The Abdomen

Pain

Pain is probably the most important symptom of abdominal disease. Although abdominal neoplasia may be painless, most abdominal disease manifests itself with some amount of pain. Pain can result from mucosal irritation, smooth muscle spasm, peritoneal irritation, capsular swelling, or direct nerve stimulation. Abdominal pain necessitates speedy diagnosis and therapy.

There are three broad categories of abdominal pain: visceral, parietal, and referred. Visceral pain develops when hollow abdominal organs such as the gallbladder, stomach, or intestines contract forcefully or their walls are stretched. If the capsule of the liver or spleen is stretched, visceral pain can also develop. For the patient, it may be difficult to localize such pain. The pain can be described typically as gnawing, burning, or aching. When the pain is severe, nausea, vomiting, and sweating may develop. Parietal pain stems from inflammation of the peritoneum. The pain is extremely severe, and the patient is often more able to localize the pain over a specific organ. The patient lies extremely still, board-like, as any movement tends to exacerbate the pain. Referred pain is a term used to describe pain originating in the internal organs but described by the patient as located in the abdominal or chest wall, shoulder, jaw, or other areas supplied by the somatic nerves. Pain appears to originate in areas supplied by the somatic nerves entering the spinal cord at the same segment as the sensory nerves from the organ responsible for the pain. The pain is usually localized. For example, right shoulder pain or right scapular pain may result from acute cholecystitis; testicular pain may result from renal colic or from appendicitis. The common sites for referred pain are shown in Fig. 17.3 . The locations of pain in abdominal disease are summarized in Table 17.2 .

When a patient complains of abdominal pain, ask the following questions:

• “Where is the pain?”

• “Has the pain changed its location since it started?”

• “Do you feel the pain in any other part of your body?”

• “How long have you had the pain?”

• “Have you had recurrent episodes of abdominal pain?”

• “Did the pain start suddenly?”

• “Can you describe the pain? Is it sharp? Dull? Burning? Cramping?”

• “Is the pain continuous? Does it come in waves?”

• “Has there been any change in the severity or nature of the pain since it began?”

• “What makes it worse?”

• “What makes it better?”

• “Is the pain associated with nausea? Vomiting? Sweating? Constipation? Diarrhea? Bloody stools? Abdominal distention? Fever? Chills? Eating? Menstrual cycle?”

• “Have you ever had gallstones? Kidney stones?”

• “When you have the pain in your abdomen, do you feel the pain in any other part of your body at the same time?”

• If the patient is a woman, ask this question:

• “When was your last period?”

• If the woman is of child-bearing age and is sexually active, ask the question:

• “Is there a possibility that you might be pregnant?”

Note the exact time at which the pain started and what the patient was doing at that time. Obtain a good chronologic assessment of the pain. Sudden, severe pain awakening a patient from sleep may be associated with acute perforation, inflammation, or torsion of an abdominal organ. A stone in the biliary or renal tract also causes intense pain. Note acuteness of the pain. Acute rupture of a fallopian tube by an ectopic pregnancy, perforation of a gastric ulcer, peritonitis, and acute pancreatitis cause such severe pain that fainting may result.

It is crucial to determine the location of the pain at its onset, its localization, its character, and its radiation. Commonly, when an abdominal organ ruptures, pain is felt “all over the belly,” without localization to a specific area. Pain arising from the small intestine is commonly felt in the umbilical or epigastric regions; for example, pain from acute appendicitis often begins at the umbilicus.

In time, pain may become localized to other areas. Pain from acute appendicitis travels from the umbilicus to the right lower quadrant approximately 1 to 3 hours after the initial event. Pain in the chest followed by abdominal pain should raise the suspicion of a dissecting aortic aneurysm.

Note the nature of the pain. Pain caused by a perforated gastric ulcer is often described as “burning,” dissecting aneurysm as “tearing,” intestinal obstruction as “gripping,” pyelonephritis as “dull” or “aching,” and biliary or renal colic as “crampy” or “constricting.”

The time of occurrence and factors that aggravate or alleviate the symptoms (e.g., meals or defecation) are particularly important. Periodic epigastric pain occurring to 1 hour after eating is a classic symptom of gastric peptic ulcers. Patients with a duodenal peptic ulcer have pain 2 to 3 hours after eating or before the next meal. Food tends to lessen the pain, especially in duodenal ulcers. Perforation of a duodenal ulcer to the pancreas may produce backache, simulating an orthopedic problem. Nocturnal pain is a classic symptom of duodenal peptic ulcer disease. Pain after eating may also be associated with vascular disease of the abdominal viscera. Patients with this condition are older and have postprandial pain, anorexia, and weight loss. This triad is seen in abdominal angina resulting from obstructive vascular disease in the celiac axis or the superior mesenteric artery. Table 17.3 summarizes the important maneuvers for ameliorating abdominal pain.

Determine whether the abdominal pain is associated with anything else such as before meals, while eating, or after meals.

Suprapubic pain may be caused by urinary bladder disorders such as a bladder infection or cystitis. The pain is often described as dull pressure as is commonly associated with burning during urination, incontinence, frequency, flank pain, fever, nausea, or vomiting.

Ureteral pain is extremely severe and colicky. The patient cannot find a comfortable position. It results from sudden distention of the ureter and renal pelvis and is generally caused by acute obstruction such as from a kidney stone. Always inquire about associated fever, chills, or hematuria. More questions related to abdominal pain in a woman are described in Chapter 19 , Female Genitalia.

Nausea and Vomiting

Vomiting may be caused by severe irritation of the peritoneum resulting from the perforation of an abdominal organ; from obstruction of the bile duct, ureter, or intestine; or from toxins. Vomiting resulting from a perforation is commonly not massive. Obstruction of the bile duct or other tube produces stretching of the muscular wall, resulting in episodic vomiting that occurs at the height of the pain. Intestinal obstruction prevents the intestinal contents from passing distally; consequently, vomiting may result in the expulsion of intestinal contents. Toxins generally cause persistent vomiting. Not all abdominal emergencies cause vomiting. Intraperitoneal bleeding may occur in the absence of vomiting. Vomiting is frequently also caused by inflammation of intra-abdominal structures, as well as by extra-abdominal conditions, including drug toxicity, central nervous system disorders, myocardial infarction, and pregnancy. Ask the following questions if a patient complains of nausea, vomiting, or both:

• “How long have you had nausea or vomiting?”

• “What is the color of the vomit?”

• “Is there any unusually foul odor to the vomitus?”

• “How often do you vomit?”

• “Is vomiting related to eating?” If yes, “How soon after eating do you vomit? Do you vomit only after eating certain foods?”

• “Do you have nausea without vomiting?”

• “Is the nausea or vomiting associated with abdominal pain? Constipation? Diarrhea? A loss of appetite? A change in the color of your stools? A change in the color of your urine? Fever? Chest pain?”

• “Have you noticed a change in your hearing ability?”

• “Have you noticed ringing in your ears?”

• If the patient is a woman, ask this question:

• “When was your last period?”

• If the patient is of child-bearing age and sexually active, ask the question:

• “Is there a possibility that you might be pregnant?”

The relationship of the pain to vomiting is important and may help in providing the diagnosis. In acute appendicitis, pain precedes the vomiting usually by a few hours. The character of the vomitus may aid in determining its cause. Acute gastritis causes the patient to vomit stomach contents. Biliary colic produces bilious, or greenish-yellow, vomitus. Intestinal obstruction often causes the patient to expel bilious vomitus, followed by feculent-smelling fluid. Feculent vomitus is usually caused by intestinal obstruction.

Nausea without vomiting is a common symptom in patients with hepatocellular disease, pregnancy, and metastatic disease. Nausea may be associated with a hearing loss and tinnitus in patients with Ménière disease. More questions related to nausea and vomiting in a woman are described in Chapter 19 , Female Genitalia.

Change in Bowel Movements

Take a careful history of bowel habits. A change in bowel movements necessitates further elaboration. Ask these questions of the patient with acute onset of diarrhea:

• “How long have you had the diarrhea?”

• “How many bowel movements do you have a day?”

• “Did the diarrhea start suddenly?”

• “Did the diarrhea begin after a meal?” If yes, “What did you eat?”

• “Have you traveled recently?” If so, “To where?”

• “Are the stools watery? Bloody? Malodorous?”

• “Is the diarrhea associated with abdominal pain? Loss of appetite? Nausea? Vomiting?”

The acute onset of diarrhea after a meal suggests an acute infection or toxin. Watery stools are often associated with inflammatory processes of the small bowel and colon. Shigellosis is a disease of the colon that produces bloody diarrhea. Amebiasis is also associated with bloody diarrhea.

The patient with chronic diarrhea should be asked the following:

• “How long have you had diarrhea?”

• “Do you have periods of diarrhea alternating with constipation?”

• “Are the stools watery? Loose? Floating? Malodorous?”

• “Have you noticed blood in the stools? Mucus? Undigested food?”

• “What is the color of the stools?”

• “How many bowel movements do you have a day?”

• “Does the diarrhea occur after eating?”

• “What happens when you fast? Do you still have diarrhea?”

• “Is the diarrhea associated with abdominal pain? Abdominal distention? Nausea? Vomiting?”

• “Have you noticed that the diarrhea is worse at certain times of the day?”

• “How is your appetite?”

• “Has there been any change in your weight?”

• “Have you had any recent travel?” If so, “To where?”

Diarrhea and constipation frequently alternate in patients with colon cancer or diverticulitis. Loose bowel movements are common in diseases of the left colon, whereas watery movements are seen in severe inflammatory bowel disease and protein-losing enteropathies. Floating stools may result from malabsorption syndromes. Patients with ulcerative colitis commonly have stool mixed with blood and mucus. Any inflammatory process of the small bowel or colon can manifest with blood mixed with stool or undigested food. Irritable bowel syndrome usually leads to severe diarrhea in the morning.

Patients complaining of constipation should be asked these questions:

• “How long have you been constipated?”

• “How often do you have a bowel movement?”

• “What is the size of your stools?”

• “What is the color of your stools?”

• “Is the stool ever mixed with blood? Mucus?”

• “Have you noticed periods of constipation alternating with periods of diarrhea?”

• “Have you noticed a change in the caliber of the stool?”

• “Do you have much gas?”

• “How's your appetite?”

• “Has there been any change in your weight?”

Change in the caliber of the stool is significant. “Pencil”-diameter stools may result from an anal or a distal rectal carcinoma. A change in the color of stools is important. As discussed later, pale brown to gray stools indicate an absence of bile. This can result from an obstruction to bile flow from the gallbladder or from decreased production of bile. Weight changes are important with the symptom of constipation. An increase in weight may indicate decreased metabolism seen in hypothyroidism; a decrease in weight may be associated with cancer of the colon or other hypermetabolic conditions.

Black feces can also be caused by several medications, such as bismuth subsalicylate (the active ingredient in Pepto-Bismol® and Kaopectate®) and dietary iron supplements, or foods such as black licorice or blueberries. Bismuth subsalicylate–containing products are used to treat indigestion, heartburn, nausea, and diarrhea.

Rectal Bleeding

Rectal bleeding may be manifested by bright red blood, blood mixed with stool, or black, tarry stools. Bright red blood per rectum, ¹

1 Often abbreviated as BRBPR.

also known as hematochezia, can occur from colonic tumors, diverticular disease, or ulcerative colitis. Blood mixed with stool can be the result of ulcerative colitis, diverticular disease, tumors, or hemorrhoids. Ask the patient who describes rectal bleeding the following questions:

• “How long have you noticed bright red blood in your stools?”

• “Is the blood mixed with the stool?”

• “Are there streaks of blood on the surface of the stool?”

• “Have you noticed a change in your bowel habits?”

• “Have you noticed a persistent sensation in your rectum that you have to move your bowels, but you cannot?”

Tenesmus is the painful, continued, and ineffective straining at stool. It is caused by inflammation or a space-occupying lesion such as a tumor at the distal rectum or anus. Hemorrhoidal bleeding is a common cause of hematochezia and streaking of stool with blood.

Melena is a black, tarry stool that results from bleeding above the first section of the duodenum, with partial digestion of the hemoglobin. Inquire about the presence of melena. A useful way of questioning is to show the patient the black tubing on the stethoscope and ask, “Have your bowel movements ever been this color?” If asked directly whether the bowel movements have ever been black, the patient may answer in the affirmative, equating dark (normal) stools with black stools. Ask these questions of a patient who describes melena:

• “Have you passed more than one black, tarry stool?” If yes, “When?”

• “How long have you been having black, tarry stools?”

• “Have you noticed feeling lightheaded?”

• “Have you had any nausea associated with these stools? Any vomiting? Diarrhea? Abdominal pain? Sweating?”

The answers to these questions can provide some information regarding the acuteness and the amount of the hemorrhage. Lightheadedness, nausea, and diaphoresis are seen with rapid gastrointestinal bleeding and hypotension.

The presence of silver-colored stools is rare but pathognomonic of acholic stools with melena, a condition strongly suggestive of cancer of the ampulla of Vater in the duodenum. The cancer produces biliary obstruction (acholic stools), and the cancerous fronds are sloughed, causing bleeding (melanotic stools). This combination produces feces that are tarnished-silver or aluminum paint–like in color.

Jaundice

The presence of jaundice (icterus) must alert the examiner that there is either liver parenchymal disease or an obstruction to bile flow. The presence of icterus, or jaundice, results from a decreased excretion of conjugated bilirubin into the bile. This can result from intrahepatic biliary obstruction, known as medical jaundice, or from extrahepatic biliary obstruction, known as surgical jaundice. In any patient with icterus, the examiner should search for clues by asking the following questions:

• “How long have you noticed the jaundice?”

• “Did the jaundice develop rapidly?”

• “Is the jaundice associated with abdominal pain? Loss of appetite? Nausea? Vomiting? Distaste for cigarettes?”

• “Is the jaundice associated with chills? Fever? Itching? Weight loss?”

• “Have you ever had a blood transfusion? Tattooing? Inoculations?”

• “Have you ever been injured with a needle from a syringe or a scalpel blade?”

• “Do you use any recreational drugs?” If yes, “Do you use any drugs intravenously?”

• “Do you eat raw shellfish? Oysters?”

• “Have you traveled abroad in the past year?” If yes, “Where? Were you aware that you may have consumed unclean water?”

• “Have you been jaundiced before?”

• “Has your urine changed color since you noticed that you were jaundiced?”

• “What is the color of your stools?”

• “Do you have any friends or relations who are also jaundiced?”

• “What type of work do you do? What other types of work have you done?”

• “What are your hobbies?”

Viral hepatitis is associated with nausea, vomiting, a loss of appetite, and an aversion to smoking. Hepatitis A has a fecal-oral route of transmission and an incubation period of 2 to 6 weeks. It may be linked to ingestion of raw shellfish. Hepatitis B , or HBV, is blood-borne and has an incubation period of 1 to 6 months. Health professionals are at increased risk for hepatitis. Any contact with an individual with viral hepatitis places a person at a higher risk of contracting viral hepatitis. Hepatitis C , or HCV, is the most common chronic blood-borne infection in the United States. Baby boomers, individuals born between 1945 and 1965, are 5 times more likely than other age groups to be HCV infected. It has been suggested that 1 in 30 baby boomers is infected with HCV. According to the Centers for Disease Control and Prevention (CDC), many boomers were infected in the 1970s and 1980s when infection control standards were less stringent than what we have today. HCV was not discovered until 1989, and donated blood was not screened for the virus until 1992. It can take years, even decades, for symptoms of HCV to appear, so baby boomers may only be showing symptoms now.

The CDC has estimated that there are as many as 200,000 new HCV infections annually in the United States. It is estimated that as many as 3.9 million Americans have the antibody to HCV and are currently asymptomatic. They are, however, at risk for chronic liver disease, the tenth leading cause of death in the United States. Approximately 40% of chronic liver disease is HCV-related and results in 8000 to 10,000 deaths a year. End-stage liver disease secondary to HCV infection is the most common indication for liver transplantation. Once identified, a patient with chronic HCV infection is often curable with oral medications taken every day for two to six months. Several well-tolerated oral regimens are now approved to treat patients with various HCV genotypes, stages of liver disease, and comorbidities. ²

2 Kish T, Aziz A, Sorio M. Hepatitis C in a new era: a review of current therapies. P T . 42(5):316, 2017.

Slowly developing jaundice that is accompanied by pale stools and cola-colored urine is obstructive jaundice, either intrahepatic or extrahepatic. Jaundice accompanied by fever and chills is considered cholangitis until proved otherwise. Cholangitis may result from stasis of bile in the bile duct that results from a gallstone or from cancer of the head of the pancreas. Determine whether chemicals are used in a patient's occupation or hobbies because they may be related to the cause of the jaundice. Many industrial chemicals and drugs have been associated with liver disease. These agents may be responsible for a viral hepatitis-like illness, cholestasis, or for granulomas or hepatic tumors. Occupational exposure to carbon tetrachloride and vinyl chloride is well known to cause liver disease. Ask questions related to alcohol abuse. These are described in Chapter 1 , The Interviewer's Questions.

Abdominal Distention

Abdominal distention may be related to increased gas in the gastrointestinal tract or to the presence of ascites. Increased gas can result from malabsorption, irritable colon, or air swallowing (aerophagia) . Ascites can have a variety of causes, such as cirrhosis, congestive heart failure, portal hypertension, peritonitis, or neoplasia. To try to identify the cause of abdominal distention, ask these questions:

• “How long have you noticed your abdomen to be distended?”

• “Is the distention intermittent?”

• “Is the distention related to eating?”

• “Is the distention lessened by belching or by passing gas from below?”

• “Is the distention associated with vomiting? Loss of appetite? Weight loss? Change in your bowel habits? Shortness of breath?”

Gaseous distention related to eating is intermittent and is relieved by the passage of flatus or belching. A patient with ascites has the insidious development of increased abdominal girth, noted through a progressive increase in belt size. Loss of appetite is often associated with cirrhosis and malignancy, although end-stage congestive heart failure may produce this symptom as well. Shortness of breath and ascites may be symptoms of congestive heart failure, but the shortness of breath may be the result of a decrease in pulmonary capacity owing to ascites from another cause. Questions related to alcohol abuse are most appropriate and are outlined in Chapter 1 , The Interviewer's Questions.

Mass

An abdominal mass may be a neoplasm or a hernia. An abdominal hernia is a protrusion from the peritoneal cavity into which peritoneal contents are extruded. The contents may be omentum, intestine, or bladder wall. An abdominal hernia may be inguinal, femoral, umbilical, or internal, depending on its location. The most common complaint is swelling, which may or may not be painful. An inguinal hernia may manifest as a mass in the groin or scrotum. The major complications of a hernia are intestinal obstruction and intestinal strangulation from interference of blood supply. A hernia is termed reducible when it can be emptied of its contents by pressure or a change in posture.

The sign or symptom of a pulsatile abdominal mass should alert the examiner to the possibility of an aortic aneurysm.

Pruritus

Pruritus, or itching, is a common symptom. Generalized itching may be a symptom of a diffuse skin disorder ³

3 For example, dermatitis herpetiformis (a blistering disease predominantly on the buttocks, shoulders, elbows, and knees) or lichen planus.

or a manifestation of chronic renal or hepatic disease. In 50% of individuals with generalized pruritus, a systemic disease is the cause. Intense pruritus may be associated with lymphoma or Hodgkin disease, as well as with malignancies of the gastrointestinal tract. Thyroid dysfunction can also cause generalized pruritus. Medications such as opiates, hydroxychloroquine, aspirin, nonsteroidal antiinflammatory drugs, and those that are metabolized by the liver can cause generalized itching.

In older individuals, pruritus may also be caused by dry skin alone. Pruritus ani is localized itching of the anal skin. It has many causes, including fistulas, fissures, psoriasis, intestinal parasites, frequent liquid stools, anal perspiration, human immunodeficiency virus (HIV) infection, and diabetes. Pruritus ani may be caused by eating certain foods, smoking, and drinking alcoholic beverages, especially beer and wine. Some of the food items that have been associated with pruritus ani include coffee, tea, carbonated beverages, milk products, tomatoes and tomato products such as ketchup, cheeses, nuts, and chocolate. Cleanliness is almost never a factor.

Loss of Appetite

Loss of appetite or intolerance to certain or all foods is important to ascertain. Patients with hepatitis often note a lack of appetite, as well as a loss of interest in smoking if they had a smoking habit previously. Patients will commonly describe an unpleasant taste or fullness in their abdomen after eating only a light meal.

Inspection