Download Preview the material

Abdominal Pain
Part I
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.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
1
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 4 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.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
2
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.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
3
1.
Classifications of abdominal pain the following different
types:
a.
b.
c.
d.
2.
The body releases a substance called ____________,
which is an inflammatory mediator that causes the
sensation of pain.
a.
b.
c.
d.
3.
obesity and female gender.
genetic predisposition and smoking.
fatty diet and sedentary lifestyle.
excessive alcohol consumption and gallstones.
Cholecystitis caused by gallstones is called calculus
cholecystitis, which accounts for ______ of cases.
a.
b.
c.
d.
5.
adrenaline
serotonin
bradykinin
None of the above
Two most common causes of acute pancreatitis in the U.S.
are
a.
b.
c.
d.
4.
acute pain, subacute pain, chronic pain.
tension pain, inflammatory pain, ischemic pain.
severe pain, moderate pain, minimal pain.
None of the above
90%
20%
50%
75%
True or False: Corticosteroids and NSAIDs are
recommended medications used to control ischemic pain.
a. True
b. False
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
4
Introduction
Almost everyone suffers from some type of abdominal pain at one
point or another. Abdominal pain may develop from a multitude of
conditions, some of which are benign while others can be quite
serious. While many cases of abdominal pain cause minor discomfort
and are self-limiting, there are many other times when patients seek
help and treatment because of abdominal pain, which requires a
thorough patient history and physical exam, extensive testing, and
multi-faceted treatment to control the pain and prevent the condition
from becoming worse.
Abdominal pain can be difficult to diagnose and treat. The potential
causes of abdominal pain can vary widely, based on the patient’s
medical background, the presence of a disease process or injury, and
other clinical symptoms that might be present. Assessing and
interpreting the reasons for abdominal pain when a patient presents
for medical attention can seem mystifying and akin to piecing together
a complex puzzle. The clinician must use the information gained from
the history and physical exam as well as diagnostic testing to bring
together details of the patient’s history and symptoms to formulate a
diagnosis.
Types Of Abdominal Pain
Abdominal pain is considered to be pain felt in the region of the body
between the chest and the groin. It can vary in its intensity and
severity and may be caused by a number of different conditions, some
which are considered minor while others are significant medical
problems. The amount of pain that a patient experiences upon
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
5
presentation with abdominal pain does not always indicate the severity
of the condition. A patient may have mild pain, yet be suffering from a
potentially life-threatening illness. Alternatively, another patient may
complain of severe or excruciating pain that is the result of a benign
process that will eventually resolve on its own.
Abdominal pain can be caused by so many different mechanisms that
the clinician may initially be faced with a situation that requires
narrowing down broad categories of pain and possible causes as well
as potential contributing factors to isolate a specific diagnosis.
Additionally, varied pain categories exist that are defined by the pain
location or affected area of the body, time of onset, or sensation; and,
the varied pain categories can further complicate the diagnostic
process. For example, pain may be classified according to how long the
patient has been experiencing pain and whether it is acute or chronic.
Further focus is required of the clinician to determine the type of pain
according to affected areas, such as whether pain is visceral,
neurogenic, or referred pain. The potential cause of the pain must be
considered, taking into account whether the pain originates from an
inflammatory process, tension, or through ischemic disease.
The work of initially reducing the broad field of abdominal pain is often
a complex and involved process. Despite such factors as cause or time
of onset, the sensation of pain in the body develops in much the same
way for all people. A person feels the sensation of pain through a
complex body process where pain signals are transmitted from the site
of injury, or disease to the brain, where the person is able to recognize
the painful feeling. The entire process occurs quickly as the messages
span from the area of injury and travel to the brain through a tract in
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
6
the spinal cord. Areas in the abdomen and in other parts of the body
contain nociceptors, which are sensory nerves that are stimulated by
an outside response. The nociceptors are found in various areas such
as in the layers of the skin, the subcutaneous tissue, the muscles, and
the tendons. They become stimulated by various factors and are found
in most visceral organs in the abdominal cavity. Nociceptors can be
excited through stimulants from mechanical, thermal, or chemical
forms. Mechanical stimulants involve processes that can physically
damage the tissues, such as cutting or crushing mechanisms;
whereas, thermal stimulants arouse nociceptors by changes in heat,
such as with burning tissue, and chemical stimulants cause a response
by exposure to chemical irritants.
When the nociceptors are stimulated, they send messages to nerve
fibers that are either A-delta fibers or C fibers. A-delta fibers are large
nerve fibers, and when they are stimulated the patient tends to feel
sharp pain. C fibers are smaller and are associated with deep, aching,
or throbbing pain. These fibers then send messages along the spinal
cord to the thalamus of the brain. From the thalamus, the pain
message is transmitted to the parietal lobe in the brain, which is when
the patient feels the pain.27 Alternatively, without stimulus of the
parietal lobe, or where the pain message reaches this specific area,
the patient will not feel pain even if damage or injury has occurred
that would otherwise cause discomfort.
The range of causes of abdominal pain can be so extensive that a
patient presenting with a general complaint of pain in the abdomen will
need a comprehensive review of his or her medical history and current
symptoms to narrow down the possible source or underlying cause of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
7
pain. Pain in the abdomen tends to be classified according to several
different types: tension pain, inflammatory pain, and ischemic pain.
Within these classifications, there are also subcategories that further
separate types of pain according to such factors as intensity, time of
onset, and how the patient perceives or experiences the pain.
Furthermore, within each kind of pain, whether tension, inflammatory,
or ischemic pain, a number of conditions may exist as the cause of the
pain. Conditions related to pain may be chronic or acute disease
processes, or due to other factors, such as trauma or physical injury.
Because of the varied pain classifications and causes, it is easy to see
how a general presenting complaint of “abdominal pain” can quickly
lead to a complex process of diagnostics to uncover the real reason
behind the pain.
Abdominal pain, as well as other forms of pain, may be categorized as
acute or chronic. According to Turk and Melzack in the Handbook of
Pain Assessment, acute pain is associated with tissue damage,
inflammation, or a relatively brief disease process that lasts minutes,
hours, or days. Pain following a surgical procedure is an example of
acute pain. Alternatively, chronic pain can last for months or years and
is associated with an unresolved injury that was once treated
ineffectively, or a disease process that requires ongoing management
and that may cause symptoms to recur.32 An example of chronic pain
may be abdominal pain that occurs from inflammatory bowel disease.
Within the types of pain a patient experiences — whether acute or
chronic — are further classifications of pain, depending on the area
affected and how the patient is experiencing pain. These main types of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
8
abdominal pain, as described in Problem-based Approach to
Gastroenterology and Hepatology include visceral pain, parietal pain,
neurogenic pain, and psychogenic pain. A fifth type of pain, referred
pain, concerns pain that starts in one location and radiates to or is felt
in another part of the body.36 This type of pain will be discussed in a
later section.
Visceral Pain
Visceral pain is associated with the internal organs. A patient who
experiences visceral pain may complain of dull, aching pain that is not
necessarily well localized to a particular area. In some cases, such as
appendicitis, the patient may have tenderness directly over the
inflamed organ (appendix); alternatively, some other painful
conditions affecting the organs, such as a small bowel obstruction,
may cause pain that is diffuse and non-specific.36 With visceral pain,
the patient may be more likely to experience other symptoms
associated with the autonomic nervous system, such as nausea,
vomiting, or sweating.37 Visceral pain not only develops from damage
or injury to the internal organs, but may also occur with tearing of the
membranes surrounding the organs, stretching of the capsules
enclosing certain organs, such as when organomegaly develops, or
compression of the nearby tissues.
Parietal Pain
Parietal pain refers to pain in the parietal membrane lining the
abdominal cavity, known as the peritoneum. Parietal pain develops
when this membrane becomes inflamed, infected, or otherwise
irritated because of disease or trauma. The patient may experience
constant, sharp pain that is localized to the specific area of irritation
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
9
and that often worsens with movement. The patient with parietal pain
in the abdomen will most likely present with guarding and tense
abdominal muscles, often in response to attempts to limit movement
and to control the pain. In severe cases of inflammation, the abdomen
can become rigid and board-like and the patient may complain of
severe and excruciating pain.36,37
Neurogenic Pain
Neurogenic pain is sometimes described as burning pain that in some
cases may be associated with an underlying neurological condition.
The patient may complain of burning or shooting pain that seems to
move along the routes of the nerves. Underlying conditions that may
be associated with neurogenic pain include herpes zoster infection
causing shingles, intercostal neuralgia (which actually begins with
damage or trauma to part of the spinal column or ribcage and then
causes pain to spread to the floating 11th and 12th ribs as well as to
the flank), tabes dorsalis (which is associated with degeneration of
nerve fibers), or abdominal peripheral neuropathies associated with
diabetes.36
Psychogenic Pain
Psychogenic pain often cannot be defined by any physiological
characteristics, yet the patient still experiences pain. The mind-body
component of psychogenic pain often leads clinicians to believe that
such factors as stress and emotion either cause the pain or exacerbate
some conditions, and make symptoms worse. Often, this viewpoint is a
result of seeing patients who present with pain but who do not
demonstrate any physical abnormalities with diagnostic testing. The
clinician then believes that the pain to be psychogenic in nature.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
10
Additionally, psychogenic pain may be more likely to be relieved
through a change in emotional state or through distraction.37
A patient with a chronic health problem, such as irritable bowel
syndrome (IBS), may experience periods of abdominal pain or
exacerbations of symptoms when under stress and strain, and yet
show few signs of physical changes that are causing the pain. Some of
the pain may be relieved with stress reduction techniques, which is a
classic symptom management technique of psychogenic pain.
Beyond discussion of acute versus chronic pain and the associated
classifications of visceral, parietal, neurogenic, or psychogenic pain,
there are additional pain types that typically develop as a result of
specific medical conditions. These types of pain — whether visceral,
inflammatory, or ischemic — each have their own disease development
processes and each seem to cause similar symptoms as well as patient
responses to pain. Treatment requirements, however, may differ and
must be considered when making decisions about the most
appropriate forms of pain management for individuals in these
situations.
Tension Pain
Tension abdominal pain is a type of visceral pain that affects the
organs and the tissues surrounding them. When tension pain develops
in the abdomen, the effects can range from mild to excruciating. This
type of pain has often been managed according to its underlying
cause, such as an injury or disease process in the abdomen. For
instance, a patient who develops pain from an enlarged liver due to
hepatitis, which is a form of tension pain, will require management of
the underlying disease process causing liver enlargement. Only
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
11
recently have clinicians recognized that tension pain is more than
simply a symptom of another disease process, and that it should be
treated independently of and in addition to any other associated
disease.39 While the underlying disease or injury is important itself to
manage and treat, the clinician should also consider the effects of this
type of abdominal pain and consider treating it independently.
Tension Pain: Organ Distention or Blood Accumulation
Tension abdominal pain can develop for various reasons, but it is often
due to some type of damage to the abdominal organs. Tension pain
may not be felt until the condition causing the pain results in
stretching of the abdominal organs or their overlying membranes. The
smooth muscle of the hollow organs, in particular, may become
stretched and distended, which can cause tension pain in the
abdomen. Similarly, when the membranes covering the abdominal
organs become stretched from organ distention or another injury, the
patient is likely to feel abdominal pain.
Most people have experienced some sort of tension abdominal pain at
one point or another. This type of pain can be caused by benign
conditions that result in organ distention, such as indigestion from
eating too much at a meal or the discomfort associated with
constipation. Alternatively, tension pain can develop from injuries or
disease processes that can be quite serious. For instance, a patient
may develop splenomegaly as a result of a severe viral infection or a
type of cancer, such as leukemia. The provider must use clinical
judgment and good skills of assessment to analyze whether the
patient’s tension pain is caused from a benign condition or from a
significant or grave situation.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
12
Tension pain caused by damage to abdominal organs can be quite
severe; alternatively, the patient may have some areas of organ
damage and feel little to no pain at all. This is important to consider,
as damage to certain abdominal organs can occur without any
perception from the patient; consequently, considerable internal
damage can be developing but, because of the lack of sensory
receptors on certain abdominal organs, the patient may not feel any
pain.39 Therefore, when a patient presents with tension abdominal
pain, the clinician should consider the mechanism of injury or the
disease process involved and take into account the possible organs
that may be injured; although, the injured organs may not necessarily
be the cause of pain.
Some abdominal organs have nociceptors that send signals when an
injury has occurred; as a result, the brain perceives the injury as pain.
However, there are some organs that do not have these sensors and,
if they become injured, the brain will not perceive the feeling of pain.
The spleen and the liver are two examples of these types of organs.39
Consequently, the patient may have further injuries to internal organs
and be unaware of it because of a lack of pain sensation from fewer
nociceptors. In severe cases, the patient can suffer from such
conditions as severe bleeding because of abdominal organ trauma and
yet be unaware of the situation until he or she develops lifethreatening hypovolemia.
Most of the hollow organs in the abdomen contain nociceptors; when
visceral pain develops, it may be more likely to be associated with
these organs. This includes such organs as the stomach, the large and
small intestines, the bladder, and the uterus. Many people are familiar
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
13
with the pain of stomach cramping from indigestion or intestinal colic
from a gastrointestinal virus. The nociceptors on these organs are able
to send pain messages when their smooth muscles respond to a
disease process. Alternatively, many solid organs of the abdomen,
such as the liver or spleen may not cause immediate pain when
damaged because of their lack of nociceptors.39
This does not mean that a patient who has damage to solid organs in
the abdomen will not feel pain. Instead, it is often only when the
tissues surrounding these organs become stretched or damaged that
the patient begins to feel abdominal pain. For example, an enlarged
liver due to hepatitis may not cause immediate pain for the patient.
Over time, though, if the liver becomes enlarged, the size of the organ
stretches the capsule surrounding it to the point that the patient starts
to feel pain.
The abdominal organs are surrounded by the peritoneum, a membrane
that contains two layers. One layer lines the outer wall of the
abdominal cavity and the other layer surrounds the organs and keeps
them in their proper places. The space between these two layers is
known as the peritoneal cavity, which allows for movement and stays
lubricated by peritoneal fluid. Additionally, many of the abdominal
organs are surrounded by their own membranes and capsules, which
keep them further contained within their own spaces and offer
protection. For example, the greater omentum is a fatty membrane
that extends from the stomach to the transverse colon; this tissue can
prevent the spread of infection if wounds develop within its borders.40
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
14
A patient with tension abdominal pain may feel the pain due to
mechanical events of distention of these membranes, such as
stretching of sections of the peritoneum. Studies done on the
nociceptors of abdominal organs have classified most of them as
mechanoreceptors that have nerve endings within the smooth muscle
of the organs and mesenteric membranes covering the organs.
Because these nerves are classified as mechanoreceptors, they send
pain messages to the brain when mechanical forces of injury, such as
membrane or organ tension or stretching, affect the abdominal organs.
Alternatively, other types of injury that are not considered mechanical
but that affect the abdominal organs may not stimulate these
nociceptors, and the patient will not feel the pain.41
Abdominal Compartment Syndrome
Compartment syndrome is another type of tension abdominal pain that
is not only very uncomfortable for the patient, but it can also lead to
serious organ damage. Similar to compartment syndrome that
develops in an extremity, abdominal compartment syndrome occurs
when increased pressure from fluid develops within the abdominal
cavity. The fixed borders of the abdominal membrane keep the fluid
within the walls of the compartment and, as pressure increases, the
abdominal organs are at risk for ischemia and organ failure.42
Abdominal compartment syndrome (ACS) is typically classified into
three different categories: primary, secondary, and chronic
syndromes. Primary abdominal compartment syndrome develops after
some type of trauma occurs in the abdomen that leads to bleeding and
fluid build up, which results in increased pressure. Primary ACS may
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
15
develop after such events as direct trauma to one of the abdominal
organs, rupture of an aortic aneurysm, or a perforated peptic ulcer.
Secondary ACS develops when there is no injury to cause the
increased fluid or bleeding within the abdominal cavity. Secondary ACS
may occur as a result of high volumes of fluid administered with fluid
resuscitation, such as following some types of surgical procedures,
blunt trauma with no obvious signs of injury, or with patient sepsis.
Finally, chronic abdominal compartment syndrome tends to be
associated with chronic illnesses, such as kidney failure and resulting
use of peritoneal dialysis, cirrhosis that has developed from liver
disease, among patients with morbid obesity, or due to an abdominal
mass.42
A patient with ACS may be very uncomfortable and may complain of
pain and pressure in the abdominal cavity. The patient’s girth tends to
increase as fluid accumulation progresses. The increased pressure can
also cause difficulties with breathing, particularly when fluid presses on
the diaphragm and displaces it upward so that it presses on the lungs,
causing ineffective lung expansion.
Without proper treatment, abdominal compartment syndrome can lead
to serious consequences, including renal failure, breathing difficulties,
and respiratory failure. The abdominal organs will become ischemic
from a lack of adequate blood flow due to the increased pressure;
shock and multiple organ failure can ultimately result.42 When pressure
develops to the point that the patient becomes decompensated, rapid
treatment through paracentesis (which involves inserting a needle into
the abdominal cavity to draw off excess fluid) as well as other
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
16
treatments to remove excess abdominal fluid are necessary to stop the
disease process.
Patient Behavior with Abdominal Pain
The patient with tension abdominal pain will most likely feel extremely
uncomfortable and will look for a comfortable position. Movement may
or may not worsen the pain, and so a patient who presents with
tension pain may be more likely to squirm and reposition as compared
to patient responses of close guarding and little movement typically
occurring with different types of abdominal pain.
It can be difficult to determine the cause of the pain associated with
abdominal organ injury or compartment syndrome and tension pain.
For a patient with compartment syndrome, he or she may feel
abdominal pain before the signs of increased abdominal pressure
appear. The patient may be feeling pain from the causative event
without any initial outward signs. For example, a patient may have
pain from blunt trauma to the abdomen without any external signs of
injury right away. Only later, with subsequent bruising or swelling, do
the outward signs develop.
Patients with tension pain are often restless and uncomfortable. They
may be distracted from the pain and might not be able to provide a lot
of information through the history-taking portion of the physical exam.
A patient with abdominal compartment syndrome may also become
lightheaded or dizzy when more fluid accumulates in the abdomen,
which can make the exam difficult to finish and the provider may have
difficulty generating answers from the patient. Diagnostic measures
are necessary to isolate the cause of the pain and to determine if it is
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
17
benign or if it has the potential for severe illness through blood loss or
internal organ damage.
In serious cases of tension pain caused by internal bleeding, the
patient can become quite ill very quickly without proper intervention.
Rapid deterioration can occur with few outward signs. When this
happens, the patient may develop breathing difficulties, become
cyanotic, or appear pale and listless. The clinician must recognize
these critical signs and respond rapidly at this point to manage the
situation and to avoid further deterioration of the patient’s health.42
Inflammatory Pain
A second type of pain, inflammatory pain, develops in response to the
inflammatory process that occurs in the body after an injury or during
the course of a disease affecting an area. In the abdomen, such
incidents as trauma to the organs or tissues, infections (viral,
bacterial, or fungal), allergic reactions, and chemical irritants can all
start the process of an inflammatory response. Additionally, the
autoimmune process that occurs with certain diseases, such as type 1
diabetes or celiac disease, can also cause inflammation in the
abdomen. The patient may or may not be aware of the inflammation
until the pain associated with it develops to a noticeable level.
After an injury or disease process affects an area of the abdomen, the
body responds by releasing inflammatory mediators, which stimulate
vasodilation to increase blood flow to the site. The blood that rushes to
the area brings leukocytes and plasma; the capillaries become more
permeable and the plasma leaks into surrounding tissue, which causes
swelling from the increase in fluid that has gathered. The plasma and
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
18
leukocytes are designed to protect the body from infectious organisms,
but the body also releases a substance called bradykinin, which is an
inflammatory mediator that causes the sensation of pain. This is why
when acute inflammation develops in an organ or another area of the
abdomen, the patient typically experiences pain and he or she often
limits use of the area. In the case of abdominal organ inflammation
that causes pain, the patient often exhibits guarding and decreased
movement.
A number of inflammatory conditions cause abdominal pain and
immobility for the affected patient. Often, disease processes may
cause chronic inflammation that is not always noticeable right away
when compared to acute inflammation. For example, some people
have food allergies that can cause chronic inflammation in the gut, but
symptoms of an allergic reaction might only be noticed if the person
has a response to eating associated foods. Alternatively, the patient
may present with abdominal pain associated with acute inflammation
that has developed because of an infectious process, an injury to some
area within the abdomen (whether obvious or not), or because a
chronic disease has caused enough inflammation and swelling that the
patient is aware of the pain. There are a number of specific conditions
that cause abdominal inflammation that clinicians may encounter when
a patient presents to a health unit with a complaint of abdominal pain.
Peritonitis
The layer of membrane that covers the abdominal organs is known as
the peritoneum. Bacterial or fungal infection of this membrane results
in peritonitis, a condition in which the peritoneum becomes inflamed
and causes pain. The most common source of peritonitis is a break in
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
19
the wall separating the organs and the abdominal cavity, which allows
bacteria or fungi to enter the abdominal space. Some conditions, such
as a ruptured appendix, diverticulitis, a perforated ulcer, or
pancreatitis can cause a disruption that allows pathogens from the
infected organ to enter the abdominal cavity and infect the peritoneal
membrane.19 Peritonitis can be very painful and, if it is not treated
quickly, can cause life-threatening complications.
Peritonitis is often classified as one of two different types: spontaneous
or secondary peritonitis. Spontaneous peritonitis is much less common
when compared with secondary peritonitis, but it still causes
abdominal pain and tenderness for the affected patient. It is typically
caused by chronic alcohol use, hepatitis infection, or another condition
that leads to cirrhosis. Alternatively, secondary peritonitis is much
more common and leads to the noted inflammation of the peritoneum.
Individuals with peritonitis will not only have severe abdominal pain,
but may also experience fever, chills, nausea, a change in appetite,
and excess thirst. Some patients who use peritoneal dialysis may be
prone to peritonitis when bacteria from the tubing enter the patient’s
body through the catheter site. Peritonitis can quickly develop into a
life-threatening emergency without rapid intervention. As the condition
progresses, the patient may have other symptoms associated with
abdominal organ dysfunction, including ileus, ascites, and renal
failure.45 The patient may have abdominal distention, and hypoactive
or absent bowel sounds. In addition to examination of the abdomen,
the patient may also need a rectal and/or pelvic exam to rule out other
conditions that could be mistaken for peritonitis, such as a hernia,
bladder infection, or pelvic inflammatory disease in a female patient.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
20
Because peritonitis can cause such severe pain, the patient may be
more likely to seek help for treatment quickly, which can improve the
outcome. Abdominal tissue or fluid samples should be taken and
cultured to isolate a specific organism, since peritonitis is usually
caused by an infection from bacteria or fungus. Often, abdominal fluid
sampling may be done through paracentesis to withdraw a small
amount through a needle inserted into the affected area of the
abdomen. Examination of this specimen can then guide the clinician
toward treatment with use of the appropriate type of antibiotic or antifungal medication.
Peritonitis is typically treated with medications to stop the infectious
process causing the inflammation and pain. With severe inflammation,
abscess formation may develop as the body attempts to contain the
infection. If medications are not given quickly to prevent the spread of
bacteria, the patient may develop a peritoneal abscess, which appears
as one or more pockets of infected material, such as exudate and pus,
localized within an area. The risk of abscess formation is
approximately 30% among certain people, including those who have
developed peritonitis because of bowel perforation with leakage of
intestinal contents into the abdominal cavity, inflammation that has
developed following bowel ischemia, or a pre-existing
immunocompromised condition.45
Pancreatitis
Pancreatitis, otherwise considered inflammation of the pancreas, can
develop as an acute or chronic condition. Acute pancreatitis starts with
inflammation in the pancreas and extends into the surrounding
tissues. The two most common causes of acute pancreatitis in the U.S.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
21
are excessive alcohol consumption and gallstones; however, acute
pancreatitis has also developed as a result of high cholesterol levels,
hypercalcemia, the use of certain medications, including furosemide or
sulfa drugs, and infection or trauma to the pancreas.18 The condition
typically develops when the digestive enzymes that are normally
secreted by the pancreas become active inside the organ before
secretion, often because an obstruction prevents them from being
secreted normally. The enzymes end up digesting some of the tissue
inside the pancreas. This action causes the pancreas to swell and
bleed; in some cases, blood flow to the pancreas can be cut off,
causing pancreatic ischemia and necrosis.
Most patients with acute pancreatitis suffer from pain in the abdomen
and in the back. They may also have associated gastrointestinal
symptoms such as nausea, vomiting, or anorexia; other systemic
complaints typically include fever, low blood pressure, and elevated
heart rate. Upon exam, the patient may have decreased bowel sounds
and significant guarding with rebound tenderness.
Alternatively, chronic pancreatitis occurs as inflammation of the
pancreas that does not improve; instead, the condition worsens over
time and the pancreas does not heal. Chronic pancreatitis is typically
caused from such situations as autoimmune disorders, chronic
alcoholism, cystic fibrosis, or a form of pancreatitis that runs in the
family and is known as familial pancreatitis. Although in some cases
chronic pancreatitis may not cause pain for the patient, many people
with the condition experience chronic abdominal pain that is
sometimes worse with activities such as eating or drinking. The pain
may begin in the right upper quadrant of the abdomen but then may
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
22
spread to other areas of the abdomen as well. Other symptoms
associated with chronic pancreatitis include weight loss, nausea and
vomiting, fatty stools, and diarrhea.88
The patient with chronic pancreatitis often experiences significant and
lasting pain from inflammation. The pain is recurrent and requires
regular administration of medications for pain control. When drugs are
no longer effective in controlling pain, the patient may need surgery,
which often involves removing inflamed areas, masses, or painful
tissues to provide relief on a consistent basis.88 Other drugs and
complementary therapies may also be used to reduce inflammation
and to control some of the pain associated with this condition.
Appendicitis
The most common cause of acute abdominal pain, appendicitis
develops as inflammation of the appendix, a finger-like appendage
that hangs from the cecum of the large intestine.20 The condition
develops due to an obstruction at the opening where the appendix
connects to the intestine. The obstruction causes the pressure inside
the appendix to increase and there is increased bacterial proliferation.
Over a short period of time, the appendix then becomes inflamed and
enlarged due to build up of infectious materials within its borders.44
If appendicitis is not treated, the pressure inside the appendix persists
and causes ischemia to occur. The tissue on the wall of the appendix
begins to break down and contents can leak out into the surrounding
abdominal cavity; this is what occurs when the appendix is said to
have ruptured or burst. This is the common reason why rapid
treatment of appendicitis is critical, as this leakage of fluid and
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
23
bacteria into the abdominal cavity can cause widespread inflammation,
infection of the visceral membranes, and severe abdominal pain.
At one time, appendicitis was understood to cause symptoms of right
lower quadrant abdominal pain, nausea, and tenderness over the
umbilicus. While these symptoms are still present for some with
appendicitis, they actually account for only about 50% of diagnosed
cases. Appendicitis symptoms actually tend to be quite diverse in their
presentation, which can make diagnosis more difficult.44
Abdominal pain is a cardinal symptom of appendicitis; the pain may
start as epigastric or umbilical pain or may develop in the area of the
appendix in the right lower quadrant. Pain can also be elicited through
moving the leg by turning it at the hip during diagnostic testing. The
patient with appendicitis may also have nausea, vomiting, constipation
or diarrhea, and anorexia. Although appendicitis is a very common
cause of abdominal pain, it can become a clinical emergency that leads
to widespread inflammation and infection if the appendix ruptures
without treatment. Because the patient with appendicitis needs rapid
treatment, the provider must have clinical understanding of symptom
presentation, including the variety of symptoms that this condition
may cause, and the ability to quickly perform diagnostic testing to
confirm the situation.
If possible, the clinician should diagnose and confirm appendicitis as
soon as possible to avoid further complications and difficulties
associated with the condition. Appendicitis is associated with a high
rate of morbidity and, when complications arise, it is affiliated with a
high rate of mortality. Rapid assessment, recognition of factors that
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
24
signify appendicitis, the ability to perform the physical tests that can
elicit a pain response, and quick reaction to provide treatment can all
prevent associated complications that can lead to severe pain and
infection.
The most common form of treatment for appendicitis is surgical
intervention to remove the inflamed appendix. An appendectomy
usually requires only a small incision when it is performed
laparoscopically and may even be done on an outpatient basis, if
needed. Some patients are prescribed antibiotics following the
procedure to further control possible infection. If an abscess has
formed around the appendix, it must first be drained before the
appendix is removed. The patient needs a tube placed in the abdomen
to drain the abscess while taking antibiotics to control the infection;
the appendix is then removed later after the infection has been
managed.
Cholecystitis
Cholecystitis is the technical name for inflammation of the gallbladder,
which most often occurs due to gallstones that become trapped in one
area and block the cystic duct. Cholecystitis is a common cause of
inflammatory abdominal pain but it is usually treated quite easily and
causes few complications if it is caught early. When gallstones are
present that are causing the cholecystitis, the condition is said to be
calculus cholecystitis, which accounts for 90% of cases; the other
10% of cases develop with inflammation of the gallbladder without the
presence of gallstones and are referred to as acalculus cholecystitis.43
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
25
The patient with cholecystitis may present with pain in the right upper
quadrant with significant guarding present. When stones are the cause
of the condition, cholecystitis begins as a type of tension abdominal
pain as the gallbladder becomes distended. The stones typically form
and block the cystic duct that drains bile from the gallbladder; the
blockage causes the bile to back up into the gallbladder, resulting in
distention and pain. As the gallbladder becomes more distended with
fluid build up, lymph drainage declines and the gallbladder becomes
inflamed. Without correction in severe cases, the gallbladder can
become ischemic from lack of blood flow, and organ failure can
develop.
Acalculus cholecystitis also leads to a build up of bile in the
gallbladder; it is caused from conditions other than gallstones, such as
biliary stasis, abdominal trauma, sickle cell disease, and prolonged
total parenteral nutrition (TPN) use. Whatever the injury or disease
process causing reduced bile drainage, the long-term result is the
same as for calculus cholecystitis; the patient develops abdominal pain
from the distended and inflamed gallbladder and the condition must be
treated before ischemia and necrosis develops.
Approximately 10 to 20% of people in the U.S. have gallstones,
however, these stones are not necessarily a cause of abdominal pain.
Many people with gallstones are not aware that they exist. For those
who do develop pain, it happens after gallbladder inflammation
develops from increased bile within the organ. Surgery is a common
option and cholecystectomy, or removal of the gallbladder, is one of
the most commonly performed surgical procedures in the U.S.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
26
Surgical intervention to remove the gallbladder is warranted in up to
30% of cases of cholecystitis.43 Surgery may be done to remove the
gallbladder when stone blockage has caused enough damage and
inflammation that removal is necessary to prevent necrosis.
Additionally, cholecystectomy may also be done in cases of acalculus
cholecystitis when biliary stasis is present to the point that the organ is
damaged from inflammation.
The patient with cholecystitis typically also needs rest, fluids, and
antibiotics to prevent complications. With severe pain, intravenous
analgesia may also be necessary, and patients with nausea and
vomiting typically need antiemetics. Without treatment, cholecystitis
can progress to empyema, which is a collection of pus in the
abdominal cavity near the organ. The patient who develops empyema
may have marked abdominal pain; the treatment still requires a
cholecystectomy but the abscess must also be removed and the
affected area cleaned and drained.
Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) refers to an inflammatory disease
process that affects one or more points in the digestive tract. It is a
form of chronic disease that typically results in repeated bouts of pain
and recurrent inflammation, caused by an abnormal response from the
body’s immune system. Inflammatory bowel disease typically causes
severe abdominal pain, as well as diarrhea, fatigue, and weight loss.
The condition can be debilitating to the affected patient and often
results in poor quality of life in addition to medical complications. The
two main types of IBD are Crohn’s disease and ulcerative colitis (UC).
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
27
Ulcerative colitis is an inflammatory condition that affects the interior
lining of the large intestine; the condition may extend throughout the
entire large intestine or it may be limited to a specific portion, such as
the rectum. A patient with UC develops inflammation and ulcerations
in the interior of the large intestine.
According to a 2009 article in the journal Nursing Standard, ulcerative
colitis is classified by the area of the bowel affected, as the condition
may cover a range of areas within the large intestine. When UC affects
only the rectum, it is known as proctitis; when it extends from the
rectum to the sigmoid colon, it is known as proctosigmoiditis; and
when it extends to the splenic flexure at the top of the descending
colon, it is referred to as left-sided colitis. Further extension of the
disease may be called extensive colitis when it stretches all the way
across the transverse colon to the hepatic flexure. Finally, if ulcerative
colitis affects the entire large intestine, it is called pancolitis.46
The exact cause of ulcerative colitis is not entirely clear. The patient
often has severe diarrhea, which may be bloody, as well as a lowgrade fever and abdominal distention. The extent of symptom severity
depends on the amount of the intestine affected. Patients with mild
disease that affects a small portion of the large intestine typically have
fewer and less severe symptoms when compared to those who have
extensive colitis throughout the large intestine. Severe disease can
lead to multiple bouts of bloody stools throughout the day, as well as
significant abdominal pain. Furthermore, continued symptoms lead to
other complications such as anemia from blood loss or hypovolemia
and dehydration due to near-constant diarrhea.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
28
Patients with UC are at higher risk of developing colorectal cancer
within 5 to 10 years of diagnosis; the risk depends on the extent of the
affected areas within the colon. With proper adherence to treatment
regimens, the risk of developing colorectal cancer is reduced. Surgery
is often the only form of definitive treatment for UC, and involves
removing the affected portions of the colon. For patients with
pancolitis, which affects the entire colon, surgery is needed to remove
the entire large intestine and to place an ileostomy for permanent
diversion of waste from the section of small intestine called the ileum.
Crohn’s disease is another form of inflammatory bowel disease. Named
after Burrill Crohn, who definitively described the condition during the
1930s as an inflammatory process affecting the intestinal tract,
Crohn’s disease causes pain and inflammation in the gut and can
develop anywhere along the gastrointestinal tract, affecting both the
large and small intestines.21 The condition is more likely to develop
following a bout with gastroenteritis; in fact, some people without a
personal history of Crohn’s disease during child- or young adulthood
have developed the disease after having a case of gastroenteritis.23
Unlike UC, Crohn’s disease can affect all layers of the intestinal wall in
both the large and small intestines and its lesions typically develop in
patchy areas, which are known as skip lesions. The most common
areas affected with Crohn’s are the ileum of the small intestine, the
cecum, and the anus.
Severe cases of Crohn’s disease can lead to scar tissue development
and fistulas stretching between abdominal organs. A person with
Crohn’s disease may not always have symptoms and will often go
through periods of remission. However, the potential for extra-
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
29
intestinal symptoms is very common and the patient may develop
other issues within the abdomen in addition to the intestinal disease,
such as gallstones or fatty liver disease. Some patients also have
extra-intestinal symptoms that are unrelated to the abdomen entirely,
including bone and joint diseases such as arthritis and osteoporosis;
and conditions affecting the eyes and skin, including psoriasis, vitiligo,
necrotizing vasculitis, or corneal ulcers.24
In both types of inflammatory bowel diseases, the patient typically
experiences chronic intestinal inflammation that leads to abdominal
pain and diarrhea. The lining of the gut develops ulcers that are
inflamed and swollen and typically bleed. Some individuals, particularly
when the disease affects the distal portion of the large intestine, have
blood, mucous, and pus in the stools. The chronic nature of these
diseases, which leads to scarring within the intestinal tract, may also
cause difficulties with adequate absorption of nutrients and anemia as
well as an increased risk for bowel obstruction.22
Deep Inflammatory Pain
Patients affected with inflammatory pain have often described the pain
as occurring deep within the abdomen. The pain may more likely
radiate internally rather than toward the skin and subcutaneous
tissues. Although pain can be elicited with light palpation of the skin
and soft tissues, the patient with inflammation often feels intense pain
that seems to stretch deep into the abdominal cavity.
Pain may also be described differently based on the underlying cause
or disease process associated with it. For example, peritonitis may
cause different types of pain for affected patients. The pain of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
30
peritonitis has been described as either dull or sharp, but it is typically
severe. The abdomen may become swollen and highly tender to the
touch.
Additionally, acute pancreatitis causes deep pain that starts in the
epigastric area and radiates toward the back. It may worsen after
eating a large meal or drinking large amounts of alcohol. The pain is
often not well regulated and does not necessarily go away; instead,
the patient may have had pain for several days with acute pancreatitis
before finally seeking help in the emergency room. Pain control
through analgesia is important for patients with acute pancreatitis, as
pain can be severe and debilitating. In particular, chronic pancreatitis
causes long-lasting pain from chronic inflammation. The pain
associated with chronic pancreatitis may be constant and can be
aggravated by certain factors that tend to exacerbate symptoms at
times.
A patient with inflammatory abdominal pain may complain of pain that
is concentrated within the abdomen. The pain may be localized over
the affected area or it may be generalized and encompass a larger
area because of referred pain. Pain may last longer among older adults
when compared to children, young adults, or those of middle age. For
example, Dr. Sandy Craig, author of Practice Essentials: Appendicitis,
stated that although the duration of appendicitis pain is less than 48
hours in 80% of adults, it tends to last longer among older adults.
Furthermore, the rate of mortality jumps among older adults from an
overall mortality rate of 0.08% among adults to almost 20% mortality
among older adults.44
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
31
Patient Activities
Certain physical movement with inflammatory abdominal pain often
causes the pain to worsen and the patient may most likely want to lie
still. The clinician may observe this as the patient moves or changes
position during the physical examination. Activities such as walking or
even coughing can cause very intense abdominal pain. The abdomen
in these cases is often very tender and persistent guarding is typically
present.
Often, the patient may want to find a comfortable position and stay in
that position without moving. For example, patients with appendicitis
often find some relief by bending the knees and pulling the legs up
toward the chest or curling the body up into a ball. This position may
provide some pain relief because it avoids stretching the muscles near
the inflamed area and causing further pain.
Many patients with acute pancreatitis suffer from deep pain that
extends to the back. Resting is appropriate for these patients while
they undergo fluid resuscitation and pain control. Similar to those with
appendicitis, patients with pancreatitis also seem to find some relief by
pulling the knees toward the chest and curling up into the fetal
position. In the case of pancreatitis, the patient should be kept without
oral intake; and, should avoid much movement, as third spacing of
fluid may be more likely to develop in such a situation.
The disease process associated with pancreatitis may cause the
patient’s body to sequester fluids into the tissues, resulting in
hypovolemia and the need for intravascular volume replacement. The
clinician must provide adequate intravenous fluids to replace fluid lost
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
32
from third spacing while simultaneously providing comfort care
measures for the patient, and avoiding over-administration of fluids
during resuscitation. Because aggressive management is often
required in cases of acute pancreatitis, it may be beneficial to
treatment that the patient is more likely to choose to lie still and limit
movement.
Ischemic Pain
Pain in the abdomen that develops as a result of reduced blood flow
and oxygenation is termed ischemic pain. Lack of proper blood flow
through the arteries results in tissue ischemia and over time, necrosis;
this condition most often affects the vessels that serve the abdominal
organs, including the large and small intestines. Tissue and organ
necrosis lead to organ failure and, ultimately, overwhelming sepsis,
followed by death of the patient.10 Early identification of the ischemia
as a cause of abdominal pain is essential to restore blood flow to the
abdomen and to prevent complications.
Lack of blood flow to the bowel is a common cause of ischemic
abdominal pain. In fact, intestinal ischemia accounts for approximately
1 out of every 1,000 hospital admissions for abdominal pain.15 The
ischemia may occur from occlusions or changes in the vessels that
feed the intestines or may develop from some other cause of
diminished blood flow to the area. After identifying intestinal ischemia
as a potential cause of abdominal pain, the provider must then also
determine whether the ischemic area affects the small intestine or the
colon.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
33
Bowel ischemia often occurs when the mesenteric vessels — the
arteries and veins that reach the intestines — become occluded or
otherwise develop abnormal and reduced blood flow. The mesenteric
arteries and veins and their branches serve both the small and large
intestines and their components, including the appendix, cecum, and
rectum.11 When blood flow to any of these areas is reduced, decreased
oxygen and glucose to the intestines can lead to severe illness and
significant pain, as the affected areas of bowel are no longer able to
work appropriately. Over time, affected areas of the intestine can
become necrotic or gangrenous.
Sudden Onset of Pain
A patient with ischemic bowel disease typically experiences a sudden
onset of abdominal pain. Often, the pain is described as intense and
severe. When evaluating abdominal pain, a sudden onset is often an
ominous sign and must be investigated quickly, as it could indicate a
condition that can rapidly become life threatening. Pain is considered
to be the classic symptom of ischemic injury in the intestines. When
compared to inflammatory pain, which develops gradually and
increases in intensity over time, ischemic pain may develop much
more rapidly with an abrupt onset.
Ischemic bowel disease can develop with atherosclerosis of the arteries
that supply blood to the intestines. The lumen of the vessel wall
becomes smaller with the buildup of plaques on the interior wall of the
affected artery. Atherosclerosis increases the risk of a blood clot,
which causes an embolus if it breaks off and travels through circulation
to lodge in a smaller vessel and occlude blood flow. When the ischemia
is related to an occlusion from an embolus, the pain may develop
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
34
quickly and the patient will experience a sudden onset of diffuse
abdominal pain from lack of blood flow through the artery.
Intense Pain
Initially, the patient with ischemic abdominal pain may complain of
severe pain that is diffuse across the abdomen and not localized to any
particular area. While pain may be significant and intense, it is not
always accompanied by muscle tension and abdominal rigidity, at least
during the early stages of ischemia. As ischemia progresses and areas
of infarct develop in the bowel, the abdomen is more likely to develop
board-like rigidity and the condition leads to blood in the stools.10
A patient with ischemic pain may describe the pain as intense or may
rate the pain as significant when asked about the level of intensity.
The high intensity of the pain occurs as a result of lack of blood flow,
tissue ischemia, and ultimately, tissue death if the condition is not
managed. Fortunately, because of the intensity, many patients who
develop ischemic abdominal pain seek treatment relatively quickly, as
the pain is so difficult to manage. Seeking early treatment is most
beneficial for these patients as the condition can then be caught at an
earlier stage, which may save some of the affected bowel.
Progressive Severity
Initially, the body is able to compensate from decreased blood flow
that causes ischemia to the bowel, whether the cause is occlusion or a
non-occlusive state. The bowel can actually compensate and become
accustomed to a 75% reduction in blood flow and maintain that
adaptive state for up to 12 hours when the ischemic condition
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
35
develops.15 However, although compensation may be adequate for
some time following injury, it is not enough if the condition is not
relieved and eventually the damage ensues. According to Goldman and
Schafer of Goldman’s Cecil Medicine, damage to the intestinal tract
after compensation from ischemia may become permanent and
irreversible, even when correcting the underlying cause of the
condition. The hypoxia that occurs to the intestinal tissue causes
microvascular injury and ultimately organ damage.15
Without proper identification and treatment of the condition, the
abdominal pain typically continues and becomes progressively worse.
It is usually intense and unrelenting and continues to worsen with
increased areas of ischemia in the abdomen.
Medication Pain Relief
Medications such as anti-inflammatory drugs are given for pain relief
because they block pain-sensitizing chemicals that are released in
response to such painful processes as inflammation. However, because
ischemic pain is caused by diminished blood flow to the abdominal
tissues, it is typically not relieved by the administration of analgesics.
Consequently, when a person has pain as a result of ischemia, these
types of analgesics will not necessarily manage the pain.
Corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs)
are medications used for pain management, in particular, where
inflammation is involved. Corticosteroids and NSAIDs are not
necessarily helpful in controlling ischemic pain. Corticosteroids work by
disrupting the activity of inflammatory mediators released in response
to injury or disease, when the body creates inflammation. Because
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
36
ischemic pain occurs as a lack of blood flow, corticosteroids would not
necessarily be effective against this type of pain. In fact, normal
inflammatory mediators often cause vasodilation during the initial
stages of inflammation. By suppressing inflammation, corticosteroids
can also suppress some blood flow, which can further perpetuate the
ischemic process.
Instead of administering analgesics to remedy this type of abdominal
pain, the clinician instead must manage the condition by restoring
blood flow, which then often resolves the pain. Management of the
condition involves removing the clot if it is the cause of the occlusion,
as well as providing intravenous fluids, increasing cardiac output and
vessel size, and administering antibiotics to avoid infection and
potential sepsis. These measures are used in place of pain
medications, as treatment measures to improve blood flow and resolve
ischemia are usually effective for pain control in these situations.15
Other Symptoms of Intestinal Ischemia
Although pain is a cardinal sign of intestinal ischemia, other symptoms
may also be present, and these should be accounted for and
documented to consider with diagnosis. As mentioned, the patient may
have nausea and vomiting; other symptoms often seen include
diarrhea, pain or difficulties with eating, fever, a distended abdomen,
and an altered mental status. Because ischemia of the abdominal
organs can quickly turn to necrosis and gangrene, ischemic conditions
are some of the most serious conditions seen that result in abdominal
pain.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
37
Upon examination, the patient may have low blood pressure, a
distended abdomen, tachycardia, and decreased bowel sounds on
auscultation. Occult blood may be found in the stool as an early sign.
Gastrointestinal bleeding and hematochezia are considered late
symptoms and are considered ominous findings.15 Early diagnosis and
rapid treatment is essential to prevent complications that can be life
threatening. When ischemia of the small intestine occurs as a result of
mesenteric artery occlusion, the patient can rapidly deteriorate and die
within several hours. When ischemia develops in the large intestine,
the prognosis appears to be better as compared to small intestine
ischemia; however, prompt treatment and management of the
condition is still warranted regardless of the location.
Common Causes of Bowel Ischemia
Bowel ischemia can be caused by several factors that are often
associated with occlusion of the mesenteric vessels that supply blood
to the intestines. At times, bowel ischemia is not associated with a
vessel occlusion but is instead related to other factors, including
adhesions that cause scar tissue and obstruction of the bowel itself.
Occlusive Conditions
Occlusive conditions that cause ischemia develop after an object in the
bloodstream, usually a blood clot, blocks the flow of blood in one or
more of the arteries. People who suffer from heart arrhythmias or who
are at greater risk of blood clots may develop an embolus that travels
through the bloodstream to lodge in one of the mesenteric vessels. A
person who has a history of atrial fibrillation, heart attack, cardiac
valve disease, or a structural heart defect may be at higher risk of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
38
mesenteric embolus, as these conditions increase the risk of blood
clots.10
Thrombosis of the mesenteric vessels that supply blood to the
intestines is another cause of potential ischemia. Arterial thrombosis
most commonly occurs after having a chronic state of decreased blood
supply, often due to conditions that narrow these arteries, such as
atherosclerosis. Before developing intense abdominal pain from
ischemia, the patient with chronic ischemia from arterial thrombosis
may have suffered from non-specific symptoms, such as nausea,
weight changes, pain after eating, or diarrhea, for quite some time.
People who are more likely to develop ischemia from arterial
thrombosis are older adults and those with a history of heart disease,
such as atherosclerosis.
Occasionally, ischemia may develop from venous thrombosis of the
mesenteric veins. This condition is less common than arterial
thrombosis or embolus, but it can develop among people who have
had a history of deep vein thrombosis, certain types of cancer, trauma,
liver disease, or other hypercoagulable state.10,15 Just as a venous
thrombosis occludes blood flow when it develops in other veins in the
body, the response is the same when it occurs in the mesenteric veins.
The clot causes restricted blood flow to the bowel, resulting in
ischemia and areas of infarct.
Lack of Blood Flow
Ischemia may also develop through other situations that are not
related to vessel occlusion, but still result in decreased perfusion.
Conditions that result in low blood pressure through the circulatory
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
39
system can decrease blood flow through the mesenteric vessels and
ultimately decrease perfusion to major abdominal organs, including
the bowel. Following a meal, blood flow to the intestines increases to
approximately 25% of cardiac output.15 The flow of blood through the
mesenteric arteries and their collateral vessels is mostly controlled by
the sympathetic nervous system, although other local factors also play
a role in their regulation of blood flow. As a result, issues with the
sympathetic nervous system may also contribute to low blood flow to
the intestine, causing a non-occlusive condition that leads to intestinal
ischemia.
Other conditions can also decrease overall blood flow and lead to
intestinal ischemia. Examples of some of these conditions that can
result in decreased perfusion include hypotension, heart failure,
cardiogenic shock, sepsis; and certain medications, such as digoxin.10
Decreased blood flow that occurs without an occlusion present is
typically the result of another condition that should be identified as
part of management of perfusion and subsequent abdominal pain. For
instance, a patient taking certain cardiac medications for treatment of
arrhythmia may develop low blood pressure and decreased bowel
perfusion that can lead to ischemia. Factors that cause ischemic
abdominal pain that develops as a result of low blood pressure and
perfusion can be identified while taking the patient’s medical history.
Bowel Obstruction
One of the most common causes of ischemia in the abdomen is due to
strangulation of the bowel. Strangulation occurs when a condition cuts
off blood supply to a portion of the bowel, resulting in ischemia. When
ischemia develops, the portion of the bowel that does not receive
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
40
adequate circulation becomes gangrenous and necrotic, causing
intense and severe pain.
Strangulation of the bowel is a type of bowel obstruction that prohibits
the normal passage of intestinal contents through the intestine. A
bowel obstruction can occur in either the small or large intestine and
can develop at any point along the intestinal tract. When a portion of
the bowel is obstructed, the area above the obstruction continues to
function and attempts to move food through the digestive tract.
Once ingested food reaches the obstruction, it is not able to pass and
food, fluid, and gas back up within the intestine, which becomes
distended. If the obstruction is not relieved, the bowel extension above
the obstruction may cause the intestinal wall to rupture, which leads to
significant pain and infection within the abdominal cavity.12
Small bowel obstruction (SBO) is one of the most common reasons
why patients present to emergency departments with complaints of
abdominal pain. Up to 20% of patients who seek care for abdominal
pain in the emergency department have some form of small bowel
obstruction.13 When strangulation of the bowel occurs, a portion of the
bowel is trapped, twisted, or rotated so that it does not function
properly. The abnormality typically cuts off blood flow and food and
fluid cannot continue to move through the bowel in a normal manner.
Strangulation may develop in several ways, such as:
 intussusception
 volvulus
 hernia
 scar tissue
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
41
Intussusception
Intussusception occurs when a portion of the intestine slides inward
into another part of the intestine, in a manner similar to a telescope.
This process cuts off circulation to the affected portion of the bowel,
resulting in a type of bowel strangulation. The bowel cannot continue
to function normally through digestion in a normal manner when
intussusception develops.
Volvulus
Another form of obstruction and strangulation is a volvulus, which
occurs as a twisting of the bowel. Pothiawala and Gogna clarify in the
World Journal of Emergency Medicine that the condition of twisting is
referred to as a volvulus when it occurs in the large intestine.
Whereas, when twisting of the small intestine is referred to as a loop
obstruction.13 With a volvulus, a portion of the gut becomes twisted
into a closed loop, which cuts off blood supply to the area within the
loop and prevents passage of food for digestion. As with
intussusception, volvulus that causes strangulation results in severe
abdominal pain.
Hernia
A hernia normally occurs when an area of tissue bulges through an
opening in a nearby muscle wall. A hernia may develop when the
bowel protrudes through a weakened muscle area. If the intestine
bulges through an opening and blood supply is cut off because of its
position, ischemia can also develop. This condition is known as a
strangulated hernia.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
42
Scar Tissue
Adhesions are forms of scar tissue that may be present in areas in the
gut. The scar tissue can develop from such conditions as surgery or
infectious processes. Adhesions form between two areas within the
body and cause the associated surfaces to adhere to each other.
Adhesions that develop at some point on the intestine can cause parts
of the bowel to stick together, potentially obstructing the affected
portion and causing strangulation and ischemia.14
Unfortunately, there are many forms of obstructions that can lead to
ischemic pain and tissue loss from inadequate oxygenation. The health
provider may have a lot of information to sort through while taking the
patient’s history and performing a physical exam. Because of the
potential seriousness of ischemic conditions in the abdomen, the
history and physical examination often need to be completed rapidly
with the health team anticipating serious complications that can
appear quickly.
Summary
There are many different possible causes of abdominal pain. The
clinician may initially be required to narrow down and isolate the cause
of abdominal pain, which includes consideration of potential
contributing factors and to identify a specific diagnosis.
Pain categories are defined by the pain location or affected area of the
body, including time of pain onset and sensation. Often, identifying the
underlying cause of acute or chronic abdominal pain can be
complicated and cloud the diagnosis. The pain may be visceral,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
43
neurogenic, or referred; and, additionally, pain may originate from an
inflammatory process, tension, or through ischemic disease.
Pain symptoms in an acute or chronic condition involving abdominal
organs and/or tissue should be investigated and documented when
considering diagnosis. Often there are other corresponding symptoms
that must be taken into account, such as nausea and vomiting,
diarrhea, fever, loss of appetite, and altered vital signs and mental
status. In particular, ischemia of abdominal organs is a serious
condition that can lead to rapid deterioration and grave outcomes.
Early diagnosis and rapid treatment of abdominal pain is essential to
prevent potential complications that can be life threatening. Prompt
identification of underlying cause, treatment and management of
abdominal pain requires a knowledgeable health team that is aware of
possible etiology and corresponding factors influencing a patient’s
prognosis and outcome.
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.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
44
1.
Classifications of abdominal pain the following different
types:
a.
b.
c.
d.
2.
The body releases a substance called ____________,
which is an inflammatory mediator that causes the
sensation of pain.
a.
b.
c.
d.
3.
obesity and female gender.
genetic predisposition and smoking.
fatty diet and sedentary lifestyle.
excessive alcohol consumption and gallstones.
Cholecystitis caused by gallstones is called calculus
cholecystitis, which accounts for ______ of cases.
a.
b.
c.
d.
5.
adrenaline
serotonin
bradykinin
None of the above
Two most common causes of acute pancreatitis in the U.S.
are
a.
b.
c.
d.
4.
acute pain, subacute pain, chronic pain.
tension pain, inflammatory pain, ischemic pain.
severe pain, moderate pain, minimal pain.
None of the above
90%
20%
50%
75%
True or False: Corticosteroids and NSAIDs are
recommended medications used to control ischemic pain.
a. True
b. False
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
45
6.
Ulcerative colitis is associated with
a.
b.
c.
d.
7.
Ischemic bowel disease typically leads to
a.
b.
c.
d.
8.
gradual, dull onset of abdominal pain.
sudden, severe onset of abdominal pain.
referral to a cancer specialist to investigate insidious cause.
None of the above
Without stimulus of the ___________ lobe, or where the
pain message reaches this specific area, the patient will
not feel pain even if damage or injury has occurred that
would otherwise cause discomfort.
a.
b.
c.
d.
9.
risk of cancer based on extent of affected areas
higher risk of developing colorectal cancer
a need for proper adherence to treatment regimens
All of the above
parietal
frontal
occipital
temporal
The most common cause of acute abdominal pain is
a.
b.
c.
d.
constipation.
gallbladder stones.
appendicitis.
acid reflux disease.
10. Following a meal, blood flow to the intestines increases to
approximately __________ of cardiac output.
a.
b.
c.
d.
10%
25%
40%
None of the above
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
46
11. True or False: Crohn’s disease causes pain and
inflammation in the gut and can develop only in the large
intestine.
a. True
b. False
12. Strangulation of the bowel may develop in all EXCEPT for:
a.
b.
c.
d.
intussusception
volvulus
hernia
diverticulum
13. Up to ________ of patients who seek care for abdominal
pain in the emergency department have some form of
small bowel obstruction.
a.
b.
c.
d.
20%
25%
30%
45%
14. A patient with ischemic pain may describe the pain as
______________; because the intensity of the pain is due
to lack of blood flow or tissue ischemia.
a.
b.
c.
d.
low
moderate
intense
low to moderate
15. Patients with ulcerative colitis (UC) are at higher risk of
developing colorectal cancer within ________ years of
diagnosis.
a.
b.
c.
d.
5 – 10
10 – 15
15 – 20
> 20
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
47
16. Acalculus cholecystitis leads to a buildup of bile in the
gallbladder and is caused from conditions, EXCEPT
a.
b.
c.
d.
conditions other than gallstones.
abdominal trauma.
eating high protein food.
sickle cell disease.
17. True or False: Occult blood and hematochezia are both
considered early sign of gastrointestinal bleeding.
a. True
b. False
18. It has been stated that the duration of appendicitis pain is
less than 48 hours in 80% of adults, and tends to last
________ among older adults.
a.
b.
c.
d.
longer
less
the same
None of the above
19. The rate of mortality among older adults jumps from an
overall mortality rate of 0.08% among adults to almost
______ mortality among older adults.
a.
b.
c.
d.
10%
20%
30%
50%
20. The most common areas affected with Crohn’s are the
a.
b.
c.
d.
ileum.
cecum.
anus.
All of the above
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
48
21. Pain is a cardinal sign of intestinal ischemia but other
symptoms include
a.
b.
c.
d.
nausea
vomiting and diarrhea
jaundice
Answers a., and b., above
22. Chronic pancreatitis is typically caused from such
situations, EXCEPT
a.
b.
c.
d.
autoimmune disorders.
chronic use of NSAIDs.
cystic fibrosis.
familial pancreatitis.
23. Scar tissue in the gut can develop from such conditions as
surgery or
a.
b.
c.
d.
infection.
antibiotic infusion into the gut.
hereditary cause.
None of the above
24. Risk of abscess formation is approximately ______ among
certain people, including those who have developed
peritonitis because of bowel perforation with leakage of
intestinal contents into the abdominal cavity, inflammation
that has developed following bowel ischemia, or a preexisting immunocompromised condition.
a.
b.
c.
d.
10%
20%
30%
50%
25. True or False: Mechanoreceptors send pain messages to
the brain when mechanical forces of injury, such as
membrane or organ tension or stretching, affect the
abdominal organs.
a. True
b. False
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
49
26. The abdominal organs are surrounded by the ___________
membrane that contains two layers.
a.
b.
c.
d.
musculature
peritoneum
arterial and venous vasculature
None of the above
27. True or False: Pain relieved with stress reduction
techniques is a classic symptom management technique of
psychogenic pain.
a. True
b. False
28. Corticosteroids and NSAIDs are _____________ helpful in
controlling ischemic pain.
a.
b.
c.
d.
very
not necessarily
moderately
the primary treatment as highly
29. Acute pain is associated with tissue damage, inflammation,
or a relatively brief disease process that lasts minutes,
hours, or days: _____________________ is an example of
acute pain.
a.
b.
c.
d.
an unresolved, previously treated injury
a disease that requires ongoing management
a surgical procedure
inflammatory bowel disease
30. A patient, who complains of a burning or shooting pain that
seems to move along the routes of the nerves, is
experiencing
a.
b.
c.
d.
abdominal pain.
parietal pain.
visceral pain.
neurogenic pain.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
50
31. Abdominal compartment syndrome occurs when increased
pressure _________________ develops within the
abdominal cavity.
a.
b.
c.
d.
from fluid
from organ damage
causing little or no pain
caused by renal failure
32. True or False: Gallbladder stone blockage may be relieved
by cholecystectomy but surgery is never indicated for
acalculus cholecystitis.
a. True
b. False
33. A patient who develops pain from an enlarged liver due to
hepatitis, has a form of
a.
b.
c.
d.
tension pain.
psychogenic pain.
parietal pain.
moderate pain.
34. Tension pain caused by damage to abdominal organs
a.
b.
c.
d.
is always severe.
may cause no pain at all.
usually leads to psychogenic pain.
is called compartment syndrome.
35. A patient with abdominal compartment syndrome may also
___________________________ when more fluid
accumulates in the abdomen.
a.
b.
c.
d.
become immunocompromised
have fatty stools
become lightheaded or dizzy
suffer hematochezia
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
51
36. ______________ peritonitis is much more common and
leads to the noted inflammation of the peritoneum.
a.
b.
c.
d.
Primary
Spontaneous
Secondary
Abdominal
37. Abdominal fluid sampling may be done through
______________ to withdraw a small amount through a
needle inserted into the affected area of the abdomen.
a.
b.
c.
d.
peritoneal dialysis
a urine sample
a stool sample
paracentesis
38. Acute pancreatitis may also develop as a result of
a.
b.
c.
d.
high cholesterol levels.
chronic use of NSAIDs.
compartment syndrome.
paracentesis.
39. True or False: Appendicitis causes symptoms of right lower
quadrant abdominal pain, nausea, and tenderness over the
umbilicus in almost 100% of the cases.
a. True
b. False
40. The most common form of treatment for appendicitis is
a.
b.
c.
d.
antibiotic treatment.
an appendectomy.
a change in diet.
paracentesis to relieve the pressure.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
52
41. Inflammatory bowel disease typically causes
a.
b.
c.
d.
weight gain.
constipation.
severe abdominal pain.
little or no pain.
42. Patients affected with inflammatory pain have often
described the pain as
a.
b.
c.
d.
occurring deep within the abdomen.
radiating toward the skin and subcutaneous tissues.
minor to moderate.
All of the above
43. Acute _______________ causes deep pain that starts in
the epigastric area and radiates toward the back
a.
b.
c.
d.
Crohn’s disease
peritonitis
appendicitis
pancreatitis
44. True or False: Bowel ischemia often occurs when the
mesenteric vessels become occluded or otherwise develop
abnormal and reduced blood flow.
a. True
b. False
45. Atherosclerosis of the arteries that supply blood to the
intestines can
a.
b.
c.
d.
reverse ischemic bowel disease.
increase the risk of a blood clot.
cause the lumen of the vessel wall to enlarge.
reduce plaque buildup.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
53
Correct Answers:
1.
Classifications of abdominal pain the following different
types:
b. tension pain, inflammatory pain, ischemic pain.
2.
The body releases a substance called ____________,
which is an inflammatory mediator that causes the
sensation of pain.
c. bradykinin
3.
Two most common causes of acute pancreatitis in the U.S.
are
d. excessive alcohol consumption and gallstones.
4.
Cholecystitis caused by gallstones is called calculus
cholecystitis, which accounts for ______ of cases.
a. 90%
5.
True or False: Corticosteroids and NSAIDs are
recommended medications used to control ischemic pain.
b. False
6.
Ulcerative colitis is associated with
d. All of the above
7.
Ischemic bowel disease typically leads to
b. sudden, severe onset of abdominal pain.
8.
Without stimulus of the ___________ lobe, or where the
pain message reaches this specific area, the patient will
not feel pain even if damage or injury has occurred that
would otherwise cause discomfort.
a. parietal
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
54
9.
The most common cause of acute abdominal pain is
c. appendicitis.
10. Following a meal, blood flow to the intestines increases to
approximately __________ of cardiac output.
b. 25%
11. True or False: Crohn’s disease causes pain and
inflammation in the gut and can develop only in the large
intestine.
b. False
12. Strangulation of the bowel may develop in all EXCEPT for:
d. diverticulum.
13. Up to ________ of patients who seek care for abdominal
pain in the emergency department have some form of
small bowel obstruction.
a. 20%
14. A patient with ischemic pain may describe the pain as
________; because the intensity of the pain is due to lack
of blood flow or tissue ischemia.
c. intense
15. Patients with ulcerative colitis (UC) are at higher risk of
developing colorectal cancer within ________ years of
diagnosis.
a. 5 – 10
16. Acalculus cholecystitis leads to a buildup of bile in the
gallbladder and is caused from conditions, EXCEPT
c. eating high protein food.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
55
17. True or False: Occult blood and hematochezia are both
considered early sign of gastrointestinal bleeding.
b. False
18. It has been stated that the duration of appendicitis pain is
less than 48 hours in 80 % of adults, and tends to last
________ among older adults.
b. less
19. The rate of mortality among older adults jumps from an
overall mortality rate of 0.08% among adults to almost
______ mortality among older adults.
b. 20%
20. The most common areas affected with Crohn’s are the
d. All of the above
21. Pain is a cardinal sign of intestinal ischemia but other
symptoms include
d. Answers a., and b., above
22. Chronic pancreatitis is typically caused from such
situations, EXCEPT
b. chronic use of NSAIDs.
23. Scar tissue in the gut can develop from such conditions as
surgery or
a. infection.
24. Risk of abscess formation is approximately ______ among
certain people, including those who have developed
peritonitis because of bowel perforation with leakage of
intestinal contents into the abdominal cavity, inflammation
that has developed following bowel ischemia, or a preexisting immunocompromised condition.
c. 30%
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
56
25. True or False: Mechanoreceptors send pain messages to
the brain when mechanical forces of injury, such as
membrane or organ tension or stretching, affect the
abdominal organs.
a. True
26. The abdominal organs are surrounded by the ___________
membrane that contains two layers.
b. peritoneum
27. True or False: Pain relieved with stress reduction
techniques is a classic symptom management technique of
psychogenic pain.
a. True
28. Corticosteroids and NSAIDs are _____________ helpful in
controlling ischemic pain.
b. not necessarily
29. Acute pain is associated with tissue damage, inflammation,
or a relatively brief disease process that lasts minutes,
hours, or days: _____________________ is an example of
acute pain.
c. a surgical procedure
30. A patient, who complains of a burning or shooting pain that
seems to move along the routes of the nerves, is
experiencing
d. neurogenic pain.
31. Abdominal compartment syndrome occurs when increased
pressure _________________ develops within the
abdominal cavity.
a. from fluid
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
57
32. True or False: Gallbladder stone blockage may be relieved
by cholecystectomy but surgery is never indicated for
acalculus cholecystitis.
b. False
33. A patient who develops pain from an enlarged liver due to
hepatitis, has a form of
a. tension pain.
34. Tension pain caused by damage to abdominal organs
b. may cause no pain at all.
35. A patient with abdominal compartment syndrome may also
___________________________ when more fluid
accumulates in the abdomen.
c. become lightheaded or dizzy
36. ______________ peritonitis is much more common and
leads to the noted inflammation of the peritoneum.
c. Secondary
37. Abdominal fluid sampling may be done through
______________ to withdraw a small amount through a
needle inserted into the affected area of the abdomen.
d. paracentesis
38. Acute pancreatitis may also develop as a result of
a. high cholesterol levels.
39. True or False: Appendicitis causes symptoms of right lower
quadrant abdominal pain, nausea, and tenderness over the
umbilicus in almost 100% of the cases.
b. False
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
58
40. The most common form of treatment for appendicitis is
b. an appendectomy.
41. Inflammatory bowel disease typically causes
c. severe abdominal pain.
42. Patients affected with inflammatory pain have often
described the pain as
a. occurring deep within the abdomen.
43. Acute _______________ causes deep pain that starts in
the epigastric area and radiates toward the back
d. pancreatitis
44. True or False: Bowel ischemia often occurs when the
mesenteric vessels become occluded or otherwise develop
abnormal and reduced blood flow.
a. True
45. Atherosclerosis of the arteries that supply blood to the
intestines can
b. increase the risk of a blood clot.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
59
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.
Bickley, L. S. (2013). Bates’ guide to physical examination and
history taking (11th ed.). [Chapter 11]. Philadelphia, PA:
Lippincott Williams & Wilkins
2. ATI Nursing Education. (n.d.). Abdominal examination. Retrieved
from
http://atitesting.com/ati_next_gen/skillsmodules/content/physical
-assessment-adult/equipment/ad_exam.html
3. O’Laughlen, M. C. (2009). Making sense of abdominal
assessment. Nursing Made Incredibly Easy! 7(5): 15-19.
Retrieved from
http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2009
/09000/Making_sense_of_abdominal_assessment.5.aspx
4. Dennis, M., Talbot Bowen, W., Cho, L. (2012). Mechanisms of
clinical signs. Chatswood, NSW: Elsevier Australia
5. Shimizu, T., Tokuda, Y. (2013). Visible intestinal peristalsis. BMJ
Case Rep. doi: 10.1136/bcr-2013- 201748
6. Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (Eds.).
(2010). Brunner and Suddarth’s textbook of medical-surgical
nursing, Volume 1 (12th ed.). Philadelphia, PA: Lippincott Williams
& Wilkins
7. Kauffman, M. (2014). History and physical examination: A
common sense approach. Burlington, MA: Jones & Bartlett
Learning
8. University of California, San Diego. (2009, Jul.). Exam of the
abdomen. Retrieved from
http://meded.ucsd.edu/clinicalmed/abdomen.htm
9. Stanford School of Medicine. (2014). Examination of the spleen.
Retrieved from
http://stanfordmedicine25.stanford.edu/the25/spleen.html
10. Patel, S. (2010). Mesenteric ischemia. Retrieved from
http://www.cdemcurriculum.org/ssm/gi/mesenteric_ischemia/me
senteric_ischemia.php
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
60
11. University of Arkansas for Medical Sciences. (2007). Superior
mesenteric artery and small intestine, inferior mesenteric artery
and large intestine. Retrieved from
http://anatomy.uams.edu/intestines.html
12. Merck Manuals. (2012, Oct.). Intestinal obstruction. Retrieved
from
http://www.merckmanuals.com/home/digestive_disorders/gastroi
ntestinal_emergencies/intestinal_obstruction.html
13. Pothiawala, S., Gogna, A. (2012). Early diagnosis of bowel
obstruction and strangulation by computed tomography in
emergency department. World J Emerg Med 3(3): 227-231
14. Medline Plus. (2014, Feb.). Small intestinal ischemia and
infarction. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/001151.htm
15. Goldman, L., Schafer, A. I. (2012). Goldman’s Cecil medicine
(24th ed.). Philadelphia, PA: Elsevier
16. Drugs.com. (2014, Nov.). Papaverine. Retrieved from
http://www.drugs.com/cdi/papaverine.html
17. Alobaidi, M. (2013, Jul.). Mesenteric ischemia imaging. Retrieved
from http://emedicine.medscape.com/article/370688overview#a01
18. Lee, P., Stevens, T. (2014). Acute pancreatitis. Retrieved from
http://www.clevelandclinicmeded.com/medicalpubs/diseasemana
gement/gastroenterology/acute-pancreatitis/
19. University of Maryland Medical Center. (2012, Dec.). Peritonitis.
Retrieved from
http://umm.edu/health/medical/altmed/condition/peritonitis
20. Karul, M., Berliner, C., Keller, S., Tsui, T. Y., Yamamura, J.
(2014). Imaging of appendicitis in adults. Fortschr Röntgenstr
186(6): 551-558. Retrieved from https://www.thiemeconnect.com/products/ejournals/html/10.1055/s-0034-1366074
21. University of Maryland Medical Center. (2014, May). Abdominal
pain. Retrieved from
http://umm.edu/health/medical/ency/articles/abdominal-pain
22. Hunter, J. (2010). Inflammatory bowel disease: The essential
guide to controlling Crohn’s disease, colitis and other IBDS.
Chatham, UK: Ebury Publishing
23. Baumgart, D. C., Sandborn, W. J. (2012, Nov.). Crohn’s disease.
The Lancet 380(9853): 1590-1605. Retreived from
http://www.thelancet.com/journals/lancet/article/PIIS01406736(12)60026-9/fulltext
24. Levine, J. S., Burakoff, R. (2011, Apr.). Extraintestinal
manifestations of inflammatory bowel disease. Gastroenterol
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
61
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
Hepatol (NY) 7(4): 235-241. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127025/
Cox, C. (Ed.). (2010). Physical assessment for nurses (2nd ed.).
West Sussex, UK: Blackwell Publishing
Eckman, M. (Ed.). (2008). Assessment made incredibly easy! (4th
ed.). Amber, PA: Lippincott Williams & Wilkins
Wilson, S. F., Giddens, J. F. (2013). Health assessment for
nursing practice (5th ed.). St. Louis, MO: Elsevier Mosby
Subramanian, P., Allcock, N., James, V., Lathlean, J. (2012).
Challenges faced by nurses in managing pain in a critical care
setting. Journal of Clinical Nursing 21:1254-1262. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1111/j.13652702.2011.03789.x/abstract?deniedAccessCustomisedMessage=&
userIsAuthenticated=false
Melzack, R. (1975). The McGill Pain Questionnaire: Major
properties and scoring methods. Pain 1(3): 277-299
Melzack, R. (1971). The McGill Pain Questionnaire. Montreal,
Canada: McGill University
Bickley, L. S. (2013). Bates’ guide to physical examination and
history taking (11th ed.). [Chapter 1]. Philadelphia, PA: Lippincott
Williams & Wilkins
Turk, D. C., Melzack, R. (2011). Handbook of pain assessment.
New York, NY: The Guilford Press
U.S. Food and Drug Administration. (2014, Aug.). Computed
tomography (CT). Retrieved from http://www.fda.gov/RadiationEmittingProducts/RadiationEmittingProductsandProcedures/Medica
lImaging/MedicalX-Rays/ucm115317.htm
Nursing Central. (2014). Ultrasound, abdomen. Retrieved from
http://nursing.unboundmedicine.com/nursingcentral/view/DavisLab-and-Diagnostic-Tests/425425/all/Ultrasound__Abdomen
Northwestern Medicine. (2014, Jan.). Abdominal x-rays. Retrieved
from
http://encyclopedia.nm.org/Library/TestsProcedures/Gastroentero
logy/92,P07685
Plevris, J., Howden, C. (Eds.). (2012). Problem-based approach to
gastroenterology and hepatology. West Sussex, UK: Blackwell
Publishing, Ltd.
Gyawali, C. P. (Ed.). (2012). The Washington Manual:
Gastroenterology (3rd ed.). St. Louis, MO: Washington University
School of Medicine
Cervero, F. (n.d.). Visceral pain. Retrieved from
http://www.wellcome.ac.uk/en/pain/microsite/science3.html
Saladin, K. S. (2012). Anatomy and physiology (6th ed.). New
York: NY: McGraw-Hill
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
62
40. Gebhart, G. F., Bielefeldt, K. (2008). Visceral pain. Retrieved from
http://rfi.fmrp.usp.br/pg/fisio/cursao2012/viscelpainp1.pdf
41. Paula, R. (2014, Sep.). Abdominal compartment syndrome.
Retrieved from http://emedicine.medscape.com/article/829008overview
42. Bloom, A. A. (2014, Apr.). Cholecystitis. Retrieved from
http://emedicine.medscape.com/article/171886-overview
43. Craig, S. (2014, Jul.). Appendicitis. Retrieved from
http://emedicine.medscape.com/article/773895-overview
44. Daley, B. J. (2013, Apr.). Peritonitis and abdominal sepsis.
Retrieved from http://emedicine.medscape.com/article/180234overview
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
Brothers Publishing
47. Panebianco, N. L., Jahnes, K., Mills, A. M. (2011). Imaging and
laboratory testing in acute abdominal pain. Emerg Med Clin N Am
29: 175-193
48. Lab Tests Online. (2014, Nov.). Lactate. Retrieved from
http://labtestsonline.org/understanding/analytes/lactate/tab/test/
49. Weber, J. R., Kelley, J. H. (2014). Health assessment in nursing
(5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins
50. Lippincott Williams & Wilkins. (2009). Nursing know-how:
Evaluating signs and symptoms. Philadelphia, PA: Lippincott
Williams & Wilkins
51. Daniels, R. (2010). Delmar’s guide to laboratory and diagnostic
tests (2nd ed.). Clifton Park, NY: Delmar Cengage Learning
52. Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (Eds.).
(2010). Brunner and Suddarth’s textbook of medical-surgical
nursing, Volume 1 (12th ed.). Philadelphia, PA: Lippincott Williams
& Wilkins
53. Centers for Disease Control and Prevention. (2014, Jul.). Pelvic
inflammatory disease (PID)—CDC fact sheet. Retrieved from
http://www.cdc.gov/std/PID/STDFact-PID.htm
54. Orthopaedic Specialists of North Carolina. (2014). Orthopedic
physical therapy frequently asked questions. Retrieved from
http://www.orthonc.com/patient-information/faqs/physicaltherapy-faqs#heat4
55. Fishman, S., Ballantyne, J., Rathmell, J. P. (2010). Bonica’s
management of pain. Philadelphia, PA: Lippincott Williams &
Wilkins
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
63
56. Baylor Surgicare at Garland. (2009). Frequently asked questions.
Retrieved from http://www.pas-garland.com/index.php?q=faq
57. Braun, M. B., Simonson, S. J. (2014). Introduction to massage
therapy (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins
58. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical
problems (9th ed.). St. Louis, MO: Elsevier Mosby
59. Söyüncü, S., Bektas, F., Cete, Y. (2012, Jan.). Traditional Kehr’s
sign: Left shoulder pain related to splenic abscess. Ulus Travma
Acil Cerrahi Derg 18(1): 87-88.
60. Fiebach, N. H., Kern, D. E., Thomas, P. A., Ziegelstein, R. C.
(Eds.). (2007). Principles of ambulatory medicine. Philadelphia,
PA: Lippincott Williams & Wilkins
61. Ombregt, L. (2013). A system of orthopaedic medicine (3rd ed.).
London, UK: Churchill Livingstone Elsevier
62. Centers for Disease Control and Prevention. (2013, Aug.).
Helicobacter pylori. Retrieved from
http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3infectious-diseases-related-to-travel/helicobacter-pylori
63. Crowe, S. E. (2013, Aug). Patient information: Helicobacter pylori
infection and treatment. Retrieved from
http://www.uptodate.com/contents/helicobacter-pylori-infectionand-treatment-beyond-the-basics
64. The National Pancreas Foundation. (2014). About chronic
pancreatitis. Retrieved from
http://www.pancreasfoundation.org/patient-information/chronicpancreatitis/
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.
Retrieved from
http://www.cdemcurriculum.org/ssm/gi/biliary/biliary.php
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
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
64
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
responsibility for the appropriate orientation of healthcare professionals.
Hospitals or other organizations using this publication as a part of their own
orientation processes should review the contents of this publication to ensure
accuracy and compliance before using this publication.
Hospitals and facilities that use this publication agree to defend and indemnify, and
shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates,
officers/directors, and employees from liability resulting from the use of this
publication.
The contents of this publication may not be reproduced without written permission
from NurseCe4Less.com.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
65