as the transport proceeds.

Acute Abdomen History and Physical Exam

Because an acute abdomen has so many possible causes, there can be a wide range of chief complaints. The following are the most common.

Abdominal Pain

There are several different types of abdominal pain: visceral, parietal (somatic) and referred. Abdominal pain can be generalized (diffuse) or localized.

• Visceral pain—Visceral pain is the most common type of abdominal pain and is characterized as a dull, achy, crampy, diffuse pain with a gradual onset. Visceral pain may be associated with nausea, vomiting and diaphoresis. The stomach, kidneys, gallbladder, urinary bladder, intestines and reproductive organs are most commonly affected by visceral pain.

• Parietal pain—Parietal pain is characterized by localized sharp or stabbing pain that’s aggravated by movement, coughing or palpation. Parietal pain occurs due to local irritation of the peritoneal lining of the abdominal cavity. Patients with parietal pain prefer to lie still.

Visceral and parietal pain can occur simultaneously. As an example, a patient with appendicitis may initially complain of poorly localized periumbilical pain described as dull or achy (visceral pain). As the appendix becomes inflamed and irritates the adjacent peritoneal lining, the pain becomes localized to the right lower quadrant with rebound tenderness (parietal pain).

• Referred pain—Referred pain is pain felt in a location different from the actual source of the pain. Common sites for referred pain include:

—Right shoulder/scapula: liver, gallbladder or perforated duodenal ulcer;

—Right-sided chest pain: gallbladder;

—Right upper back: gallbladder;

—Left shoulder: ruptured ectopic pregnancy, blood irritation of the left diaphragm.

Colicky Pain

Patients with colicky pain complain of a cycles of sharp, cramping-type pain lasting several minutes followed by several minutes of relief.

GI Bleeding

Hematemesis (vomiting blood) and hematochezia (rectal bleeding) are signs of GI bleeding. Hematemesis is indicative of upper GI bleeding. Blood may be bright red or resemble coffee grounds. Rectal bleeding can also be bright red or dark (tarry). In the prehospital setting it is not as important to determine the cause or source of the bleeding as it is to monitor the patient for signs and symptoms of shock. Causes of GI bleeding can include peptic ulcer, esophageal varices, esophageal tears caused by severe vomiting, diverticulosis and inflammatory bowel disease.

Location of Abdominal Pain

The location of the abdominal pain discovered either by history or tenderness to palpation on physical exam is a key indicator of its etiology. The abdomen can be divided into four major quadrants plus three midline regions. The location of tenderness in each of these zones helps to narrow the diagnostic possibilities.

• Right upper quadrant (RUQ)—gallstones, hepatitis, perforated duodenal ulcer;

• Left upper quadrant (LUQ)—peptic ulcer disease (PUD), gastritis;

• Midline upper/epigastric—AAA, pancreatitis, PUD, myocardial ischemia;

• Midline central/periumbilical—AAA, early appendicitis;

• Midline lower/suprapubic—UTI, pelvic inflammatory disease;

• Left lower quadrant (LLQ)—diverticulitis, ruptured ovarian cyst, kidney stone, ectopic pregnancy;

• Right lower quadrant (RLQ)—appendix, ruptured ovarian cyst, kidney stone, diverticulitis, ectopic pregnancy.

Expanding on the chief complaint with further questioning to delineate the OPQRST (onset, palliative/provocative/previous episodes, quality, radiation/region, severity, timing) and associated symptoms greatly helps the paramedic to differentiate the causes of abdominal pain (see Figure 1). The pattern of each diagnosis can begin to take shape with the additional historical information OPQRST can provide, so perform these extra lines of questioning whenever time and patient condition allow.

Once the chief complaint is ascertained and its OPQRST performed, we look to the past, social and family history to evaluate risk factors for the various causes of abdominal pain. Depending upon the information obtained, the paramedic may begin to suspect one or more of the possible diagnoses as the most likely etiology (see Figure 2).

Physical Exam

The physical exam is very important in diagnosing the etiology of abdominal pain (see Figure 3). Palpation of the abdomen is the most important step, but as with all exams, we begin with a general impression and then perform a rapid head-to-toe survey concentrating on areas of the exam that are more likely to yield important information.

• General impression—Look to see if the patient is lying still or moving/rocking. Peritoneal pain feels better when lying still. Appendicitis patients often prefer to lie still in a fetal position. Colicky pain tends to feel better when moving or rocking. Patients with kidney stones tend to want to keep moving. Based on these patterns, just watching the patient can assist the medic with narrowing down the possibilities.

Signs such as decreased LOC and diaphoresis may indicate blood loss and shock. Skin color changes can be associated with blood loss (pallor) or gallstone disease (jaundice).

• Vital signs—Narrow pulse pressure may indicate blood loss. Wide pulse pressure may indicate an infectious etiology. Tachycardia may reflect a sympathetic response to pain or evidence of shock.

• Eyes—Yellow sclera (icterus) is often associated with hepatitis or gallbladder disease.

• Chest—Breath sounds may indicate crackles at the bases. Lower lobe pneumonia can be a cause of upper abdominal pain. Tachypnea is a common sign in shock.

Detailed Abdominal Exam

For proper assessment of the abdomen, the patient should be supine with their head relaxed on a pillow, because neck flexion may cause the abdominal muscles to contract. Their hands should be relaxed at their sides. If the patient is unable to straighten their legs, the knees can be slightly bent so the soles of the feet are flat. This will help relax the abdominal muscles and allow a better exam.

Expose the abdomen and inspect for surgical scars, hernias and ascites (an accumulation of fluid in the abdomen secondary to cirrhosis, cancer, CHF or kidney disease). Look for signs of abdominal hemorrhage; Cullen’s sign is periumbilical ecchymosis seen in patients with a ruptured ectopic pregnancy, acute hemorrhagic pancreatitis and ruptured AAA. Grey Turner’s sign is ecchymosis located on the flanks, indicative of hemorrhagic pancreatitis or ruptured AAA.

• Palpation—Palpate all four quadrants and then the midline of the abdomen from epigastric to suprapubic beginning with the area farthest from the pain. Assess for guarding, tenderness/rebound tenderness and rigidity. Rebound tenderness indicates focal peritonitis. It is elicited by pushing down on a non- or minimally tender area of the abdomen, rapidly releasing one’s hands and finding the patient feels an increase in pain at the location of the peritonitis.

• Back—For urinary symptoms, flank or testicular pain, percuss the costovertebral angle by gently tapping on the area between the angle formed from the vertebral column and the 12th rib. If percussion elicits pain, it may indicate a kidney stone or kidney infection.

• Auscultation—For cases of abdominal pain, auscultation provides only limited information in the prehospital arena. The paramedic may notice either a lack of bowel sounds (late sign) or hyperactive bowel sounds (early sign) in cases of small bowel obstruction. In addition, a bruit may be heard over the epigastrium or periumbilical area in some cases of AAA.

Overview of Abdominal Pain/Discomfort

Peritonitis

Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity and organs. It often results from bacterial infections. Cirrhosis of the liver, peritoneal dialysis, pancreatitis or diverticulitis can put patients at risk for developing peritonitis. Additionally, peritonitis can develop from perforation of the appendix or perforation of a peptic ulcer.

Signs and symptoms of peritonitis include severe abdominal pain or tenderness that increases with movement, coughing or palpation of the abdominal wall; rigidity; guarding; nausea and/or vomiting; a bloated feeling; and fever/chills. Signs of shock may also be present due to sepsis or severe hemorrhage. Because there are so many different causes of peritonitis, it is difficult to generalize the typical presentation. In general, any patient with severe abdominal pain and tenderness to palpation should be considered to have peritonitis.

Abdominal Aortic Aneurysm

AAAs increase as age increases. They are most common in Caucasian males between 65–80 years old. There is a 4:1 male-to-female ratio.^1,2

The aorta is the largest blood vessel in the body. When it’s ruptured exsanguination can occur in minutes, resulting in a high mortality rate. This is why an AAA is one of the most fatal medical emergencies in the prehospital setting. Rapid surgical intervention is the only definitive treatment for a ruptured AAA. Therefore, rapid transport to the appropriate medical facility is the best course of action. On-scene times should be minimized and ideally less than 10 minutes. Stabilization should occur en route to the hospital.

Approximately 50% of patients with a ruptured AAA will present with all three of the classic signs and symptoms (back pain, pulsating abdominal mass and hypotension).³ Patients will typically look acutely ill with signs of shock. They often have a feeling of impending doom. Tachycardia and hypotension may occur as the patient develops hemorrhagic shock. A pulsatile abdominal mass is essentially diagnostic of AAA but is found in less than half of cases. Mottling of the lower extremities may be present. Cullen’s sign of bruising near the umbilicus or Grey Turner’s sign of bruising along the flank are uncommon signs but if present indicate internal hemorrhage.

Differential diagnosis: kidney stones, GI bleeding, diverticulitis, appendicitis.

Ectopic Pregnancy

It is estimated that up to 1 in 40 pregnancies will result in an ectopic pregnancy. Ectopic pregnancies can result in life-threatening hemorrhagic shock. Symptoms can begin in as little as four weeks to later than 12 weeks.

Consider an ectopic pregnancy in patients with abdominal/pelvic pain, missed period(s) and vaginal spotting/bleeding. Half of women will have all three of the classic symptoms of an ectopic pregnancy (missed period, abdominal/pelvic pain and vaginal spotting/bleeding).⁴

Patients who have a ruptured ectopic pregnancy may present with signs and symptoms of hemorrhagic shock with pallor, tachycardia and in severe cases hypotension. Lower abdominal tenderness over the affected adnexa and an adnexal mass may be present.

Differential diagnosis: appendicitis, UTI, ruptured ovarian cyst.

Appendicitis

Acute appendicitis occurs when the appendix becomes infected or obstructed. Symptoms can take up to 48 hours to develop into the more classic presentation of anorexia, nausea and vomiting, abdominal pain (periumbilical migrating to the RLQ) and fever. Approximately 8% of the population will develop appendicitis during their lifetimes. The classic presentation that begins with vague periumbilical pain occurs only about 31% of the time, but 95% will have right lower quadrant pain.⁵

Complications include perforation, which can lead to peritonitis and/or sepsis. Patients initially present with vague periumbilical pain, nausea, vomiting and anorexia. If there is fever, typically it is low-grade (100ºF–101ºF). Over time the pain migrates to the RLQ. Peritoneal signs can develop as a result of the appendix perforating.

Abdominal tenderness, especially in the right lower quadrant at McBurney’s point, is typical. McBurney’s point is located midway between the navel and the right iliac crest. As peritoneal inflammation develops, rebound tenderness becomes evident. Once peritoneal signs develop, patients will prefer not to move or walk. Even bumps in the road during transport can become painful.

Differential diagnosis: gastroenteritis, UTI, ovarian cyst, ectopic pregnancy, DKA.

Diverticulitis

Diverticulosis occurs when pouches called diverticula develop in the digestive tract, most commonly in the descending and sigmoid colon. When these diverticula become inflamed or infected, a patient is said to have diverticulitis. If left untreated, diverticulitis can develop into an abscess or bowel perforation, resulting in peritonitis.

The most common presenting symptom is LLQ pain and tenderness, which occurs 70% of the time.⁶ Other symptoms are fever, constipation, nausea and vomiting.

Differential diagnosis: bowel obstruction, constipation, ectopic pregnancy, appendicitis, ruptured ovarian cyst, UTI.

Gallbladder

Gallbladder pain is most often caused by gallstones. When gallstones temporarily block either the cystic or common bile duct, the gallbladder strongly contracts to help relieve the obstruction. These strong contractions are known as biliary colic and produce the classic presentation of epigastric or RUQ pain/discomfort. Pain can radiate to the tip of the right scapula (Collins’ sign) or middle back and is often associated with nausea and vomiting. If the gallbladder then becomes inflamed or infected, it is known as cholecystitis. Gallstones are also a major cause of pancreatitis.

Think of the “five Fs”—female, fat, 40, fair and fertile—when considering gallbladder disease as a prehospital diagnosis. There is a female preponderance for the disease and obesity, age over 40, light skin color and history of multiple pregnancies are considered risk factors for the development of gallstones. (The fair skin color classically referrs to those of Northern European descent, but diverticulitis is also prevalent in American Indians and those of Mexican descent. It is less common in those of sub-Saharan African descent.)

In addition to right upper quadrant tenderness, Murphy’s sign may be present. This sign is elicited when the examiner puts steady pressure in the right upper quadrant immediately after the patient exhales fully. The patient is asked to inhale, causing the diaphragm to push the patient’s gallbladder down into the examiner’s hands and thus eliciting pain.⁷

Differential diagnosis: pancreatitis, appendicitis, peptic ulcer disease.

Kidney Stone

Kidney stones develop in the kidney(s) and become lodged in the ureter, blocking the flow of urine and causing the kidney to swell. Pain from a kidney stone is called renal colic and is usually severe. Risk factors depend on the type of stone produced. The location of a kidney stone (renal vs. ureteral) will determine the type of symptoms. The classic presentation of a kidney stone is sudden severe colicky flank pain radiating to the groin. If kidney stones go untreated, they can lead to pyelonephritis (kidney infection). Palpation of the abdomen often does not increase the pain. Costovertebral tenderness may be present on the affected side. Patients often appear to be in severe pain and cannot sit or stand still.⁸

Differential diagnosis: pyelonephritis, AAA, ectopic pregnancy.

Pancreatitis

Pancreatitis is an inflammation of the pancreas. The two most common causes of acute pancreatitis are gallstones (the top cause) and excessive alcohol consumption. When a gallstone blocks the bile duct, enzymes produced by the pancreas that are normally delivered to the small intestine are blocked and back up into the pancreas, causing irritation and inflammation. The mechanism by which alcohol causes pancreatitis is not fully understood. Pancreatitis presents with upper abdominal pain and tenderness, which may radiate to the mid back. Fever, nausea and vomiting may also occur.⁹

Differential diagnosis: gallstones, MI, peptic ulcer disease, DKA.

Peptic Ulcer Disease

Peptic ulcers are open sores that can be located on the lining of the stomach (gastric ulcers) and duodenum (duodenal ulcers). There are two main causes for the development of peptic ulcers, bacterial infection with helicobacter pylori and excessive use of nonsteroidal anti-inflammatories (aspirin, ibuprofen). The classic presentation of PUD is epigastric burning. Ulcers that go untreated can result in GI bleeding, peritonitis and sepsis. Signs and symptoms will depend on the location of the ulcer. Generally, unless they perforate, ulcers cause only mild to moderate pain with mild epigastric tenderness. They are a common source for GI bleeding.¹⁰

Differential diagnosis: gastritis, gallstones, gastroesophageal reflux disease.

Conclusion

Abdominal pain can be a challenging topic for paramedics. Making the correct prehospital diagnosis can be lifesaving for patients with deadly etiologies. Knowing how to navigate the historical questioning and correctly interpret the physical examination signs will greatly assist the skilled paramedic in rapidly discovering the correct prehospital diagnosis.

In this article series, we have repeatedly encouraged paramedics to recognize the patterns of the most common and deadly illnesses. Having an organized template for information gathering is critical to developing that pattern recognition skill. Knowing the ultimate outcome of your patients will help to refine that skill by reinforcing your initial diagnostic impressions or allowing you to modify them when needed.

With the information gained from this installment in the series, let’s revisit the 30-year-old female with abdominal pain. Given her age, sex and complaint of lower abdominal pain, you and your crew are already thinking about ectopic pregnancy, kidney stones and appendicitis as possible causes. She tells you she is late for her period and has had vaginal spotting today. You learn from asking about her past history that she had an appendectomy years ago, so you remove that possible diagnosis from your list. She has extreme tenderness in the left lower abdomen, just left of the midline. After reading this article you know kidney stones, while painful, usually do not cause abdominal tenderness. You make a prehospital diagnosis of ruptured ectopic pregnancy and decide to transport her to the closest hospital with gynecology services.

At the emergency department a bedside ultrasound confirms your suspicion. Your patient is taken emergently to the operating room, where, thanks to the quick thinking of you and your crew, her life is saved.

References

1. Chung J. Epidemiology, risk factors, pathogenesis and natural history of abdominal aortic aneurysm. UpToDate.com, www.uptodate.com/contents/epidemiology-risk-factors-pathogenesis-and-natural-history-of-abdominal-aortic-aneurysm.

2. Rahimi SA. Abdominal Aortic Aneurysm. Medscape, https://emedicine.medscape.com/article/1979501-overview.

3. Singh MJ. Abdominal Aortic Aneurysm. Society for Vascular Surgery, https://vascular.org/patient-resources/vascular-conditions/abdominal-aortic-aneurysm.

4. Sepilian VP. Ectopic Pregnancy. Medscape, https://emedicine.medscape.com/article/2041923-overview#a5.

5. Nshuti R, Kruger D, Luvhengo TE. Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital. Int J Emerg Med, 2014; 7: 12.

6. Shahedi K. Diverticulitis. Medscape, https://emedicine.medscape.com/article/173388-overview?src=refgatesrc1.

7. Stinton LM, Shaffer EA. Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer. Gut Liver, 2012 Apr; 6(2): 172–87.

8. Chirag D. Nephrolithiasis. Medscape, https://emedicine.medscape.com/article/437096-overview.

9. Gardner TB. Acute Pancreatitis. Medscape, https://emedicine.medscape.com/article/181364-overview

10. Anand B. Peptic Ulcer Disease. Medscape, https://emedicine.medscape.com/article/181753-overview.

Kenneth A. Scheppke, MD, is board-certified in EMS and emergency medicine. He has been practicing emergency medicine for over 20 years and is the EMS medical director for six fire-rescue agencies in Palm Beach County, FL, including Palm Beach Gardens, Palm Beach County, West Palm Beach, Boynton Beach, the Town of Palm Beach and Greenacres. For more than 15 years he has trained paramedics and EMTs as medical director for the Palm Beach State College EMS Academy. He also serves as the assistant medical director of the JFK Medical Center emergency department in Atlantis, FL.

Keith Bryer, BBA, EMT-P, has been employed with Palm Beach Gardens Fire Rescue for more than 25 years. He currently serves as the department’s deputy chief of operations.