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