When you want, or need, to know more than the superficial, such as when you are
where there is no access to a physician.
Prototypically: Medicine at Sea
This medical information is provided for education purposes only. I am making no attempt to practice medicine over the internet. This is being written to give some basic knowledge for those that are physically isolated from access to professional medical care, such as sailors at sea. This is to help in deciding whether an emergent medical condition exists, how to initially deal with it, and whether evacuation is needed. It is by no means exhaustive or meant to replace personal medical attention. Please do not contact me regarding your personal condition. Over the years I have received many emails from people asking for help with their personal chest pain, or whatever. Sometimes they write during acute pain. This is ridiculous. You can't practice medicine over the internet. If I find their email, after it has been filtered by my spam filter, it may be days or weeks later. My response, if any, will be to contact their regular provider. Even a bad doctor in person is better than an email. Please use this information in the spirit in which it is intended.
Sincerely, Mark R. Anderson, M.D.
my other interests
The approach to
Acute Abdominal Pain and Symptoms
for the lay person without medical training,
where there is no physician
Like I've said elsewhere, this is not to substitute for professional medical advice and evaluation. This is intended to provide some guidance when you absolutely can't get that medical advice. The prototypical situation is if you're in isolation, such as the wilderness or the middle of the ocean on a cruising sailboat. (Well, I suppose powerboaters can use the information also ;-))
As in all of medicine, you start with the story of the symptoms to determine the pattern and progression. This may be simple or complicated, but should not be skipped. Then you proceed with the examination. Please see my Physical Exam page for a more complete physical exam.
I've tried to note the key points of each diagnosis. Unfortunately there is a lot of overlap and abdominal pain evaluation is one of the trickiest aspects of medical practice. This information is only intended for acute symptoms. Chronic symptoms are a whole other kettle of fish and should be evaluated when you reach medical expertise. I'm providing a chart of symptoms and then more details below.
Use of Abdominal Disorders Chart:
Dx: Diagnosis. The more common diagnoses are underlined in the more detailed bottom section.
Pain characteristics: Based on the patient’s story.
Amt.?: Amount, severity of pain. Rated on 1 to 4+ scale. I.e. mild to excrutiating.
Where?: i.e. where is it felt.
Gen’l: Generalized, throughout the abdomen and/or poorly localized.
Quadrants: Divide the abdomen into 4 quadrants by vertical and horizontal lines through the belly button.
RUQ: Right upper quadrant LUQ: Left upper RLQ: Right lower LLQ: Left lower
Mid: central, and possibly poorly localized
Flank: On the side of the abdomen
Epigastric: (Epig.) Mid upper abdomen, under where the ribs come together
CVA: CostoVertebral Angle: In the back on one side below where the ribs join the spine
How?: How does it feel? Type of pain.
Steady: unchanging with time
Crampy: waxes and wanes with periodic intense increases.
Burning, sharp, ache: as it sounds. By "sharp" I mean in quality. It is not the same as intense.
When?: When does it occur and how did it start, i.e. sudden or gradual. Is it affected by movement or breathing? Is it related to eating or something else?
+ : Means this characteristic should generally be present for that diagnosis.
++ or +++: More important or more prominent. Same as 2+ or 3+ etc.
+/- : The characteristic may or may not be present. If present, it’s generally not prominent. It’s not a major decision maker.
- : The characteristic is generally absent, or minor.
This must be distinguished from the pain itself. I.e. tenderness is pain caused by pushing at that area. You can have severe pain without tenderness and tenderness without otherwise having pain. Watching the facial expression and bodily reaction of the patient during the exam as a more convincing indication of tenderness than what the patient says. A reaction that disappears if the patient is distracted or deceived shows the absence of true tenderness. (E.g. feeling the abdomen with the stethoscope.)
SLR (Straight leg raise). If the tenderness is the same or increases (inc'd) when the patient tenses the abdominal wall, such as by doing a SLR, then the problem is in the abdominal wall (superficial injury or strain, though it could be a hernia). If it decreases (dec'd) then the problem is internal.
If the patient is ticklish, then sandwich their hand between your hands. You can't tickle yourself and this will remove the ticklishness.
Guarding is a tightening of the abdomen when the examiner touches or pushes on a sore area. Voluntary guarding can be stopped by the patient and may be nothing more than anxiety that the exam will hurt. Otherwise, guarding, like facial wincing indicates tenderness. Involuntary guarding can’t be stopped by the patient. It is a convincing indication of true tenderness and probably inflammation. Involuntary guarding is more serious. Rigidity of the abdomen, either locally or generally is the ultimate in involuntary guarding and usually means peritonitis (see). Rigidity means the abdominal is tight even if not touched, but you determine it by lightly touching the abdomen.
Rebound pain is pain that momentarily increases when pressure on the abdomen is suddenly released. (Differentiate this from a simple startle reaction.) Consistent rebound tenderness is a sign of peritonitis. The same information can be gained several ways. Light tapping of the abdomen. Gentle shaking of the abdomen by shaking the hips, or a thump on the sole, or jostling the bed. When any movement, e.g. walking, or standing on tip toes and dropping down onto the heels, is clearly more painful than not moving, think peritonitis.
B.S. Bowel Sounds.
Your stomach always rumbles. True absence of bowel sounds is a severe problem. Listen w/ ear or stethoscope to abdomen. Usually you'll hear some in a few seconds. Don’t consider them absent unless there are no sounds for three minutes.
T° Temperature. Fever. Don’t consider it a fever unless over 100.5° F.
D Diarrhea. A couple loose stools a day is not diarrhea. I mean at least 4 loose, non-formed or watery stools per day.
Surgery: That’s obvious
Antibx: Antibiotics. Recommendations may be made in the detailed section.
BRAT: A diet of Bananas, Rice, Applesauce and Toast. Good for absorbing the excess fluid of diarrhea.
Clear liquids: Self explanatory. Doesn’t include milk or citrus products. Carbonated products should be allowed to go flat.
H2B (Histamine 2 blockers): Medicines that reduce the secretion of acid by the stomach, by blocking the Histamine type 2 receptors. These include cimetidine (Tagamet), famotidine (Pepcid), and ranitidine (Zantac). To get the full prescription benefit from the over the counter strengths, 2-4 pills per day may need to be taken. Since these reduce the production of acid, and do nothing to acid that is already formed, they don’t have any immediate effect, but rather take at least a couple hours. PPIs (proton pump inhibitors) e.g. omeprazole (Prilosec) are even better for continued use. They are not as fast acting, but they last longer.
Antacids: Neutralize the acid that’s already made. I prefer the liquid antacids. Maalox, Mylanta, or whatever the patient prefers. Baking soda is absorbed and shouldn’t be taken frequently.
General statements on abdominal pain:
Tentative diagnoses are a best guess based on the pattern of the illness and pain and the physical exam. The history of the illness is most important. Age, sex, exposures, family history. Time pattern of symptoms. Symptom progression and changes, plus as detailed description as can be obtained. Some people simply can’t describe their symptoms very well. The clever diagnostician rephrases the questions in several ways and reads between the lines to look for clues. The physical exam generally is used to narrow down the diagnostic choices that seemed most likely after the history is taken. Occasionally important findings point in unexpected directions.
The examiner should have warm hands and start feeling the abdomen away from the area of pain. Feel the painful area last. First feel gently for soft or tense abdomen. Then progressively deeper. Having the patient bend hips and knees with the feet on the bed helps to relax the abdomen. Sometimes you only get relaxation when the patient takes a breath. If ticklishness is a problem, the patient should put their hand on top of the examiner’s hand.
Intestinal pain tends to be very poorly localized. The intestines feel pain of stretching (e.g. cramping colicky pain of gastroenteritis and obstructions) and pain of inflamation (e.g. appendicitis, diverticulitis. It becomes more localized as inflammation develops.
Appendicitis starts as a vague mid abdominal pain and later becomes more localized and more tender in the RLQ, though variability in the size and position of the appendix can make the pain quite variable and confusing. Somebody with appendicitis doesn’t want to move or be moved.
Pneumonia in the base of a lung, by the diaphragm, can be felt as an abdominal pain. Heart pain can also be felt in the epigastrium.
Irritation of the diaphragm can cause a pain in the shoulder of the same side. T his can occur with liver or gall bladder problems, spleen problems, abdominal trauma with internal bleeding, and pneumonia.
Kidney stone patients often can’t hold still!
Digested blood is black. Therefore stomach bleeding shows up as black stools, (unless very rapid). A rapid stomach bleeding is dark, even blackish, burgundy colored and smells incredibly bad! Dark red rectal bleeding is from the colon. Brighter red if it’s from near the anus. Blood from near the anus is on the stool or toilet paper. Blood from higher up is mixed into the stool. Similarly vomited blood is usually black (like coffee grounds) unless enough to make dark red clots. Bright red vomited blood is likely from esophagus, throat or lungs.
ACUTE ABDOMINAL DISORDERS
More common diagnoses underlined.
Aortic Aneurysm: Ruptured
Generally elderly and usually with a known history of hypertension and/or other vascular disease, e.g. angina, heart attack, stroke. Usually sudden severe gen'l abdominal pain that often goes into the back. May go to groin, or up into chest. May collapse and go into immediate shock. May lose pulses in legs. Nearly 100% fatal if there isn’t immediate surgery. May expand or leak w/o rupture and have less dramatic Sx. May feel pulsatile mass in abdomen. May or may not know of pre-existing aneurysm that "they're watching".
Symptoms tend to be poorly localized, at least at first. Then more localized w/ inflammatory problems, e.g. appendicitis, diverticulitis. Often there’s a change of stool.
Great masquerader! > 90 % lose appetite early. Not sudden. Develops over 12-48 hrs. Typically starts vaguely around navel. Tenderness in RLQ and pain shifting there develops later. Hurts to move! If they're hungry and/or can jump up and down without pain, they rarely have it. May have up to 3 days before it ruptures causing generalized peritonitis. May temporize with antibiotics, but SURGERY is needed!
Bloating and pain over hours to days. Waves of crampy pain every 5-30 minutes. Not much pain in between in early stages. Passing no stool or farts. Abdomen may be distended and tense, but not very tender. Vomiting becomes prominent and progresses to feculent. (gastric contents, -> yellow -> green -> brown and smells like feces)
Causes: hernias, scars from previous surgery, cancer.
Tx: Bowel rest, IV fluids, often surgery. Could progress to ruptured bowel causinggeneral peritonitis (see below) and life threatening infection.
Stool variable. Often w/ blood or mucus. Diarrhea may alternate with constipation. Acute or chronic.
Types: Ulcerative, Crohn’s, Spastic, Infectious. (Only the last requires antibiotics (Cipro and/or flagyl often good) and is usually more acute, i.e. a few days.)
Pain due to poor blood supply to intestines. Rare. Pain may occur periodically after eating. Pain tends to be extreme and out of proportion to the minimal physical findings. Usually in the elderly w/ known vascular disease (e.g. angina, high blood pressure, or diabetes).
Diverticulitis. (infection of diverticuli pouches on colon that develop w/ age)
Steady pain and tenderness usually LLQ developing over days. Possibly w/ bloody stool. Generally over 50 yrs. old. If rebound, then it's likely ruptured and needs hospitalization and usually surgery.
Antibiotics: Ciprofloxin and Metronidazole twice a day for 10 days.
Gastroenteritis (“stomach flu”)
Viral or bacterial. Bloody stools (Dysentery) and lots of cramps may mean need for antibx.
Parasites: May be acute dysentery, or chronic mild symptoms. Needs special antibx.
Diabetic KetoAcidosis (DKA):
Vomiting and pain in the diabetic on insulin may mean DKA. Blood sugar of several hundred, dehydration and increased breathing. Fruity odor to breath.
Tx: IV fluids, insulin, critical monitoring. Could be fatal.
Hernias: Bulge through weakness in abdominal wall, usually the groin.
Sliding: Acute hernias that slide in and out may be tender and painful. Chronic ones don’t hurt until there’s a problem.
Incarcerated: Can’t be slid back in. Little tenderness. Use ice and steady pressure to reduce. Urgent surgery if not reducible.
Strangulated: Ist incarcerated. Then strangulated as blood supply is cut off. Becomes more tender, and perhaps discolored. Emergent surgery.
HEPATOBILIARY PROBLEMS: (LIVER and GALL BLADDER)
Biliary colic (Gall bladder cramp) due to a stone blocking gall bladder contraction after a meal.
Often after a fatty or spicy meal. Esp. common if over 35, overweight, gassy, and more common in women.
Mild. to severe pain Epig/RUQ->back Min.-Hrs. No fever. Little tenderness. Treat w/ Analgesia and antiemetics.
Cholecystitis (Gall bladder infection)
Fairly severe pain RUQ->back Steady Hrs.-days Antibx -> surgery
May or may not have prior biliary colic. More tender than biliary colic. Murphy’s sign: pain and sudden stopping inspiration while pressing up under ribs. Can be chronic.
Mild to moderate RUQ pain. Dull/steady lasting days to weeks Tender with RUQ light thump of a fist onto the other hand laid over the liver. Liver edge tender.
Treatment: Low protein. Time
May be mild. Likely dark urine (like tea) May have jaundice (yellow eyeballs and skin). May have vomiting and diarrhea. Occasionally severe.
Hepatitis A: Onset 2-6 wks after exposure to contaminated food or water. Preventable w/ vaccine.
Hepatitis B: Onset up to 6 mos. after exposure to body fluids (sex, blood, dirty needles). Preventable w/ vaccine.
Mod. to severe pain. Epig->through to mid back Developing over hours and persisting.
Most likely due to gall stones or alcoholism. Tx: Analgesia, No alcohol, Clear liq.
PEPTIC DISEASES: (Ulcers, gastritis, acid reflux)
More than just temporary indigestion/dyspepsia, this is mild to moderate epigastric recurring steady burning/gnawing pain that may be briefly relieved by bland foods or antacids, but then aggravates again.
Ulcer pain often very localized. (Point w/ one finger.) Acid reflux (GERD) is felt behind breast bone.
Black vomit or stools indicates bleeding which may be minor or serious. Rapid pulse &/or dizzy is serious.
Rarely leads to perforation. (Usual pain is followed by generalized severe abdominal pain and peritonitis, possibly shock) Surgical emergency.
Tx: H2 blockers, PPIs, antacids for a couple months. Avoid caffeine, tobacco, anti-inflammatories (ibuprofen, aspirin, naproxen, etc.) and alcohol. Avoid aggravating foods. Special tests may show need for antibiotics to treate H. pylori infection.
Severe steady pain and tenderness that may be localized or gen’l Sooner or later abdomen becomes boardlike rigid! Any movement hurts.
Treatment depends on cause. Antibiotics may temporize but usually surgery is needed post haste.
Always an emergency, regardless of cause. Prior course may indicate cause and treatment. You need help!!!
UROLOGICAL PROBLEMS: (kidney, ureter, bladder)
Kidney stone (ureterolithiasis)
As long as a stone remains in the kidney it generally causes no symptoms unless it gets infected. It causes severe pain (renal colic) when it starts to move down the ureter to the bladder. It may get stuck along the way, get unstuck, move on and get stuck again. Once it's in the bladder you're home free.
Severe pain Goes from Flank->groin Steady or cramp Usually sudden onset. Writhing in pain w/ no position of comfort.. May be sweating and vomiting.
Tx: Analgesia, FLUIDS Anti-inflammatories (especially ketoralac) may help. Calcium channel blockers (a type of high blood pressure pill) may help to pass the stone. Most small stones pass within a couple days. Intervention may be needed if it doesn't.
If a fever develops, (i.e. kidney infection in a stone blocked kidney) it becomes very serious, even life threatening. Start antibx and evacuate.
Urinary Tract Infections (UTI)
Common in women. Uncommon in men unless older w/ prostate problems. (Sexually transmitted urethritis often has a drip.)
Bladder infection (cystitis)
Burning on urination, frequency and urgency of urination. No fever or kidney (CVA) tenderness.
Tx: Antibiotics to cure. (ciprofloxin, TMP/SMX, macrodantin, cephalexine) Azopyridine for symptoms but don't it for more than 2 d. because it hides the infection and you want to know if the antibx are working.
Mod. to severe dull ache pain in the back or flank. Usually on 1 side. Tender w/ a thump at the CVA.
Tx: Antibiotics, azopyridine, and pain pills. Needs longer antibx, e.g. 10 days. Sometimes IV antibx, if lots of vomiting or very sick.
BLUNT ABDOMINAL TRAUMA: (Penetrating trauma essentially always needs surgery.)
Mild to moderate pain at the area of impact. Patient is stable or improving
Tx: Ice, wait, observe for signs of more serious injury
Pain becomes more severe with time (over minutes to hours) and may be local to the injury or generalized. Worsening pain and tenderness w/ time. If becoming unstable, time is of the essence.
LUQ = Spleen injury/bleeding, RUQ = Liver injury/bleeding. Gen’l = loose bleeding. Lightheaded & rapid pulse (>120) is bad.
Frequent reevaluations to decide need for evac. EARLY DECISION saves lives.
OBSTETRICAL and GYNECOLOGICAL (Female) Problems: OB/GYN
Pelvic Inflamatory Disease (PID)
Moderate to severe steady pain developing over a day or more in mid lower abd. and both lower quadrants. May have fever.
Usually venereal. Painful sex. Often starts about 1 week after period. Periods are normal. Vaginal discharge may or may not be obvious.
If rebound develops or high fever, hospitalization usually needed.
Tx: Azithromycin or doxycycline plus metronidazole.
More minor vaginal discharge:
Itchy? Think yeast and treat w/ OTC yeast tx, e.g. clotrimazole
Smells fishy? Think bacterial vaginosis and treat w/ metronidazole.
Generally a low background pain in one lower quadrant, that can become acute if it ruptures. Rarely dangerous. Background pain may last a month or more. Acute pain usually subsides in a day or two.
Ovarian Torsion (twisted ovary, shutting off it's blood supply)
Sudden excrutiating pain in one lower quadrant. Pain far exceeds the amount of tenderness or other physical findings.
Quite uncommon to rare. Time is of the essence to save the ovary with surgery.
Moderate Mid-low crampy pain in early pregnancy followed by vaginal bleeding and possibly passing 'tissue'. Preceeding period missed or abnormal.
Tx: Fluids, no aspirin.
Usually passes naturally. Sustained heavy bleeding, ( more than 1 pad/hr.) indicates possible need for intervention (D&C).
Ectopic pregnancy: (Tubal pregnancy)
R or LLQ Steady pain w/ variable amount of vaginal bleeding. Last period missed or abnormal.
Treatment is usually Surgery, however some may be treated with medication if ultrasound finds it small. Anyway, medical intervention is needed.
LIFETHREATENING. May be SUBTLE. Likely to be more tender & more one sided than miscarriage which is the other usual consideration. Ectopic is more likely if low blood pressure and rapid pulse or lightheaded while standing.
Bladder obstruction: Urinary retention. Rarely in women.
Inability to urinate enough to empty bladder with steady gradual full bladder type pain.
Catheter to drain. Treat infection if present.
Older men, usually w/ large prostates. Acute onset may be triggered by infection or meds (e.g. nausea or allergy meds)
Epididymitis: (Infection of tubes on and from testes.)
Moderate to severe scrotal pain developing over a few days. Tender 'cords' down to testes. May get quite sick, high fever. May be scrotal swelling.
Tx: Antibiotics, (ciprofloxin) elevate scrotum, warm baths.
May have painful urination. May have high fever. Usually sexually transmitted if < 35 y.o., not veneral if > 50.
More gradual onset usually distinguishes this from testicular torsion.
Like urine infection (UTI) plus a penile discharge. Usually venereal (gonorrhea or chlamydia) if young, not if old. Profuse
discharge usually means gonorrhea. Intestinal bacteria in older men.
Tx: young (azithromycin or doxycycline, amoxicillin) old (ciprofloxin)
Testicular Torsion: (i.e. twisted testicle)
Sudden moderate to severe pain in one testes. Tender. Pain is sometimes reduced by elevating testes or gently twisting in one direction, but not the other. May be dramatic testes or scrotal swelling. Generally 2-30 yrs. old. May have had intermittent lesser episodes of pain before.
Surgery! Testicular death if not treated w/in sev’l hrs.. Always consider if rapid development of severe testes pain.