Abdominal Pain

      An ALS ambulance responds to the report of abdominal pain. Upon arrival, the EMS crew finds a male in his mid-30s complaining of right lower quadrant discomfort. The patient, who is lying on his right side in a fetal position, says the pain started about two hours ago and he has never felt like this before.

   Physical assessment reveals that the patient is conscious and oriented, with a heart rate of 110, sinus tachycardia, respiratory rate of 32 and blood pressure 132/70. He is able to speak in complete sentences and denies any cardiac or respiratory complaints. The patient says he had experienced a cramping sensation around his umbilicus earlier and the discomfort has become more constant. The discomfort appears to be sharp and localized to the lower right side of his abdomen. A head-to-toe assessment reveals that the patient has a tender right lower abdominal quadrant. The remainder of the assessment is unremarkable. No masses or signs of trauma are noted. The patient has no significant medical history and denies the use of drugs or alcohol, as well as nausea, vomiting or diarrhea.

   Treatment is initiated with administration of supplemental oxygen and establishment of an intravenous line. During transport to the hospital, he remains on his right side with legs drawn in. He complains of lower right abdominal discomfort and is becoming nauseous. Vital signs are repeated as the crew arrives at the hospital.

   The patient is evaluated by emergency department staff and is admitted for further assessment and evaluation. Following additional consultation and physical assessment, the patient is diagnosed with appendicitis and surgery is scheduled for the next morning.

INTRODUCTION

   Because EMS agencies respond to requests for assistance due to abdominal pain, providers should have a basic understanding of abdominal anatomy, as well as the conditions that can result in abdominal pain or discomfort. The following provides a general overview of abdominal pathology.

ABDOMINAL LANDMARKS

   The abdomen is the largest cavity in the body. The abdominal wall is lined by the peritoneum, within which a majority of the abdominal organs are contained. Some organs, such as the kidneys, are retroperitoneal--located behind the peritoneum. The diaphragm separates the abdomen from the thorax. The abdominal wall is the anterior border, with the spine and back forming the posterior border. The lateral walls, or the sides, are the flank area which contains the kidneys. The epigastrium is the mid-upper abdominal area located just below the xiphoid process.^1,2

   To assist with abdominal organ location and landmarks, the abdominal region can be divided into quadrants by visualizing a median plane and a transverse plane that pass through the umbilicus at right angles and divide the abdomen into four quadrants: right upper quadrant (RUQ), right lower quadrant (RLQ), left lower quadrant (LLQ) and left upper quadrant (LUQ). Tables I and II provide an overview of the organs located within each quadrant. Figure 1 provides an example of the quadrants.¹

   Abdominal pain is a common complaint, accounting for up to 10% of emergency department visits. Abdominal pain can be associated with a variety of symptoms, including nausea, vomiting, fever, diarrhea, dark stools (melena) and urinary symptoms. A good history taken on a patient with abdominal pain should include the location, onset (sudden or gradual), intensity, quality (dull, sharp or cramping), progression and character (intermittent or constant) of the pain, as well as any associated symptoms. Aggravating or alleviating factors and previous episodes of similar pain should be considered. Past medical and surgical history, current medications and social history can be particularly helpful in patients presenting with abdominal pain. Populations that are particularly concerning when they present with abdominal pain include immunocompromised patients, the elderly and women of childbearing age, as these patients may be more likely to present with subtle findings on exam despite potentially devastating disease.