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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.
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Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education 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.
Statement of Learning 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.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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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.
b.
c.
d.
CMV, hemoglobin and hematocrit.
electrolytes and kidney function.
total protein and liver enzymes.
Answers b., and c.
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.
5. H-pylori is an infectious agent associated with
a.
b.
c.
d.
gastritis and peptic ulcer disease.
infection of the gut spread through fecal-oral transmission.
40% affected individuals in the United States.
All of the above
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 content and fluid that contains electrolytes.
Consistent vomiting can alter serum concentrations as electrolytes
move between the intracellular and extracellular spaces as
compensation of fluid loss occurs.
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
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associated with the BUN level; and, the creatinine level measures
kidney function and may also be elevated in the CMP laboratory report
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
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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
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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
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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.
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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 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
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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.
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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,
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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
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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
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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 and omeprazole.
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.
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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 acidbase 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.
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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
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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,
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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.
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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
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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 there are cases where this
procedure is 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
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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 extraintestinal 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.
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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.
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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.
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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.
It is 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
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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 Xray 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
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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 Xray, 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
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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
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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.
The 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.
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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
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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.
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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
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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.
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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
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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 principal
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.
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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.
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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
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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.
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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
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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
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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
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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.
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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
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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 NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the
article, and providing feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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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.
b.
c.
d.
CMV, hemoglobin and hematocrit.
electrolytes and kidney function.
total protein and liver enzymes.
Answers b., and c.
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.
5. H-pylori is an infectious agent associated with
a.
b.
c.
d.
gastritis and peptic ulcer disease.
infection of the gut spread through fecal-oral transmission.
40% affected individuals in the United States.
All of the above
6. CT scan for appendicitis is performed to identify
a.
b.
c.
d.
an abnormally shaped or enlarged appendix.
thinning of the wall of the appendix.
a softened texture to the bowel mucosa.
None of the above
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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.
b.
c.
d.
infection.
necrosis.
organ failure.
All of the above
9. Pain management techniques considered by the clinician
must
a.
b.
c.
d.
include a review of more than one form of treatment.
include a review of the best single method of treatment.
factor in patient differences and responses to pain.
Answers a., and c.
10. ______________ are the largest of all of the white blood
cells and they work by destroying dead tissue and by
protecting against certain types of cancer.
a.
b.
c.
d.
Lymphocytes
Monocytes
Eosinophils
Neutrophils
11. Red blood cells, called _____________ at maturity, are
created in the bone marrow.
a.
b.
c.
d.
erythrocytes
lymphocytes
monocytes
eosinophils
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12. 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
13. It has been shown that patients who had normal results
with an abdominal X-ray as an initial diagnostic exam, ___
percent had positive findings when later tested through CT
or ultrasound.
a.
b.
c.
d.
35
48
72
81
14. True or False: In acute pancreatitis, a plain film can
definitively identify acute pancreatitis, but cannot rule
other causes of abdominal pain.
a. True
b. False
15. ___________________, used to treat spasms of smooth
muscle tissue, may be administered to patients with
ischemic bowel disease caused by venous thrombosis or
other conditions that cause vasoconstriction not related to
vessel occlusion.
a.
b.
c.
d.
Inderal
Papaverine
Flexeril
Gabapentin
16. Lactic acid is
a. a by-product of cell metabolism.
b. able to accumulate and result in lactic acidosis.
c. known to lead to ischemia due to lack of oxygen reaching
tissues and cells, if elevated.
d. All of the above
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17. A back rub does more than provide a calming effect for the
patient. It improves circulation by promoting
a.
b.
c.
d.
vasoconstriction to increase blood and lymph flow.
vasodilation to increase blood and lymph flow.
an increase in levels of substance P.
Answers a., and c.
18. Up to ___ percent of pregnancies may end in miscarriage.
a.
b.
c.
d.
12
15
20
None of the above
19. An embolus in the mesenteric artery that restricts blood
flow to the gut requires
a.
b.
c.
d.
administration of thrombolytics.
streptokinase but not urokinase.
streptokinase and urokinase.
Answers a., and c.
20. True or False: Compared to a CT scan, the MRI is safer for
some patients because of lower levels of radiation.
a. True
b. False
21. _____________________ is/are often elevated in cases
where abdominal pain is caused by an infectious or
inflammatory process.
a.
b.
c.
d.
Erythrocytes
Hemoglobin levels
White blood cell count
Red blood cell count
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22. Moist heat is generally considered ________________
when compared to dry heat from a heating pad.
a.
b.
c.
d.
less therapeutic
more therapeutic
equally therapeutic
non-therapeutic
23. A white blood cell count of 11,000 mm3 or more is
classified as
a.
b.
c.
d.
anemia.
normal.
leukocytosis.
leukopenia.
24. ______________ comprise up to 70% of white blood cells
and are often the first type of cell to arrive at the site of
infection.
a.
b.
c.
d.
Lymphocytes
Monocytes
Eosinophils
Neutrophils
25. ______________, a type of granulocyte, are activated in
response to allergens and to other foreign pathogens, such
as parasitic infections.
a.
b.
c.
d.
Band cells
Monocytes
Lymphocytes
Basophils
26. The __________ regulate(s) erythrocyte production
through erythropoietin, which stimulates the bone marrow
to make more cells.
a.
b.
c.
d.
kidneys
lymph nodes
pancreas
spleen
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27. True or False: Patients who are in an immunocompromised
state or those diagnosed with cancer will have an elevated
white blood cell count in the presence of infection.
a. True
b. False
28. Hemoglobin levels may be elevated in such conditions as
a.
b.
c.
d.
bone marrow dysfunction.
folic acid overdose.
polycythemia.
decreased testosterone levels.
29. If the patient is suspected of being anemic, the hematocrit
serves to determine
a.
b.
c.
d.
the body’s ability to produce enough platelets.
the degree of severity of anemia.
whether anemia is present.
the body’s clotting factors.
30. The hematocrit is defined as
a.
b.
c.
d.
the area in the bone marrow that creates monocytes.
a measure of the oxygen levels in the blood.
the area in the bone marrow that creates erythrocytes.
a measure of the percent of RBCs within a volume of whole
blood.
31. __________________ may reveal acidosis because of the
lack of adequate oxygen to the abdominal tissues.
a.
b.
c.
d.
Ischemic conditions
Inflammatory conditions
Anemic conditions
Autoimmune diseases
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32. Ulcerative colitis or gastrointestinal bleeding lead to
decreased
a.
b.
c.
d.
band cell counts.
hemoglobin levels.
leukocytosis.
granulocyte counts.
33. Patients who smoke, and those who live at high altitudes,
may demonstrate
a.
b.
c.
d.
increased red blood cell counts.
decreased red blood cell counts.
impaired cell function.
decreased hemoglobin levels.
34. True or False: 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.
a. True
b. False
35. Abnormally shaped red blood cells caused by disease, e.g.,
sickle cell, do not perform normally and actually contribute
to pain for a patient when cell clumping
a.
b.
c.
d.
causes vessel occlusion.
increased oxygenation.
leukocytosis.
leukopenia.
36. Elevated levels of ____________________ have been
associated with severe disease processes, including
gastrointestinal bleeding, kidney disease, an obstruction in
the urinary tract, or shock.
a.
b.
c.
d.
lactic acid
creatinine
blood urea nitrogen (BUN)
albumin
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37. The creatinine level measures ________ function.
a.
b.
c.
d.
splenic
bone marrow
pancreatic
kidney
38. High hematocrit levels may be due to
a.
b.
c.
d.
dehydration.
bone marrow disease.
kidney or autoimmune diseases.
lymphoma.
39. Low levels of hematocrit tend to be seen with
a.
b.
c.
d.
dehydration.
polycythemia.
kidney or autoimmune diseases.
heart disease.
40. True or False: Hemoglobin is important for oxygen
transport, such that elevated levels typically do not cause a
negative occurrence.
a. True
b. False
41. The fecal occult blood test, which refers to specific testing
for the presence of blood in the stool, is performed
a.
b.
c.
d.
only when a patient complains of pain when defecating.
even if blood can be seen outwardly.
only if blood cannot be seen outwardly.
only when peritonitis is suspected.
42. The fecal occult blood test may lead to false positive
results if the patient
a.
b.
c.
d.
has ingested horseradish.
has hemorrhoids.
recently taken aspirin or NSAID.
All of the above
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43. Which of the following tests have food or drug restrictions?
a.
b.
c.
d.
the stool DNA test.
fecal immunochemical test.
fecal occult blood test.
All of the above
44. Increased glucose in the bloodstream that appears in a
urinalysis test may indicate
a.
b.
c.
d.
poorly managed diabetes.
an infection.
dehydration.
that the patient recently ingested horseradish.
45. True or False: In some cases of an ectopic pregnancy, no
symptoms develop.
a. True
b. False
46. A woman who experiences stretching of the uterine
ligaments during pregnancy may have severe pain that
could be confused with
a.
b.
c.
d.
polycythemia.
autoimmune disease.
kidney disease.
appendicitis.
47. A woman is more likely to have an ectopic pregnancy if she
has
a.
b.
c.
d.
used assistive technology to achieve pregnancy.
had appendicitis.
heart disease.
All of the above
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48. Which of the following tests is not used to detect H. pylori
infection?
a.
b.
c.
d.
blood tests.
stool tests.
breath tests.
None of the above
49. Proton pump inhibitors used to treat H. pylori infection, are
useful because they
a.
b.
c.
d.
kill the bacteria.
promote tissue breakdown.
control stomach acid, which promotes better healing.
treat the infection.
50. True or False: Amylase is used for digestion of
carbohydrates; the pancreas secrets it and amylase is
found in saliva.
a. True
b. False
51. When levels of the enzymes amylase and lipase are tested
and they appear in the bloodstream, it generally means
that some form of
a.
b.
c.
d.
pelvic inflammatory disease is present.
damage to the pancreas has occurred.
kidney disease is present.
infection is present in the gallbladder.
52. Macroamylasemia is a condition in which
a.
b.
c.
d.
amylase particles are too easily cleared from the body.
lipase particles are too easily cleared from the body.
amylase particles abnormally bind to protein.
the patient suffers noticeable abdominal pain.
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53. Pelvic inflammatory disease (PID) is less likely in women
a.
b.
c.
d.
who use intrauterine devices for birth control.
who douche regularly.
who do not use intrauterine devices for birth control.
Answers a., and b.
54. When performing a CT scan for appendicitis, the presence
of abscess formation in the nearby tissue can indicate that
the appendix
a.
b.
c.
d.
has ruptured and is advancing to peritonitis.
wall may be thickening.
has calcified.
has not ruptured yet.
55. True or False: Pelvic inflammatory disease (PID) is a
sexually transmitted disease that affects only women.
a. True
b. False
56. Unnecessary appendectomies are increased when patients
do not undergo _________________ prior to the surgical
procedure.
a.
b.
c.
d.
blood urea nitrogen (BUN) test
antibiotic treatment
intravenous fluid replacement
radiologic imaging
57. If biopsy or tube placement is required, ______________
can be used to guide the instruments internally.
a.
b.
c.
d.
an X-ray
a CT scan.
the ultrasound.
a CT scan with contrast.
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58. Typically, ___________________ may be used for treating
an uncomplicated case of infection or inflammation.
a.
b.
c.
d.
a single preparation antibiotic
a broad-spectrum antibiotic
vitamin supplements
papaverine
59. Administration of ____________ has been shown to
improve mortality in patients affected by ischemic bowel
disease.
a.
b.
c.
d.
antibiotics
proton pump inhibitors
vitamin supplements
papaverine
60. True or False: When sepsis is suspected, high levels of
serum lactic acid can indicate the need for rapid treatment.
a. True
b. False
61. For those patients who need intravenous fluid replacement
because of their conditions, ________________ are
typically the first choice.
a.
b.
c.
d.
dextran solutions
colloid solutions
albumin solutions
crystalloid solutions
62. An ultrasound is a particularly accurate test to diagnose
appendicitis
a.
b.
c.
d.
with an obese patient with excess fat tissue in the abdomen.
as the cause of abdominal pain.
if the appendix is in a slightly different position than normal.
All of the above
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63. Management of pain and ___________________ is/are at
the heart of comprehensive health management.
a.
b.
c.
d.
the principal disease process
the principles of the disease process
secondary disease processes
administering pain medication
64. In the case of a patient who presents with symptoms of
gallstones, ______________ is often used as a first-line
diagnostic test to visualize the gallstones and to formulate
a diagnosis if they are present.
a.
b.
c.
d.
an X-ray
a KUB
a magnetic resonance imaging (MRI)
an abdominal ultrasound
65. True or False: If a patient complains of abdominal pain,
and testing for sexually transmitted diseases (STDs) is
indicated, the clinician should limit the testing to the STDs
that cause abdominal pain.
a. True
b. False
66. Simply listening to a patient when they experience pain
can help to alleviate anxiety.
a. True
b. False
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CORRECT ANSWERS:
1. The following is true of the CBC white blood cell (WBC)
count:
d. All of the above
2. The complete metabolic profile (CMP) tests the patient’s
d. Answers b., and c.
3. True or False: Ischemic conditions may reveal metabolic
alkalosis due to lack of adequate oxygen to the abdominal
tissues.
b. False
4. Classic symptoms of an ectopic pregnancy include
c. abdominal pain with abnormal vaginal bleeding after
amenorrhea.
5. H-pylori is an infectious agent associated with
d. All of the above
6. CT scan for appendicitis is performed to identify
a. an abnormally shaped or enlarged appendix.
7. True or False: Thrombolytic medications used to manage
emboli of the mesenteric arteries include streptokinase or
urokinase.
a. True
8. Fluid maintenance is important in the treatment of
pancreatitis for prevention of
d. All of the above
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9. Pain management techniques considered by the clinician
must
d. Answers a., and c.
10. ______________ are the largest of all of the white blood
cells and they work by destroying dead tissue and by
protecting against certain types of cancer.
b. Monocytes
11. Red blood cells, called _____________ at maturity, are
created in the bone marrow.
a. erythrocytes
12. 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.
b. False
13. It has been shown that patients who had normal results
with an abdominal X-ray as an initial diagnostic exam, ___
percent had positive findings when later tested through CT
or ultrasound.
d. 81
14. True or False: In acute pancreatitis, a plain film can
definitively identify acute pancreatitis, but cannot rule
other causes of abdominal pain.
b. False
15. ___________________, used to treat spasms of smooth
muscle tissue, may be administered to patients with
ischemic bowel disease caused by venous thrombosis or
other conditions that cause vasoconstriction not related to
vessel occlusion.
b. Papaverine
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16. Lactic acid is
d. All of the above
17. A back rub does more than provide a calming effect for the
patient. It improves circulation by promoting
b. vasodilation to increase blood and lymph flow.
18. Up to ___ percent of pregnancies may end in miscarriage.
c. 20
19. An embolus in the mesenteric artery that restricts blood
flow to the gut requires
d. Answers a., and c.
20. True or False: Compared to a CT scan, the MRI is safer for
some patients because of lower levels of radiation.
a. True
21. _____________________ is/are often elevated in cases
where abdominal pain is caused by an infectious or
inflammatory process.
c. White blood cell count
22. Moist heat is generally considered ________________
when compared to dry heat from a heating pad.
b. more therapeutic
23. A white blood cell count of 11,000 mm3 or more is
classified as
c. leukocytosis.
24. ______________ comprise up to 70% of white blood cells
and are often the first type of cell to arrive at the site of
infection.
d. Neutrophils
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25. ______________, a type of granulocyte, are activated in
response to allergens and to other foreign pathogens, such
as parasitic infections.
d. Basophils
26. The __________ regulate(s) erythrocyte production
through erythropoietin, which stimulates the bone marrow
to make more cells.
a. kidneys
27. True or False: Patients who are in an immunocompromised
state or those diagnosed with cancer will have an elevated
white blood cell count in the presence of infection.
b. False
28. Hemoglobin levels may be elevated in such conditions as
c. polycythemia.
29. If the patient is suspected of being anemic, the hematocrit
serves to determine
b. the degree of severity of anemia.
30. The hematocrit is defined as
d. a measure of the percent of RBCs within a volume of whole
blood.
31. __________________ may reveal acidosis because of the
lack of adequate oxygen to the abdominal tissues.
a. Ischemic conditions
32. Ulcerative colitis or gastrointestinal bleeding lead to
decreased
b. hemoglobin levels.
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33. Patients who smoke, and those who live at high altitudes,
may demonstrate
a. increased red blood cell counts.
34. True or False: 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.
a. True
35. Abnormally shaped red blood cells caused by disease, e.g.,
sickle cell, do not perform normally and actually contribute
to pain for a patient when cell clumping
a. causes vessel occlusion.
36. Elevated levels of ____________________ have been
associated with severe disease processes, including
gastrointestinal bleeding, kidney disease, an obstruction in
the urinary tract, or shock.
c. blood urea nitrogen (BUN)
37. The creatinine level measures ________ function.
d. kidney
38. High hematocrit levels may be due to
a. dehydration.
39. Low levels of hematocrit tend to be seen with
c. kidney or autoimmune diseases.
40. True or False: Hemoglobin is important for oxygen
transport, such that elevated levels typically do not cause a
negative occurrence.
b. False
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41. The fecal occult blood test, which refers to specific testing
for the presence of blood in the stool, is performed
b. even if blood can be seen outwardly.
42. The fecal occult blood test may lead to false positive
results if the patient
d. All of the above
43. Which of the following tests have food or drug restrictions?
c. fecal occult blood test.
44. Increased glucose in the bloodstream that appears in a
urinalysis test may indicate
a. poorly managed diabetes.
45. True or False: In some cases of an ectopic pregnancy, no
symptoms develop.
a. True
46. A woman who experiences stretching of the uterine
ligaments during pregnancy may have severe pain that
could be confused with
d. appendicitis.
47. A woman is more likely to have an ectopic pregnancy if she
has
a. used assistive technology to achieve pregnancy.
48. Which of the following tests is not used to detect H. pylori
infection?
d. None of the above
49. Proton pump inhibitors used to treat H. pylori infection, are
useful because they
c. control stomach acid, which promotes better healing.
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73
50. True or False: Amylase is used for digestion of
carbohydrates; the pancreas secrets it and amylase is
found in saliva.
a. True
51. When levels of the enzymes amylase and lipase are tested
and they appear in the bloodstream, it generally means
that some form of
b. damage to the pancreas has occurred.
52. Macroamylasemia is a condition in which
c. amylase particles abnormally bind to protein.
53. Pelvic inflammatory disease (PID) is less likely in women
c. who do not use intrauterine devices for birth control.
54. When performing a CT scan for appendicitis, the presence
of abscess formation in the nearby tissue can indicate that
the appendix
a. has ruptured and is advancing to peritonitis.
55. True or False: Pelvic inflammatory disease (PID) is a
sexually transmitted disease that affects only women.
b. False
56. Unnecessary appendectomies are increased when patients
do not undergo _________________ prior to the surgical
procedure.
d. radiologic imaging
57. If biopsy or tube placement is required, ______________
can be used to guide the instruments internally.
c. the ultrasound.
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74
58. Typically, ___________________ may be used for treating
an uncomplicated case of infection or inflammation.
b. a broad-spectrum antibiotic
59. Administration of ____________ has been shown to
improve mortality in patients affected by ischemic bowel
disease.
d. papaverine
60. True or False: When sepsis is suspected, high levels of
serum lactic acid can indicate the need for rapid treatment.
a. True
61. For those patients who need intravenous fluid replacement
because of their conditions, ________________ are
typically the first choice.
d. crystalloid solutions
62. An ultrasound is a particularly accurate test to diagnose
appendicitis
b. as the cause of abdominal pain.
63. Management of pain and ___________________ is/are at
the heart of comprehensive health management.
a. the principal disease process
64. In the case of a patient who presents with symptoms of
gallstones, ______________ is often used as a first-line
diagnostic test to visualize the gallstones and to formulate
a diagnosis if they are present.
d. an abdominal ultrasound
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65. True or False: If a patient complains of abdominal pain,
and testing for sexually transmitted diseases (STDs) is
indicated, the clinician should limit the testing to the STDs
that cause abdominal pain.
b. False
66. True or False: Simply listening to a patient when they
experience pain can help to alleviate anxiety.
a. True
References Section
The reference section of in-text citations include published works
intended as helpful material for further reading. Unpublished works
and personal communications are not included in this section, although
may appear within the study text.
1.
2.
3.
4.
5.
Bickley, L. S. (2013). Bates’ guide to physical examination and
history taking (11th ed.). [Chapter 11]. Philadelphia, PA:
Lippincott Williams & Wilkins
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O’Laughlen, M. C. (2009). Making sense of abdominal
assessment. Nursing Made Incredibly Easy! 7(5): 15-19.
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Dennis, M., Talbot Bowen, W., Cho, L. (2012). Mechanisms of
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Shimizu, T., Tokuda, Y. (2013). Visible intestinal peristalsis. BMJ
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6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
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(2010). Brunner and Suddarth’s textbook of medical-surgical
nursing, Volume 1 (12th ed.). Philadelphia, PA: Lippincott Williams
& Wilkins
Kauffman, M. (2014). History and physical examination: A
common sense approach. Burlington, MA: Jones & Bartlett
Learning
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University of Arkansas for Medical Sciences. (2007). Superior
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20. Karul, M., Berliner, C., Keller, S., Tsui, T. Y., Yamamura, J.
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21. University of Maryland Medical Center. (2014, May). Abdominal
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22. Hunter, J. (2010). Inflammatory bowel disease: The essential
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23. Baumgart, D. C., Sandborn, W. J. (2012, Nov.). Crohn’s disease.
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24. Levine, J. S., Burakoff, R. (2011, Apr.). Extraintestinal
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26. Eckman, M. (Ed.). (2008). Assessment made incredibly easy! (4th
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27. Wilson, S. F., Giddens, J. F. (2013). Health assessment for
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28. Subramanian, P., Allcock, N., James, V., Lathlean, J. (2012).
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29. Melzack, R. (1975). The McGill Pain Questionnaire: Major
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30. Melzack, R. (1971). The McGill Pain Questionnaire. Montreal,
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31. Bickley, L. S. (2013). Bates’ guide to physical examination and
history taking (11th ed.). [Chapter 1]. Philadelphia, PA: Lippincott
Williams & Wilkins
32. Turk, D. C., Melzack, R. (2011). Handbook of pain assessment.
New York, NY: The Guilford Press
33. U.S. Food and Drug Administration. (2014, Aug.). Computed
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34. Nursing Central. (2014). Ultrasound, abdomen. Retrieved from
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35. Northwestern Medicine. (2014, Jan.). Abdominal x-rays. Retrieved
from
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logy/92,P07685
36. Plevris, J., Howden, C. (Eds.). (2012). Problem-based approach to
gastroenterology and hepatology. West Sussex, UK: Blackwell
Publishing, Ltd.
37. Gyawali, C. P. (Ed.). (2012). The Washington Manual™:
Gastroenterology (3rd ed.). St. Louis, MO: Washington University
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38. Cervero, F. (n.d.). Visceral pain. Retrieved from
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39. Saladin, K. S. (2012). Anatomy and physiology (6th ed.). New
York: NY: McGraw-Hill
40. Gebhart, G. F., Bielefeldt, K. (2008). Visceral pain. Retrieved from
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41. Paula, R. (2014, Sep.). Abdominal compartment syndrome.
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42. Bloom, A. A. (2014, Apr.). Cholecystitis. Retrieved from
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43. Craig, S. (2014, Jul.). Appendicitis. Retrieved from
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44. Daley, B. J. (2013, Apr.). Peritonitis and abdominal sepsis.
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45. Sephton, M. (2009). Nursing management of patients with severe
ulcerative colitis. Nursing Standard 24(15): 48-57
46. Lokwani, D. P. (2013). The ABC of CBC: Interpretation of
complete blood count and histograms. New Delhi, India: Jaypee
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47. Panebianco, N. L., Jahnes, K., Mills, A. M. (2011). Imaging and
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51. Daniels, R. (2010). Delmar’s guide to laboratory and diagnostic
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(2010). Brunner and Suddarth’s textbook of medical-surgical
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& Wilkins
53. Centers for Disease Control and Prevention. (2014, Jul.). Pelvic
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54. Orthopaedic Specialists of North Carolina. (2014). Orthopedic
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management of pain. Philadelphia, PA: Lippincott Williams &
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56. Baylor Surgicare at Garland. (2009). Frequently asked questions.
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57. Braun, M. B., Simonson, S. J. (2014). Introduction to massage
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58. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L. (2014).
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59. Söyüncü, S., Bektas, F., Cete, Y. (2012, Jan.). Traditional Kehr’s
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60. Fiebach, N. H., Kern, D. E., Thomas, P. A., Ziegelstein, R. C.
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63. Crowe, S. E. (2013, Aug). Patient information: Helicobacter pylori
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65. Turnbull, J. M. (1995, Oct.). Is listening for abdominal bruits
useful in the evaluation of hypertension? The Journal of the
American Medical Association (JAMA) 274(16): 1299-1301.
66. Dooley-Hash, S. (2010). Abdominal pain: Biliary tract disease.
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67. Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., Thomas, D. J.
(2011). Primary care: The art and science of advanced practice
nursing (3rd ed.). Philadelphia, PA: F. A. Davis Company
The information presented in this course is intended solely for the use of healthcare
professionals taking this course, for credit, from NurseCe4Less.com. The information
is designed to assist healthcare professionals, including nurses, in addressing issues
associated with healthcare.
The information provided in this course is general in nature, and is not designed to
address any specific situation. This publication in no way absolves facilities of their
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