William E. "Gene" Gandy
Assessing the abdomen, with its many organs performing multiple functions, is one of the most challenging tasks for EMS providers. While a comprehensive abdominal examination is impossible in the prehospital arena, applying a few simple assessment guidelines will enable providers to recognize an acute abdominal emergency. This article will provide those guidelines, and focuses on medical causes.
Judy, a healthy 71-year-old female, experiences a mild, persistent periumbilical pain an hour after eating a light dinner. She remarks to her husband that she thinks she has gas and disappears into the bathroom, where she becomes nauseated and vomits. She says she feels better and goes to bed.
The next morning she has no appetite and complains of a vague ill feeling, but tells her husband the pain has passed. The day passes routinely until late in the afternoon, when Judy declares she has a persistent and sharp pain in her lower abdomen that just won't go away. She curls up on the sofa in a fetal position. After an hour of unsuccessful attempts to comfort her, her husband decides to drive her to the hospital. As he tries to get her up to walk to the car, she collapses in pain and says she can't bear to walk. He calls 9-1-1 even though she says she doesn't think she needs an ambulance.
Major Systems in the Abdomen
The major systems in the abdomen are the alimentary system, hepatobiliary and pancreatic systems, spleen and lymphatics, and kidneys, ureters and bladder. The abdomen contains both solid and hollow organs. The solid organs are the liver, spleen, kidneys, adrenals, pancreas, ovaries and uterus. The hollow organs are the stomach, small intestines, colon, gallbladder, bile ducts, fallopian tubes, ureters and urinary bladder.
There are two different methods of dividing the abdomen topographically, one using nine regions, and one using four quadrants. Most clinicians use the four-quadrant system. In this system the right upper quadrant (RUQ) contains the liver, gallbladder, part of the pancreas, duodenum, part of the transverse colon, and the right kidney and part of its ureter. The right lower quadrant (RLQ) contains the ascending colon, appendix, part of the right ureter, ovary and fallopian tube, and right spermatic cord. The left upper quadrant (LUQ) contains part of the pancreas, spleen, part of the transverse colon, left lobe of the liver, stomach, and left kidney and part of its ureter, and part of the urinary bladder. The left lower quadrant (LLQ) contains the sigmoid and descending colon, ovary and fallopian tube, part of the left ureter and part of the urinary bladder, and left spermatic cord. The midline contains the aorta and ascending vena cava, the uterus if enlarged, and the urinary bladder if distended.1
The Acute Abdomen
An acute abdomen is an abnormal condition of the abdomen in which there's a sudden onset of severe pain. It requires immediate evaluation and diagnosis, as it may indicate a need for immediate surgical intervention.2
Abdominal pain may be divided into three categories:
• Visceral pain, caused by stretching of unmyelinated fibers in the walls of organs, can either be steady or intermittent. Patients often are unable to lie still.
Because intraperitoneal organs are bilaterally innervated, stimuli are sent to both sides of the spinal cord, often resulting in a vague, ill-defined ache. For example, stimuli from visceral fibers in the appendix enter the spinal cord at about T10, resulting in midline periumbilical pain.3
• Parietal pain, caused by irritation of myelinated fibers that innervate the parietal peritoneum covering the anterior abdominal wall, is sent from a specific area of the peritoneum. Visceral pain usually gives way to the localized point tenderness as peritonitis progresses.4
• Referred pain is felt at a distance from the affected organ, but usually on the same side. Referred pain is felt in the midline only if the site of the pain is in the midline.5
History and Physical Examination
History is as important as physical examination. Follow the usual OPQRST and SAMPLE formats, but consider some additional questions specific to the abdomen.6 These should not be your first questions, but should follow your open-ended questions. Get the patient's version before you ask specific questions. Not all these questions may be appropriate for every patient. These are meant as reminders. Use your medical judgment when asking history questions.
Past abdominal history: Have you ever had any abdominal problems like ulcers, gallbladder disease, hepatitis or jaundice, appendicitis, colitis, diverticulitis, hernias, kidney disease or stones, or operations on your abdomen?
Patients will often forget or not include a previous illness if asked simply about "abdominal problems." Specific questions yield specific answers. For females, ask about pregnancies, menstrual problems such as pain during menses (Mittelschmerz) as age-appropriate, endometriosis, ovarian cysts and pelvic inflammatory disease. For males, ask about prostate problems, hernias and testicular pain.
Present abdominal history: When did you have your last bowel movement before the pain started? Was it firm or loose? What color were the feces? Any blood in them? Have the color or consistency of your bowel movements changed since the pain started? Do you use laxatives? If so, what kind and how often? Have you vomited? If so, when and how many times? What did the vomit look like? Do you use alcohol? How much would you estimate you drink every day? Do you smoke? If so, how long have you been smoking and how many cigarettes a day do you smoke? Do you use snuff or chewing tobacco? Have you taken anything for this? Did it make a difference?
The physical exam should be short in the field. Remove all clothing over the abdomen. Have the person lying supine if possible. Having the knees drawn up will help to relax the abdominal muscles. If in the ambulance, be sure it is warm and that the patient is not cold.
Inspect the abdomen. Stand or sit to the side and look across the abdomen. Determine if there are signs of distention, surgical scars, asymmetry, skin discoloring such as rash, striae (stretch marks that can occur with sudden distention or ascites), Cullen's sign,7 Grey-Turner's sign,8 or any pulsation or movement. Distention may indicate bleeding into the peritoneal cavity or ascites.
Note the position of the patient. Is the patient still or constantly moving and turning? Restlessness and constant turning indicate attempts to find a comfortable position. Absence of movement, with knees flexed and resisting any movement, indicates peritonitis. Observe the patient's face for grimace. Shallow respirations indicate an attempt to limit pain through limitation of diaphragmatic movement.9
Palpate the abdomen. Begin gently. Explain what you are doing. First palpate the entire abdomen lightly, searching for rigidity and signs of pain. Start in the quadrant farthest from the area of pain. With four fingers close together, depress the skin about 1 cm, and move clockwise to the next area. If the patient is ticklish, place the patient's own hand under your own. Patients are not ticklish to themselves. Feel for any masses or muscle guarding.10,11 Then proceed to deep palpation. Use the same technique but push down about 2 to 3 inches. There is no need to palpate deeply for rebound tenderness in the field.
Due to the high noise levels often encountered in the field, percussion and auscultation are unlikely to produce any meaningful results.
Specific signs for appendicitis:
• McBurney's sign: Tenderness located two-thirds of the distance from the anterior iliac spine on the right side to the umbilicus.
• Psoas sign: Hyperextension of the right hip or flexion against force causes abdominal pain.
• Obturator sign: Internal rotation of flexed right hip causes RLQ pain.
• Rovsing's sign: Right lower quadrant pain with palpation of the left lower quadrant (rebound tenderness).12
• Dunphy's sign: Sharp pain in the RLQ elicited by a voluntary cough.
• Markle sign: Pain elicited when the standing patient drops from standing on toes to the heels with a jarring landing. An alternative for the supine patient is tapping on the patient's heel of the extended leg with your fist. Pain in the RLQ indicates appendicitis.
It is neither necessary nor desirable to perform all of these tests. They are included solely for information. They can be very useful, however, in identifying appendicitis and peritonitis. Positive results indicate an acute abdomen that may need urgent surgical intervention.
Ask yourself: Is this patient critically ill? Does she have a group of symptoms that fit a known disease pattern? Does she have risk factors that might make a diagnosis difficult, such as age, drug use or pain medications?13
EMTs arrive and quickly assess Judy, finding that her history is highly suggestive of appendicitis. They find RLQ tenderness and a positive Markle sign when tapping on her right heel. They quickly transport to a Level III facility nearby, where she undergoes successful surgery for appendicitis and makes a full and uncomplicated recovery.
Author's notes: Appendicitis in the elderly has a 20% mortality rate due to diagnostic and surgical delay, as opposed to 0.2% to 0.8% in the overall population.14
The signs listed above are by no means the only signs pertinent to abdominal pain. Rather, these were included to point to the specific problem in the scenario. A thorough abdominal examination includes many items not discussed here that would be done in a clinic or hospital setting and are far beyond the scope of this article. Consult standard paramedic, nursing and medical texts for more details on the complete abdominal examination.
1. Anatomy texts describe the kidneys as being retroperitoneal, or separated from the anterior abdominal cavity by connective tissue.
2. Taber's Cyclopedic Medical Dictionary, 18th ed. Philadelphia: F.A. Davis Co., 1997.
3. Tintinalli JE, et al. Tintinalli's Emergency Medicine, 7th ed. New York: McGraw-Hill, 2010.
6. Jarvis C. Physical Examination and Health Assessment, 3rd ed. Philadelphia: W.B. Saunders Co.
7. White MJ, Counselman FL. Troubleshooting Acute Abdominal Pain, www.emedmag.com/html/pre/cov/covers/011502.asp.
9. Op. cit., Jarvis.
11. LeBlond RF, Brown DD, DeGowin RL. DeGowin's Diagnostic Examination, 9th ed. New York: Mc-Graw-Hill, 2008.
12. Op. cit., White.
13. Op. cit., Tintinalli.
14. Craig S. Appendicitis, Acute, http://emedicine.medscape.com/article/773895-overview.
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He has testified in court as an expert witness in a number of cases involving EMS providers and lectures on medical/legal aspects of EMS. He lives in Tucson, AZ.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the Louisiana Association of Nationally Registered EMTs. He is a frequent EMS conference speaker and the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.