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Causes of Abdominal Cancer

Contents

Abdominal Cancer Causes: Book Excerpts

Abdominal Cancer: Related Medical Conditions

To research the causes of Abdominal Cancer, consider researching the causes of these these diseases that may be similar, or associated with Abdominal Cancer:

Abdominal Cancer: Causes and Types

Causes of Types of Abdominal Cancer: Review the cause informationfor the various types of Abdominal Cancer:

Related information on causes of Abdominal Cancer:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Abdominal Cancer may be found in:

Hidden causes of Abdominal Cancer

Causes of Abdominal Cancer: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Abdominal Cancer.

Abdominal Pain in Lower Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Right lower quadrant

Appendicitis
Diverticulitis
Salpingitis/Pelvic inflammatory disease
Endometritis
Endometriosis
Ectopic pregnancy
Hemorrhage or rupture of ovarian cyst
Renal calculus
Intussusception
Pelvic/hypogastric region
Cystitis
Salpingitis/Pelvic inflammatory disease
Ectopic pregnancy
Diverticulitis
Strangulated hernia
Endometriosis
Appendicitis
Ovarian cyst
Ovarian torsion
Testicular torsion
Bladder distension
Nephrolithiasis
Prostatitis
Malignancy
Abdominal aortic aneurysm
Left lower quadrant
Diverticulitis
Intestinal obstruction
Colitis
Strangulated hernia
Inflammatory bowel disease
Gastroenteritis
Pyelonephritis
Nephrolithiasis
Mesenteric lymphadenitis or thrombosis
Aortic aneurysm
Volvulus
Salpingitis/Pelvic inflammatory disease

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Abdominal Pain in Upper Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Right upper quadrant pain

Cholecystitis
Fatty liver or NASH
Congested liver (e.g., secondary to heart failure)
Cholangitis
Hepatitis
Gastritis or pancreatitis (see below)
Pneumonia
Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis secondary to pelvic inflammatory disease)

Epigastric pain

Gastritis
PUD
Pancreatitis
Gastroenteritis
Intestinal obstruction
Myocardial infarction
Aortic aneurysm
Left upper quadrant pain
Peptic ulcer disease
Gastritis
GERD
Splenic infarct
Pulmonary embolism
Pancreatitis
Acute splenomegaly (e.g., mononucleosis)
Left lower lobe pneumonia
Nonfocal pain
Herpes
Sickle cell crisis
Irritable bowel
Mesenteric ischemia
Peritonitis
Pleurisy
Uremia
Lead poisoning
Porphyria
Toxin ingestion

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Abdominal Pain with Rebound Tenderness: Differential Diagnosis
(In a Page: Signs and Symptoms)

Appendicitis is the most common etiology
Cholecystitis
Diverticulitis
Gastroenteritis
Pancreatitis
Perforated duodenal ulcer
Gastritis
Biliary or renal colic
Mesenteric ischemia
Ruptured abdominal aortic aneurysm
Bowel obstruction
Bacterial peritonitis
Intra-abdominal or pelvic abscess
Colitis
Urinary tract infection or pyelonephritis
Perforated viscus
Sickle cell crisis
Gynecologic etiologies
–Pelvic inflammatory disease
–Tubo-ovarian abscess
–Ruptured ectopic pregnancy
–Ovarian cyst rupture or torsion
Intussusception
Nonabdominal causes of pain that mimic an acute abdomen are numerous and may include myocardial infarction, atypical angina, pericarditis, pneumonia, pulmonary embolus, and pelvic pathology (e.g., pelvic inflammatory disease, ovarian torsion)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Abdominal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

Constipation/inability to pass stool
–Most commonly due to dehydration and/or low dietary fiber intake
–Hirschsprung's disease (congenital aganglionic megacolon)
–Medications: Narcotics, opiates, or anticholinergic medications
–Ogilvie's syndrome (colonic pseudo-obstruction)

Ascites
–May be due to malignancy, nephrotic syndrome, liver disease, or congestive heart failure

Large or small bowel obstruction

Soft tissue mass
–Tumor (e.g., ovarian, uterine, bowel, liver)
–Uterine fibroids
–Lipoma: Soft, fleshy, mobile, and contained in the subcutaneous tissue of the abdominal wall
–Hernia: Bowel sounds may be audible over the mass; incarceration causes pain; strangulation leads to bowel death
–Pyloric stenosis: Seen primarily in infants; palpable pyloric olive-shaped mass
–Pregnancy
–Massive lymphadenopathy (e.g., lymphoma)
–Organomegaly (e.g., hepatomegaly, splenomegaly)
–Infection: Intra-abdominal or tubo-ovarian abscess
–Abdominal aortic aneurysm: Associated with pulsatile mass and hypotension

Cyst
–Mesenteric cysts: Fluid collections in the mesentery; typically benign
–Hydatid cyst: Caused by larval form of Echinococcus granulosus; typically found in the liver in patients with history of travel to tropical areas
–Dermoid cyst: May be massive due to delayed presentation
Palpable gallbladder (Courvoisier's sign): Associated with common bile duct obstruction and a distended gallbladder

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Abdominal Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Epigastric pain

Peptic ulcer disease/GERD
–May be due to Helicobacter pylori or NSAID use

Gallbladder disease
–Most commonly with hemolytic disorders

Pancreatitis
–Trauma and idiopathic are common causes

Periumbilical pain

Functional abdominal pain/IBS
–Most common cause of nonorganic pain
–Occurs in children 3–15 years old
Appendicitis
–Periumbilical pain moves to RLQ
Gastroenteritis (virus, bacteria, parasite)
Carbohydrate intolerance
–Lactase, fructase, trehelase deficiency
Abdominal migraine
Drugs
–Antibiotics, anticonvulsants, bronchodilators
Small bowel bacterial overgrowth
Streptococcal pharyngitis
Suprapubic pain
Urinary tract infection
–With dysuria, fever, foul-smelling urine
–Pyelonephritis may have CVA tenderness
Constipation
–Accounts for 3% of visits to pediatrician
–May have a palpable fecal mass
Urinary retention

Hydrometrocolpos
–Associated with imperforate hymen
–Cyclic pain with onset of menstrual cycle

Right lower quadrant pain

Appendicitis
Ovarian torsion
Pelvic inflammatory disease
Ectopic pregnancy
Mittelschmerz
–Pain midcycle with ovulation
Inflammatory bowel disease
–Classic for terminal ileal Crohn disease
Iliopsoas abscess
Inguinal hernia
Right lower lobe pneumonia

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Abdominal Masses: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Wilms tumor
–More common in younger children
Neuroblastoma
–More common in younger children

Leukemia/lymphoma
–Involvement of retroperitoneal nodes, liver, or spleen

Hepatic tumors
–Hepatoblastoma, hepatocellular carcinoma, angiosarcoma, rhabdomyosarcoma of the liver, metastatic disease

Germ cell tumors
–Ovarian, teratoma
Soft tissue sarcoma
–Rhabdomyosarcoma

Rare malignancies in children
–Carcinoid tumors, adrenocortical carcinoma, pancreatoblastoma, malignant rhabdoid tumor

Cystic masses
–Ovary, renal, mesenteric

Benign tumors
–Adenomas (especially of liver), hamartomas, pheochromocytoma

Vascular lesions (e.g., hemangioma)

Renal etiologies
–Distended, nonemptying bladder, bladder outlet obstruction
–Congenital mesoblastic nephroma
–Severe hydronephrosis

Gynecologic
–Ovarian torsion, endometriosis, pelvic inflammatory disease

Gastrointestinal
–Constipation/stool impaction, intestinal obstruction (e.g., Hirschsprung), GI duplication, incarcerated hernia

Pancreatic pseudocyst

Infectious
–Abscess, hepatitis, virus (EBV, CMV) causing splenomegaly or hepatomegaly

Structures normally palpable in small children are liver edge, spleen tip (especially with viral illness), aorta, sigmoid colon, and spine

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Abdominal distention: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal cancer.Generalized abdominal distention may occur when the cancer — most commonly ovarian, hepatic, or pancreatic — produces ascites (usually in a patient with a known tumor). It’s an indication of advanced disease. Shifting dullness and a fluid wave accompany distention. Associated signs and symptoms may include severe abdominal pain, an abdominal mass, anorexia, jaundice, GI hemorrhage (hematemesis or melena), dyspepsia, and weight loss that progresses to muscle weakness and atrophy.

❑ Abdominal trauma.When brisk internal bleeding accompanies trauma, abdominal distention may be acute and dramatic. Associated signs and symptoms of this life-threatening disorder include abdominal rigidity with guarding, decreased or absent bowel sounds, vomiting, tenderness, and abdominal bruising. Pain may occur over the trauma site, or over the scapula if abdominal bleeding irritates the phrenic nerve. Signs of hypovolemic shock (such as hypotension and rapid, thready pulse) appear with significant blood loss.

❑ Cirrhosis. In cirrhosis, ascites causes generalized distention and is confirmed by a fluid wave, shifting dullness, and a puddle sign. Umbilical eversion and caput medusae (dilated veins around the umbilicus) are common. The patient may report a feeling of fullness or weight gain. Associated findings include vague abdominal pain, fever, anorexia, nausea, vomiting, constipation or diarrhea, bleeding tendencies, severe pruritus, palmar erythema, spider angiomas, leg edema, and possibly splenomegaly. Hematemesis, encephalopathy, gynecomastia, or testicular atrophy may also be seen. Jaundice is usually a late sign. Hepatomegaly occurs initially, but the liver may not be palpable if the patient has advanced disease.

❑ Heart failure. Generalized abdominal distention due to ascites typically accompanies severe cardiovascular impairment and is confirmed by shifting dullness and a fluid wave. Signs and symptoms of heart failure are numerous and depend on the disease stage and degree of cardiovascular impairment. Hallmarks include peripheral edema, jugular vein distention, dyspnea, and tachycardia. Common associated signs and symptoms include hepatomegaly (which may cause right upper quadrant pain), nausea, vomiting, a productive cough, crackles, cool extremities, cyanotic nail beds, nocturia, exercise intolerance, nocturnal wheezing, diastolic hypertension, and cardiomegaly.

❑ Irritable bowel syndrome. Irritable bowel syndrome may produce intermittent, localized distention — the result of periodic intestinal spasms. Lower abdominal pain or cramping typically accompanies these spasms. The pain is usually relieved by defecation or by passage of intestinal gas and is aggravated by stress. Other possible signs and symptoms include diarrhea that may alternate with constipation or normal bowel function, nausea, dyspepsia, straining and urgency at defecation, a feeling of incomplete evacuation, and small, mucus-streaked stools.

❑ Large-bowel obstruction. Dramatic abdominal distention is characteristic in this life-threatening disorder; in fact, loops of the large bowel may become visible on the abdomen. Constipation precedes distention and may be the only symptom for days. Associated findings include tympany, high-pitched bowel sounds, and the sudden onset of colicky lower abdominal pain that becomes persistent. Fecal vomiting and diminished peristaltic waves and bowel sounds are late signs.

❑ Mesenteric artery occlusion (acute). In this life-threatening disorder, abdominal distention usually occurs several hours after the sudden onset of severe, colicky periumbilical pain accompanied by rapid (even forceful) bowel evacuation. The pain later becomes constant and diffuse. Related signs and symptoms include severe abdominal tenderness with guarding and rigidity, absent bowel sounds and, occasionally, a bruit in the right iliac fossa. The patient may also experience vomiting, anorexia, diarrhea, or constipation. Late signs include fever, tachycardia, tachypnea, hypotension, and cool, clammy skin. Abdominal distention or GI bleeding may be the only clue if pain is absent.

❑ Paralytic ileus. Paralytic ileus, which produces generalized distention with a tympanic percussion note, is accompanied by absent or hypoactive bowel sounds and, occasionally, mild abdominal pain and vomiting. The patient may be severely constipated or may pass flatus and small, liquid stools.

❑ Peritonitis. Peritonitis is a life-threatening disorder in which abdominal distention may be localized or generalized, depending on the extent of the inflammation. Fluid accumulates within the peritoneal cavity and then within the bowel lumen, causing a fluid wave and shifting dullness. Typically, distention is accompanied by sudden and severe abdominal pain that worsens with movement, rebound tenderness, and abdominal rigidity.

The skin over the patient’s abdomen may appear taut. Associated signs and symptoms usually include hypoactive or absent bowel sounds, fever, chills, hyperalgesia, nausea, and vomiting. Signs of shock, such as tachycardia and hypotension, appear with significant fluid loss into the abdomen.

❑ Small-bowel obstruction. Abdominal distention is characteristic in small-bowel obstruction, a life-threatening disorder, and is most pronounced during late obstruction, especially in the distal small bowel. Auscultation reveals hypoactive or hyperactive bowel sounds, whereas percussion produces a tympanic note. Accompanying signs and symptoms include colicky periumbilical pain, constipation, nausea, and vomiting; the higher the obstruction, the earlier and more severe the vomiting. Rebound tenderness reflects intestinal strangulation with ischemia. Associated signs and symptoms include drowsiness, malaise, and signs of dehydration. Signs of hypovolemic shock appear with progressive dehydration and plasma loss.

❑ Toxic megacolon (acute).Toxic megacolon is a life-threatening complication of infectious or ulcerative colitis. It produces dramatic abdominal distention that usually develops gradually and is accompanied by a tympanic percussion note, diminished or absent bowel sounds, and mild rebound tenderness. The patient also presents with abdominal pain and tenderness, fever, tachycardia, and dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal mass: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm. Abdominal aortic aneurysm may persist for years, producing only a pulsating periumbilical mass with a systolic bruit over the aorta. However, it may become life-threatening if the aneurysm expands and its walls weaken. In such cases, the patient initially reports constant upper abdominal pain or, less commonly, low back or dull abdominal pain. If the aneurysm ruptures, he’ll report severe abdominal and back pain. After rupture, the aneurysm no longer pulsates.

Associated signs and symptoms of rupture include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock — such as tachycardia and cool, clammy skin — appear with significant blood loss.

❑ Cholecystitis.Deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. However, with acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right upper quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

❑ Colon cancer.A right lower quadrant mass may occur with cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.

Occasionally, cancer of the left colon also causes a palpable mass. It usually produces rectal bleeding, intermittent abdominal fullness or cramping, and rectal pressure. The patient may also report fremitus and pelvic discomfort. Later, he develops obstipation, diarrhea, or pencil-shaped, grossly bloody, or mucus-streaked stools. Typically, defecation relieves pain.

❑ Crohn’s disease. With Crohn’s disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right lower quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.

❑ Diverticulitis. Most common in the sigmoid colon, diverticulitis may produce a left lower quadrant mass that’s usually tender, firm, and fixed. It also produces intermittent abdominal pain that’s relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, a low-grade fever, and a distended and tympanic abdomen.

❑ Gastric cancer.Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness after eating, fatigue and, occasionally, coffee-ground vomitus or melena.

❑ Hepatomegaly. Hepatomegaly produces a firm, blunt, irregular mass in the epigastric region or below the right costal margin. Associated signs and symptoms vary with the causative disorder but commonly include ascites, right upper quadrant pain and tenderness, anorexia, nausea, vomiting, leg edema, jaundice, palmar erythema, spider angiomas, gynecomastia, testicular atrophy and, possibly, splenomegaly.

❑ Hernia. The soft and typically tender bulge is usually an effect of prolonged, increased intra-abdominal pressure on weakened areas of the abdominal wall. An umbilical hernia is typically located around the umbilicus and an inguinal hernia in either the right or left groin. An incisional hernia can occur anywhere along a previous incision. Hernia may be the only sign until strangulation occurs.

❑ Hydronephrosis. Enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.

❑ Ovarian cyst. A large ovarian cyst may produce a smooth, rounded, fluctuant mass, resembling a distended bladder, in the suprapubic region. Large or multiple cysts may also cause mild pelvic discomfort, low back pain, menstrual irregularities, and hirsutism. A twisted or ruptured cyst may cause abdominal tenderness, distention, and rigidity.

❑ Splenomegaly. The lymphomas, leukemias, hemolytic anemias, and inflammatory diseases are among the many disorders that may cause splenomegaly. Typically, the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but usually include a feeling of abdominal fullness, left upper quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and a low-grade fever.

❑ Uterine leiomyomas (fibroids). If large enough, these common, benign uterine tumors produce a round, multinodular mass in the suprapubic region. The patient’s chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Abdominal pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm (dissecting). Initially, this life-threatening disorder may produce dull lower abdominal, lower back, or severe chest pain. Usually, abdominal aortic aneurysm produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Other findings may include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity. Signs of shock, such as tachycardia and tachypnea, may appear.

❑ Abdominal cancer. Abdominal pain usually occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness, depression, and abdominal mass and distention.

❑ Abdominal trauma. Generalized or localized abdominal pain occurs with ecchymoses on the abdomen, abdominal tenderness, vomiting and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

❑ Adrenal crisis. Severe abdominal pain appears early, along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness; hypotension; tachycardia; oliguria; cool, clammy skin; and increased motor activity, which may progress to delirium or seizures.

❑ Anthrax, GI. An acute infectious disease, GI anthrax is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in any of the following forms: cutaneous, inhaled, or GI.

GI anthrax is caused by eating contaminated meat from an infected animal. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

❑ Appendicitis. With appendicitis, a life-threatening disorder, pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, or vomiting may occur after the onset of pain. Pain localizes at McBurney’s point in the right lower quadrant and is accompanied by abdominal rigidity, increasing tenderness (especially over McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

❑ Cholecystitis. Severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity, tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

❑ Cholelithiasis. Patients may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

❑ Cirrhosis. Dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, constipation, or diarrhea. Subsequent right upper quadrant pain worsens when the patient sits up or leans forward. Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

❑ Crohn’s disease. An acute attack in Crohn’s disease causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn’s disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding, and possibly a palpable mass in a lower quadrant. Abdominal pain is commonly relieved by defecation. Milder chronic signs and symptoms include right lower quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

❑ Diverticulitis. Mild cases of diverticulitis usually produce intermittent, diffuse left lower quadrant pain, which is sometimes relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, a low-grade fever and, in many cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left lower quadrant pain, abdominal rigidity and, possibly, signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

❑ Duodenal ulcer. Localized abdominal pain — described as steady, gnawing, burning, aching, or hunger like — may occur high in the midepigastrium, slightly off center, usually on the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again, but it may also produce weight gain. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

❑ Ectopic pregnancy. Lower abdominal pain may be sharp, dull, or cramping and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur, along with urinary frequency, a tender adnexal mass, and a 1- to 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

❑ Endometriosis. Constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, the pain may be accompanied by constipation, abdominal tenderness, dysmenorrhea, dyspareunia, and deep sacral pain.

❑ Escherichia coli O157:H7. E. coli O157:H7 is an aerobic, gram-negative bacillus that causes food-borne illness. Most strains of E. coli are harmless and are part of normal intestinal flora of healthy humans and animals. However, E. coli O157:H7, one of hundreds of strains of the bacterium, is capable of producing a powerful toxin and can cause severe illness. Eating undercooked beef or other foods contaminated with the bacteria causes the disease. Signs and symptoms include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop, and this may ultimately lead to acute renal failure.

❑ Gastric ulcer. Diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 to 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

❑ Gastritis. With acute gastritis, the patient experiences a rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. However, significant bleeding is unusual, unless the patient has hemorrhagic gastritis.

❑ Gastroenteritis. Cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It’s accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

❑ Heart failure. Right upper quadrant pain commonly accompanies heart failure’s hallmarks: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

❑ Hepatitis. Liver enlargement from any type of hepatitis causes discomfort or dull pain and tenderness in the right upper quadrant. Associated signs and symptoms may include dark urine, clay-colored stools, nausea, vomiting, anorexia, jaundice, malaise, and pruritus.

❑ Intestinal obstruction. Short episodes of intense, colicky, cramping pain alternate with pain-free intervals in an intestinal obstruction, a life-threatening disorder. Accompanying signs and symptoms may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as hypotension and tachycardia.

❑ Irritable bowel syndrome. Lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

❑ Listeriosis. A serious infection, listeriosis is caused by eating food contaminated with the bacterium Listeria monocytogenes. This food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems. Signs and symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; signs and symptoms include fever, headache, nuchal rigidity, and change in the level of consciousness.

GENDER CUE: Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

❑ Mesenteric artery ischemia. Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmia, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

❑ Ovarian cyst. Torsion or hemorrhage causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn’t. Pain is accompanied by slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass and, possibly, amenorrhea. Abdominal distention may occur if the patient has a large cyst. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

❑ Pancreatitis. Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Chronic pancreatitis produces severe left upper quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, maldigestion, and diabetes mellitus are common.

❑ Pelvic inflammatory disease. Pain in the right or left lower quadrant ranges from vague discomfort worsened by movement to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, urinary discomfort, and abnormal vaginal bleeding or purulent vaginal discharge.

❑ Perforated ulcer. With perforated ulcer, a life-threatening disorder, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

❑ Peritonitis. With peritonitis, a life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

❑ Prostatitis. Vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop with prostatitis. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

❑ Pyelonephritis (acute). Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize this disorder. Pain may radiate to the lower midabdomen or to the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

❑ Renal calculi. Depending on the location of calculi, severe abdominal or back pain may occur. However, the classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant. Pain-induced agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria may occur.

❑ Sickle cell crisis. Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice.

❑ Smallpox (variola major). Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites for the virus. The virus is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

❑ Splenic infarction. Fulminating pain in the left upper quadrant occurs along with chest pain that may worsen on inspiration. Pain usually radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

❑ Ulcerative colitis. Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom — recurrent and possibly severe diarrhea with blood, pus, and mucus — may relieve the pain. The abdomen may feel soft, squashy, and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Other causes

❑ Drugs. Salicylates and nonsteroidal anti-inflammatory drugs commonly cause burning, gnawing pain in the left upper quadrant or epigastric area, along with nausea and vomiting.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Introduction: Malignant Neoplasms: What causes cancer?
(Professional Guide to Diseases (Eighth Edition))

Researchers have found that cancer develops from mutations within the genes of cells. Thus, cancer is a genetic disease. Cancer susceptibility genes are of two types. Some are oncogenes, which activate cell division and influence embryonic development, and some are tumor suppressor genes, which halt cell division.

These genes are typically found in normal human cells, but certain kinds of mutations may transform the normal cells. Inherited defects may cause a genetic mutation, whereas exposure to a carcinogen may cause an acquired mutation. Current evidence indicates that carcinogenesis results from a complex interaction of carcinogens and accumulated mutations in several genes.

In animal studies of the ability of viruses to transform cells, some human viruses exhibit carcinogenic potential. For example, the Epstein-Barr virus, the cause of infectious mononucleosis, has been linked to Burkitt's lymphoma and nasopharyngeal cancer.

High-frequency radiation, such as ultraviolet and ionizing radiation, damages the genetic material known as deoxyribonucleic acid (DNA), possibly inducing genetically transferable abnormalities. Other factors, such as a person's tissue type and hormonal status, interact to potentiate radiation's carcinogenic effect. Examples of substances that may damage DNA and induce carcinogenesis include:

❑alkylating agents — leukemia

❑aromatic hydrocarbons and benzopyrene (from polluted air) — lung cancer

❑asbestos — mesothelioma of the lung

❑tobacco — cancer of the lung, oral cavity and upper airways, esophagus, pancreas, kidneys, and bladder

❑vinyl chloride — angiosarcoma of the liver.

Diet has also been implicated, especially in the development of GI cancer as a result of a high animal fat diet. Additives composed of nitrates and certain methods of food preparation — particularly charbroiling — are also recognized factors.

The role of hormones in carcinogenesis is still controversial, but it seems that excessive use of some hormones, especially estrogen, produces cancer in animals. Also, the synthetic estrogen diethylstilbestrol causes vaginal cancer in some daughters of women who were treated with it. It's unclear, however, whether changes in human hormonal balance retard or stimulate cancer development.

Some forms of cancer and precancerous lesions result from genetic predisposition either directly (as in Wilms' tumor and retinoblastoma) or indirectly (in association with inherited conditions such as Down syndrome or immunodeficiency diseases). Expressed as autosomal recessive, X-linked, or autosomal dominant disorders, their common characteristics include:

❑early onset of malignant disease

❑increased incidence of bilateral cancer in paired organs (breasts, adrenal glands, kidneys, and eighth cranial nerve [acoustic neuroma])

❑increased incidence of multiple primary malignancies in nonpaired organs

❑abnormal chromosome complement in tumor cells.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Malignant spinal neoplasms: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Primary tumors of the spinal cord may be extramedullary (occurring outside the spinal cord) or intramedullary (occurring within the cord itself). Extramedullary tumors may be intradural (meningiomas and schwannomas), which account for 60% of all primary malignant spinal cord neoplasms, or extradural (metastatic tumors from breasts, lungs, prostate, leukemia, or lymphomas), which account for 25% of these malignant neoplasms.

Intramedullary tumors, or gliomas (astrocytomas or ependymomas), are comparatively rare, accounting for only about 10%. In children, they're low-grade astrocytomas.

Spinal cord tumors are rare compared with intracranial tumors (ratio of 1:4). They occur equally in men and women, with the exception of meningiomas, which occur mostly in women. Spinal cord tumors can occur anywhere along the length of the cord or its roots.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Abdominal distention: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal cancer

Generalized abdominal distention may occur when the cancer—most commonly ovarian, hepatic, or pancreatic cancer—produces ascites (usually in a patient with a known tumor). It’s an indication of advanced disease. Shifting dullness and a fluid wave accompany distention. Associated signs and symptoms may include severe abdominal pain, an abdominal mass, anorexia, jaundice, GI hemorrhage (hematemesis or melena), dyspepsia, and weight loss that progresses to muscle weakness and atrophy.

Abdominal trauma

When brisk internal bleeding accompanies trauma, abdominal distention may be acute and dramatic. Associated signs and symptoms of this life-threatening disorder include abdominal rigidity with guarding, decreased or absent bowel sounds, vomiting, tenderness, and abdominal bruising. The patient may feel pain over the trauma site, or over the scapula if abdominal bleeding irritates the phrenic nerve. Signs of hypovolemic shock (such as hypotension and rapid, thready pulse) appear with significant blood loss.

Bladder distention

Various disorders cause bladder distention, which in turn causes lower abdominal distention. Slight dullness on percussion above the symphysis indicates mild bladder distention. A palpable, smooth, rounded, fluctuant suprapubic mass suggests severe distention; a fluctuant mass extending to the umbilicus indicates extremely severe distention. Urinary dribbling, frequency, or urgency may occur with urinary obstruction. Suprapubic discomfort is also common.

Cirrhosis

In cirrhosis, ascites causes generalized distention and is confirmed by a fluid wave, shifting dullness, and a puddle sign. Umbilical eversion and caput medusae (dilated veins around the umbilicus) are common. The patient may report a feeling of fullness or weight gain. Associated findings include vague abdominal pain, fever, anorexia, nausea, vomiting, constipation or diarrhea, bleeding tendencies, severe pruritus, palmar erythema, spider angiomas, leg edema, and possibly splenomegaly. Hematemesis, encephalopathy, gynecomastia, or testicular atrophy may also occur. Jaundice is usually a late sign. Hepatomegaly occurs initially, but the liver may not be palpable in advanced disease.

Gastric dilation (acute)

Left-upper-quadrant distention is characteristic in acute gastric dilation, but the presentation varies. The patient usually complains of epigastric fullness or pain and nausea with or without vomiting. Physical examination reveals tympany, gastric tenderness, and a succussion splash. Initially, peristalsis may be visible. Later, hypoactive or absent bowel sounds confirm ileus. The patient may be pale and diaphoretic and may exhibit tachycardia or bradycardia.

Heart failure

Generalized abdominal distention due to ascites typically accompanies severe cardiovascular impairment and is confirmed by shifting dullness and a fluid wave. Signs and symptoms of heart failure are numerous and depend on the disease stage and degree of cardiovascular impairment. Hallmarks include peripheral edema, jugular vein distention, dyspnea, and tachycardia. Common associated signs and symptoms include hepatomegaly (which may cause right-upper-quadrant pain), nausea, vomiting, productive cough, crackles, cool extremities, cyanotic nail beds, nocturia, exercise intolerance, nocturnal wheezing, diastolic hypertension, and cardiomegaly.

Irritable bowel syndrome (IBS)

IBS may produce intermittent, localized distention—the result of periodic intestinal spasms. Lower abdominal pain or cramping typically accompanies these spasms. The pain is usually relieved by defecation or by passage of intestinal gas and is aggravated by stress. Other possible signs and symptoms include diarrhea that may alternate with constipation or normal bowel function; nausea; dyspepsia; straining and urgency at defecation; feeling of incomplete evacuation; and small, mucus-streaked stools.

Large-bowel obstruction

Dramatic abdominal distention is characteristic in large-bowel obstruction, a life-threatening disorder; in fact, loops of the large bowel may become visible on the abdomen. Constipation precedes distention and may be the only symptom for days. Associated findings include tympany, high-pitched bowel sounds, and sudden onset of colicky lower abdominal pain that becomes persistent. Fecal vomiting and diminished peristaltic waves and bowel sounds are late signs.

Mesenteric artery occlusion (acute)

In mesenteric artery occlusion—a life-threatening disorder—abdominal distention usually occurs several hours after the sudden onset of severe, colicky periumbilical pain accompanied by rapid (even forceful) bowel evacuation. The pain later becomes constant and diffuse. Related signs and symptoms include severe abdominal tenderness with guarding and rigidity, absent bowel sounds and, occasionally, a bruit in the right iliac fossa. The patient may also experience vomiting, anorexia, diarrhea, or constipation. Late signs include fever, tachycardia, tachypnea, hypotension, and cool, clammy skin. Abdominal distention or GI bleeding may be the only clue if pain is absent.

Nephrotic syndrome

Nephrotic syndrome may produce massive edema, causing generalized abdominal distention with a fluid wave and shifting dullness. It may also produce elevated blood pressure, hematuria or oliguria, fatigue, anorexia, depression, pallor, periorbital edema, scrotal swelling, and skin striae.

Ovarian cysts

Typically, large ovarian cysts produce lower abdominal distention accompanied by umbilical eversion. Because they’re thin walled and fluid filled, these cysts produce a fluid wave and shifting dullness—signs that mimic ascites. Lower abdominal pain and a palpable mass may be present.

Paralytic ileus

Paralytic ileus, which produces generalized distention with a tympanic percussion note, is accompanied by absent or hypoactive bowel sounds and, occasionally, mild abdominal pain and vomiting. The patient may be severely constipated or may pass flatus and small, liquid stools.

Peritonitis

In peritonitis—a life-threatening disorder—abdominal distention may be localized or generalized, depending on the extent of peritonitis. Fluid accumulates first within the peritoneal cavity and then within the bowel lumen, causing a fluid wave and shifting dullness. Typically, distention is accompanied by rebound tenderness, abdominal rigidity, and sudden and severe abdominal pain that worsens with movement.

Small-bowel obstruction

Abdominal distention, which is characteristic in small-bowel obstruction—a life-threatening disorder—is most pronounced during late obstruction, especially in the distal small bowel. Auscultation reveals hypoactive or hyperactive bowel sounds, whereas percussion produces a tympanic note. Accompanying signs and symptoms include colicky periumbilical pain, constipation, nausea, and vomiting; the higher the obstruction, the earlier and more severe the vomiting. Rebound tenderness reflects intestinal strangulation with ischemia. Associated signs and symptoms include drowsiness, malaise, and signs of dehydration. Signs of hypovolemic shock appear with progressive dehydration and plasma loss.

Toxic megacolon (acute)

Toxic megacolon is a life-threatening complication of infectious or ulcerative colitis that produces dramatic abdominal distention. The distention usually develops gradually and is accompanied by a tympanic percussion note, diminished or absent bowel sounds, and mild rebound tenderness. The patient also experiences abdominal pain and tenderness, fever, tachycardia, and dehydration.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal mass: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm

An abdominal aortic aneurysm may persist for years, producing only a pulsating periumbilical mass with a systolic bruit over the aorta. However, it may become life-threatening if the aneurysm expands and its walls weaken. In such cases, the patient initially reports constant upper abdominal pain or, less often, low back or dull abdominal pain. If the aneurysm ruptures, he’ll report severe abdominal and back pain. And after rupture, the aneurysm no longer pulsates.

Associated signs and symptoms of rupture include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock—such as tachycardia and cool, clammy skin—appear with significant blood loss.

Bladder distention

A smooth, rounded, fluctuant suprapubic mass is characteristic. In extreme distention, the mass may extend to the umbilicus. Severe suprapubic pain and urinary frequency and urgency may also occur.

Cholecystitis

Deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. However, in acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right-upper-quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

A stone-filled gallbladder usually produces a painless right-upper-quadrant mass that’s smooth and sausage-shaped. However, passage of a stone through the bile or cystic duct may cause severe right-upper-quadrant pain that radiates to the epigastrium, back, or shoulder blades. Accompanying signs and symptoms include anorexia, nausea, vomiting, chills, diaphoresis, restlessness, and low-grade fever. Jaundice may occur with obstruction of the common bile duct. The patient may also experience intolerance of fatty foods and frequent indigestion.

Colon cancer

A right-lower-quadrant mass may occur in cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.

Occasionally, cancer of the left colon also causes a palpable mass. Usually though, it produces rectal bleeding, intermittent abdominal fullness or cramping, and rectal pressure. The patient may also report fremitus and pelvic discomfort. Later, he develops obstipation, diarrhea, or pencil-shaped, grossly bloody, or mucus-streaked stools. Typically, defecation relieves pain.

Crohn’s disease

In Crohn’s disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right-lower-quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.

Diverticulitis

Most common in the sigmoid colon, diverticulitis may produce a left-lower-quadrant mass that’s usually tender, firm, and fixed. It also produces intermittent abdominal pain that’s relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, low-grade fever, and a distended and tympanic abdomen.

Gallbladder cancer

Gallbladder cancer may produce a moderately tender, irregular mass in the right upper quadrant. Accompanying it is chronic, progressively severe epigastric or right-upper-quadrant pain that may radiate to the right shoulder. Associated signs and symptoms include nausea, vomiting, anorexia, weight loss, jaundice, and possibly hepatosplenomegaly.

Gastric cancer

Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness after eating, fatigue, and occasionally coffee-ground vomitus or melena.

Hepatic cancer

Hepatic cancer produces a tender, nodular mass in the right upper quadrant or right epigastric area accompanied by severe pain that’s aggravated by jolting. Other effects include weight loss, weakness, anorexia, nausea, fever, dependent edema, and occasionally jaundice and ascites. A large tumor can also cause a bruit or hum.

Hepatomegaly

Hepatomegaly produces a firm, blunt, irregular mass in the epigastric region or below the right costal margin. Associated signs and symptoms vary with the causative disorder but commonly include ascites, right-upper-quadrant pain and tenderness, anorexia, nausea, vomiting, leg edema, jaundice, palmar erythema, spider angiomas, gynecomastia, testicular atrophy, and possibly splenomegaly.

Hydronephrosis

By enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.

Ovarian cyst

A large ovarian cyst may produce a smooth, rounded, fluctuant mass, resembling a distended bladder, in the suprapubic region. Large or multiple cysts may also cause mild pelvic discomfort, low back pain, menstrual irregularities, and hirsutism. A twisted or ruptured cyst may cause abdominal tenderness, distention, and rigidity.

Pancreatic abscess

Occasionally, pancreatic abscess may produce a palpable epigastric mass accompanied by epigastric pain and tenderness. The patient’s temperature usually rises abruptly but may climb steadily. Nausea, vomiting, diarrhea, tachycardia, and hypotension may also occur.

Pancreatic pseudocysts

After pancreatitis, pseudocysts may form on the pancreas, causing a palpable nodular mass in the epigastric area. Other findings include nausea, vomiting, diarrhea, abdominal pain and tenderness, low-grade fever, and tachycardia.

Renal cell carcinoma

Usually occurring in only one kidney, renal cell carcinoma produces a smooth, firm, nontender mass near the affected kidney. Accompanying it are dull, constant abdominal or flank pain and hematuria. Other signs and symptoms include elevated blood pressure, fever, and urine retention. Weight loss, nausea, vomiting, and leg edema occur in late stages.

Splenomegaly

Lymphomas, leukemias, hemolytic anemias, and inflammatory diseases are among the many disorders that may cause splenomegaly. Typically, the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but often include a feeling of abdominal fullness, left-upper-quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and low-grade fever.

Uterine leiomyomas (fibroids)

If large enough, these common, benign uterine tumors produce a round, multinodular mass in the suprapubic region. The patient’s chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Abdominal pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm (dissecting)

Initially, abdominal aortic aneurysm—a life-threatening disorder—may produce dull lower abdominal, lower back, or severe chest pain. In most cases, however, it produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Other findings may include mottled skin below the waist, absent femoral and pedal pulses, blood pressure that’s lower in the legs than in the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity. Signs of shock, such as tachycardia and tachypnea, may appear.

Abdominal cancer

Abdominal pain usually occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness, depression, an abdominal mass, and abdominal distention.

Abdominal trauma

Generalized or localized abdominal pain occurs with ecchymoses on the abdomen; abdominal tenderness; vomiting; and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

Adrenal crisis

Severe abdominal pain appears early along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness, hypotension, tachycardia, oliguria, cool and clammy skin, and increased motor activity, which may progress to delirium or seizures.

Anthrax, GI

Anthrax is an acute infectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhaled, or GI forms.

GI anthrax is caused by eating contaminated meat from an infected animal. Initial signs and symptoms include anorexia, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

Appendicitis is a life-threatening disorder in which pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, and vomiting may occur after the onset of pain. Pain localizes at McBurney’s point in the right lower quadrant and is accompanied by abdominal rigidity, increasing tenderness (especially over McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

Cholecystitis

Severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity and tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

Patients may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

Cirrhosis

Dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, and constipation or diarrhea. Subsequent right-upper-quadrant pain worsens when the patient sits up or leans forward. Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

Crohn’s disease

An acute attack causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn’s disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding, and possibly a palpable mass in a lower quadrant. Abdominal pain is commonly relieved by defecation. Milder chronic signs and symptoms include right-lower-quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

Cystitis

Abdominal pain and tenderness usually occur in the suprapubic region. Associated signs and symptoms include malaise, flank pain, low back pain, nausea, vomiting, urinary frequency and urgency, nocturia, dysuria, fever, and chills.

Diabetic ketoacidosis

Rarely, severe, sharp, shooting, and girdling pain may persist for several days. Fruity breath odor, a weak and rapid pulse, Kussmaul’s respirations, poor skin turgor, polyuria, polydipsia, nocturia, hypotension, decreased bowel sounds, and confusion also occur.

Diverticulitis

Mild cases usually produce intermittent, diffuse left-lower-quadrant pain, which may be relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, low-grade fever and, in many cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left-lower-quadrant pain, abdominal rigidity, and possibly signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

Duodenal ulcer

Localized abdominal pain—described as steady, gnawing, burning, aching, or hungerlike—may occur high in the midepigastrium, slightly off center, usually on the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

Ectopic pregnancy

Lower abdominal pain may be sharp, dull, or cramping and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur along with urinary frequency, a tender adnexal mass, and a 1- to 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

Endometriosis

Constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, abdominal pain may be accompanied by abdominal tenderness, constipation, dysmenorrhea, dyspareunia, and deep sacral pain.

Escherichia coli O157:H7

E. coli O157:H7 is an aerobic, gram-negative bacillus that causes food-borne illness. Most strains of E. coli are harmless and are part of the normal intestinal flora of healthy humans and animals. E. coli O157:H7, one of hundreds of strains of the bacterium, is capable of producing a powerful toxin and can cause severe illness. Eating undercooked beef or other foods contaminated with the bacterium causes the disease. Signs and symptoms include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. In children younger than age 5 and the elderly, hemolytic uremic syndrome may develop and ultimately lead to acute renal failure.

Gastric ulcer

Diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 to 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

Gastritis

With acute gastritis, the patient experiences rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. However, significant bleeding is unusual, unless the patient has hemorrhagic gastritis.

Gastroenteritis

Cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It’s accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

Heart failure

Right-upper-quadrant pain commonly accompanies heart failure’s hallmarks: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

Hepatic abscess

Steady, severe abdominal pain in the right upper quadrant or midepigastrium commonly accompanies hepatic abscess—a rare disorder—but right-upper-quadrant tenderness is the most important finding. Other signs and symptoms are anorexia, diarrhea, nausea, fever, diaphoresis, elevated right hemidiaphragm and, rarely, vomiting.

Hepatic amebiasis

Rare in the United States, hepatic amebiasis causes relatively severe right-upper-quadrant pain and tenderness over the liver and possibly the right shoulder. Accompanying signs and symptoms include fever, weakness, weight loss, chills, diaphoresis, and jaundiced or brownish skin.

Hepatitis

Liver enlargement from any type of hepatitis causes discomfort or dull pain and tenderness in the right upper quadrant. Associated signs and symptoms may include dark urine, clay-colored stools, nausea, vomiting, anorexia, jaundice, malaise, and pruritus.

Herpes zoster

Intestinal obstruction

Short episodes of intense, colicky, cramping pain alternate with pain-free intervals in intestinal obstruction, a life-threatening disorder. Accompanying signs and symptoms may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive bowel sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as hypotension and tachycardia.

Irritable bowel syndrome

Lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

Listeriosis

Listeriosis is a serious infection that’s caused by eating food contaminated with the bacterium Listeria monocytogenes. This food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems. Signs and symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, it may cause meningitis, characterized by fever, headache, nuchal rigidity, and altered level of consciousness (LOC).

Gender Cue: Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Mesenteric artery ischemia

Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmias, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

Myocardial infarction (MI)

In MI—a life-threatening disorder—substernal chest pain may radiate to the abdomen. Associated signs and symptoms include weakness, diaphoresis, nausea, vomiting, anxiety, syncope, jugular vein distention, and dyspnea.

Norovirus infection

Abdominal pain or cramping is a symptom commonly associated with noroviruses. Transmitted by the fecal-oral route and highly contagious, these viruses that cause gastroenteritis may also produce acute-onset vomiting, nausea, and diarrhea. Less common symptoms include low-grade fever, headache, chills, muscle aches, and generalized fatigue. Individuals who are otherwise healthy usually recover in 24 to 60 hours without suffering lasting effects.

Ovarian cyst

Torsion or hemorrhage causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn’t. Pain is accompanied by a slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass, and possibly amenorrhea. Abdominal distention may occur if the cyst is large. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

Pancreatitis

Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move about restlessly. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Chronic pancreatitis produces severe left-upper-quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, maldigestion, and diabetes mellitus are common.

Pelvic inflammatory disease

Pain in the right or left lower quadrant ranges from vague discomfort worsened by movement to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, discomfort on urination, and abnormal vaginal bleeding or a purulent vaginal discharge.

Perforated ulcer

In a life-threatening perforated ulcer, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

Peritonitis

In this life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

Pleurisy

Pleurisy may produce upper abdominal or costal margin pain referred from the chest. Characteristic sharp, stabbing chest pain increases with inspiration and movement. Many patients have a pleural friction rub and rapid, shallow breathing; some have a low-grade fever.

Pneumonia

Lower-lobe pneumonia can cause pleuritic chest pain and referred, severe upper abdominal pain, tenderness, and rigidity that diminish with inspiration. It can also cause fever, shaking chills, achiness, headache, blood-tinged or rusty sputum, dyspnea, and a dry, hacking cough. Accompanying signs include crackles, egophony, decreased breath sounds, and dullness on percussion.

Pneumothorax

Pneumothorax is a potentially life-threatening disorder that can cause referred pain from the chest to the upper abdomen and costal margin. Characteristic chest pain arises suddenly and worsens with deep inspiration or movement. Accompanying signs and symptoms include anxiety, dyspnea, cyanosis, decreased or absent breath sounds over the affected area, tachypnea, and tachycardia. Watch for asymmetrical chest movements on inspiration.

Prostatitis

Vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

Pyelonephritis (acute)

Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize pyelonephritis. Pain may radiate to the lower midabdomen or the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

Renal calculi

Depending on their location, calculi may cause severe abdominal or back pain. However, the classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant and may be accompanied by agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria.

Sickle cell crisis

Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice.

Smallpox (variola major)

Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites for the virus, which is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the oral mucosa, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, which later separates from the skin, leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.

Splenic infarction

Fulminating pain in the left upper quadrant occurs with chest pain that may worsen on inspiration. Pain commonly radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

Systemic lupus erythematosus

Generalized abdominal pain is unusual in this disease but may occur after meals. Butterfly rash, photosensitivity, alopecia, mucous membrane ulcers, and nondeforming arthritis are characteristic signs. Other common signs and symptoms include anorexia, vomiting, abdominal tenderness with guarding, abdominal distention after meals, fatigue, fever, and weight loss. Precordial chest pain and a pericardial rub may also occur.

Ulcerative colitis

Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom—recurrent and possibly severe diarrhea with blood, pus, and mucus—may relieve the pain. The abdomen may feel soft and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Uremia

Characterized by generalized or periumbilical pain that shifts and varies in intensity, uremia causes diverse GI signs and symptoms, such as nausea, vomiting, anorexia, and diarrhea. Other findings may include bleeding, abdominal tenderness that changes in location and intensity, visual disturbances, headache, decreased LOC, vertigo, and oliguria or anuria. Chest pain may occur secondary to pericardial effusion. Localized or diffuse pruritus is common.

Other causes

Drugs

Salicylates and nonsteroidal anti-inflammatories commonly cause burning, gnawing pain in the left upper quadrant or epigastric area as well as nausea and vomiting.

Insect toxins

Generalized, cramping abdominal pain usually occurs with low-grade fever, nausea, vomiting, abdominal rigidity, tremors, and burning sensations in the hands or feet.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Chronic/Recurrent Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Irritable bowel syndrome

❑ Peptic ulcer disease

❑ Cholecystitis

❑ Chronic pancreatitis

❑ Inflammatory bowel disease

❑ Intermittent mesenteric ischemia

❑ Pancreatic cancer

❑ Gastric cancer

❑ Endometriosis

❑ Recurrent intestinal obstruction

❑ Sickle cell anemia

❑ Radiculopathy

❑ Adrenal insufficiency

❑ Lead poisoning

❑ Porphyria

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Source: Field Guide to Bedside Diagnosis, 2007

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal Mass

❑ Liver enlargement

❑ Spleen enlargement

❑ Fecal mass

❑ Diverticulitis

❑ Colon cancer

❑ Gallbladder enlargement

❑ Pancreatic pseudocyst

❑ Crohn disease

❑ Abdominal aortic aneurysm

❑ Renal enlargement

Pelvic Mass

❑ Distended bladder

❑ Pregnant uterus

❑ Salpingitis

❑ Ovarian cyst

❑ Uterine fibromyoma

❑ Ovarian cancer

❑ Endometrial cancer

❑ Ectopic pregnancy

❑ Malignant deposit

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Generalized/Periumbilical

❑ Gastroenteritis

❑ Obstipation

❑ Small bowel obstruction

❑ Large bowel obstruction

❑ Mesenteric ischemia

❑ Peritonitis

❑ Abdominal aortic dissection

❑ Sickle cell crisis

Right Upper Quadrant/Epigastrium

❑ Hepatitis

❑ Biliary colic

❑ Peptic ulcer disease

❑ Pyelonephritis

❑ Acute cholecystitis

Right Lower Quadrant

❑ Appendicitis

❑ Inflammatory bowel disease

❑ Salpingitis

❑ Rectus abdominus muscle strain

❑ Ureteral calculus

❑ Ruptured corpus luteum cyst

❑ Ruptured ectopic pregnancy

❑ Ovarian torsion

Left Upper Quadrant

❑ Pancreatitis

❑ Splenic infarction

❑ Pyelonephritis

❑ Myocardial infarction

Left Lower Quadrant

❑ Inflammatory bowel disease

❑ Diverticulitis

❑ Salpingitis

❑ Rectus abdominus muscle strain

❑ Ureteral calculus

❑ Ovarian torsion

❑ Ruptured corpus luteum cyst

❑ Ruptured ectopic pregnancy

❑ Sigmoid volvulus

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Abdominal pain: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

See Abdominal pain: Causes and associated findings, pages 6 to 11.

Abdominal aortic aneurysm (dissecting)

Initially, life-threatening abdominal aortic aneurysm may produce dull lower abdominal, lower back, or severe chest pain. Typically, it produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Abdominal cancer

Abdominal pain usually occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness, depression, and an abdominal mass and distention.

Adrenal crisis

Severe abdominal pain appears early, along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness; hypotension; tachycardia; oliguria; cool, clammy skin; and increased motor activity, which may progress to delirium or seizures.

Anthrax, GI

Anthrax is an acute infectious disease caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhaled, or GI forms.

Eating contaminated meat from an infected animal causes GI anthrax. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

With appendicitis, a life-threatening disorder, pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, or vomiting may occur after the onset of pain. Pain localizes at McBurney’s point in the right lower quadrant and is accompanied by abdominal rigidity, increasing tenderness (especially over McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

Cholecystitis

Severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity, tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

Cirrhosis

Dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, constipation, or diarrhea. Subsequent right upper quadrant pain worsens when the patient sits up or leans forward. Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

Crohn’s disease

An acute attack causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn’s disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding, and possibly a palpable mass in the lower quadrant. Abdominal pain is usually relieved by defecation. Milder chronic signs and symptoms include right lower quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

Cystitis

Abdominal pain and tenderness are usually suprapubic. Associated signs and symptoms include malaise, flank pain, low back pain, nausea, vomiting, urinary frequency and urgency, nocturia, dysuria, fever, and chills.

Diabetic ketoacidosis

Diverticulitis

Mild cases usually produce intermittent, diffuse left lower quadrant pain, which is sometimes relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, low-grade fever and, in many cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left lower quadrant pain, abdominal rigidity, and possibly signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

Duodenal ulcer

Localized abdominal pain — described as steady, gnawing, burning, aching, or hunger like — may occur high in the midepigastrium, slightly off center, and usually on the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again, but it also may produce weight gain. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

Ectopic pregnancy

Lower abdominal pain may be sharp, dull, or cramping, and constant or intermittent in ectopic pregnancy — a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur, along with urinary frequency, a tender adnexal mass, and a 1- to 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

Endometriosis

Constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, the pain may be accompanied by constipation, abdominal tenderness, dysmenorrhea, dyspareunia, and deep sacral pain.

Escherichia Coli O157:H7

E. coli O157:H7 is an aerobic, gram-negative bacillus that causes food-borne illness. Most strains of E. coli are harmless; some are present in the normal intestinal flora of healthy humans and animals. E. coli O157:H7, one of hundreds of strains of the bacterium, is capable of producing a powerful toxin and can cause severe illness. Eating undercooked beef or other foods contaminated with the bacteria causes the disease. Signs and symptoms include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. Elderly people and children younger than age 5 may develop hemolytic uremic syndrome, which may ultimately lead to acute renal failure.

Gastric ulcer

Diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 to 2 hours after meals; it may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding may also occur.

Gastritis

With acute gastritis, the patient experiences a rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. However, significant bleeding is unusual unless the patient has hemorrhagic gastritis.

Gastroenteritis

Heart failure

Right upper quadrant pain commonly accompanies the hallmarks of heart failure: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

Hepatic abscess

Steady, severe abdominal pain in the right upper quadrant or midepigastrium typically accompanies hepatic abscess, a rare disorder; however, right upper quadrant tenderness is the most important finding. Other signs and symptoms are anorexia, diarrhea, nausea, fever, diaphoresis, elevated right hemidiaphragm and, in rare cases, vomiting.

Hepatic amebiasis

Hepatic amebiasis, which is rare in the United States, causes relatively severe right upper quadrant pain as well as tenderness over the liver and, possibly, the right shoulder. Accompanying signs and symptoms include fever, weakness, weight loss, chills, diaphoresis, and jaundiced or brownish skin.

Hepatitis

Herpes zoster

Herpes zoster of the thoracic, lumbar, or sacral nerves can cause localized abdominal and chest pain in the areas served by these nerves. Pain, tenderness, and fever can precede or accompany erythematous papules that rapidly evolve into grouped vesicles. Although rare, herpes zoster can also affect the viscera of the abdominal cavity, causing adhesions and chronic pain.

Insect toxins

Generalized, cramping abdominal pain usually occurs, along with low-grade fever, nausea, vomiting, abdominal rigidity, tremors, and localized pain and swelling.

Intestinal obstruction

Short episodes of intense, colicky, cramping pain alternate with pain-free intervals in intestinal obstruction, a life-threatening disorder. Accompanying signs and symptoms may include obstipation, pain-induced agitation, visible peristaltic waves, and abdominal distention, tenderness, and guarding. The patient may also exhibit high-pitched, tinkling, or hyperactive sounds proximal to the obstruction; distally, sounds may be hypoactive or absent. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Bowel sounds are absent in complete obstruction. Late-stage obstruction produces signs of hypovolemic shock, such as hypotension and tachycardia.

Irritable bowel syndrome

Lower abdominal cramping or pain is aggravated by eating coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability may intensify the symptoms.

Listeriosis

Listeriosis is a serious infection caused by eating food contaminated with the bacterium Listeria monocytogenes. This illness primarily affects pregnant women, neonates, and those with weakened immune systems. Signs and symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; signs and symptoms include fever, headache, nuchal rigidity, and a change in the level of consciousness (LOC). Infections during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Mesenteric artery ischemia

Initially, the abdomen is soft and tender, with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absence of bowel sounds, and cool, clammy skin.

Myocardial infarction (MI)

Substernal chest pain may radiate to the abdomen in an MI, a life-threatening disorder. Associated signs and symptoms include weakness, diaphoresis, nausea, vomiting, anxiety, syncope, jugular vein distention, and dyspnea.

Ovarian cyst

Torsion or hemorrhage causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn’t. Pain may be accompanied by slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass and, possibly, amenorrhea. Abdominal distention may occur if the cyst is large. Peritoneal irritation causes high fever and severe nausea and vomiting; these symptoms also occur with rupture and ensuing peritonitis.

Pancreatitis

Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move about restlessly. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Pelvic inflammatory disease

Pain in the right or left lower quadrant ranges from vague discomfort worsened by movement to deep, severe, and progressive pain. Metrorrhagia occasionally precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, urinary discomfort, and abnormal vaginal bleeding or purulent vaginal discharge.

Perforated ulcer

With a perforated ulcer — a life-threatening disorder — sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

Peritonitis

In peritonitis, a life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever, chills, nausea, vomiting, hypoactive or absent bowel sounds, rebound tenderness and guarding, hyperalgesia, tachycardia, hypotension, tachypnea, and abdominal tenderness, distention, and rigidity. Positive psoas and obturator signs also occur.

Pleurisy

Pneumonia

Pneumothorax

Potentially life threatening, pneumothorax can cause pain across the upper abdomen and costal margin; this pain is referred from the chest. Characteristic chest pain arises suddenly and worsens with deep inspiration or movement. Accompanying signs and symptoms include anxiety, dyspnea, cyanosis, decreased or absent breath sounds over the affected area, tachypnea, and tachycardia. Watch for asymmetrical chest movements on inspiration.

Prostatitis

Pyelonephritis (acute)

Progressive lower quadrant pain in one or both sides, flank pain, and costovertebral angle tenderness characterize acute pyelonephritis. Pain may radiate to the lower midabdomen or groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

Renal calculi

Depending on the location of calculi, severe abdominal or back pain may occur. However, the classic symptom is severe, colicky pain that travels from the costovertebral angle to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant. Pain-induced agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria may occur.

Sickle cell crisis

Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice.

Smallpox (variola major)

Worldwide eradication of smallpox was achieved in 1977. The United States and Russia have the only documented storage sites for the virus, and the virus is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and, later, pustular. The lesions, which develop simultaneously rather than gradually increasing in number, occur more frequently on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust. Later, the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Splenic infarction

Systemic lupus erythematosus

Generalized abdominal pain is unusual but may occur after meals. Butterfly rash, photosensitivity, alopecia, mucous membrane ulcers, and nondeforming arthritis are characteristic. Other common signs and symptoms include anorexia, vomiting, abdominal tenderness with guarding, abdominal distention after meals, fatigue, fever, and weight loss. Precordial chest pain and a pericardial rub may also occur.

Ulcerative colitis

Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As ulcerative colitis progresses, the pain may become steady and diffuse, increasing with movement and coughing. The most common symptom — recurrent and possibly severe diarrhea with blood, pus, and mucus — may relieve the pain. The abdomen may feel soft, squashy, and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Uremia

Characterized by generalized or periumbilical pain that shifts and varies in intensity, uremia causes diverse GI signs and symptoms, including nausea, anorexia, vomiting, and diarrhea. Abdominal tenderness that changes in location and intensity may occur, along with vision disturbances, bleeding, headache, decreased LOC, vertigo, and oliguria or anuria. Chest pain may occur secondary to pericardial effusion. Localized or diffuse pruritus is common.

Other causes

Abdominal trauma

Generalized or localized abdominal pain occurs with ecchymosis on the abdomen, abdominal tenderness, vomiting and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

Diet

Highly acidic foods, such as coffee, chocolate, tomatoes, and citrus products, may cause sharp or gnawing upper quadrant pain.

Drugs

Salicylates and nonsteroidal anti-inflammatory drugs commonly cause burning, gnawing pain in the left upper quadrant or epigastric area and nausea and vomiting.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Abdominal distention: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal cancer

Generalized abdominal distention may occur when the cancer — most commonly ovarian, hepatic, or pancreatic — produces ascites (usually in a patient with a known tumor). It’s an indication of advanced disease. Shifting dullness and a fluid wave accompany distention. Associated signs and symptoms may include severe abdominal pain, an abdominal mass, anorexia, jaundice, GI hemorrhage (hematemesis or melena), dyspepsia, and weight loss that progresses to muscle weakness and atrophy.

Abdominal trauma

When brisk internal bleeding accompanies trauma, abdominal distention may be acute and dramatic. Associated signs and symptoms of this life-threatening disorder include abdominal rigidity with guarding, decreased or absent bowel sounds, vomiting, tenderness, and abdominal bruising. Pain may occur over the trauma site or over the scapula if abdominal bleeding irritates the phrenic nerve. Signs of hypovolemic shock (such as hypotension and rapid, thready pulse) appear with significant blood loss.

Bladder distention

Various disorders cause bladder distention which, in turn, causes lower abdominal distention. Slight dullness on percussion above the symphysis pubis indicates mild bladder distention. A palpable, smooth, rounded, fluctuant suprapubic mass suggests severe bladder distention; a fluctuant mass extending to the umbilicus indicates extremely severe bladder distention. Urinary dribbling, frequency, or urgency may occur with urinary obstruction. Suprapubic discomfort is also common.

Cirrhosis

With cirrhosis, ascites causes generalized distention and is confirmed by a fluid wave and shifting dullness. Umbilical eversion and caput medusae (dilated veins around the umbilicus) are common. The patient may report a feeling of fullness or weight gain. Associated findings include vague abdominal pain, fever, anorexia, nausea, vomiting, constipation or diarrhea, bleeding tendencies, severe pruritus, palmar erythema, spider angiomas, leg edema and, possibly, splenomegaly. Hematemesis, encephalopathy, gynecomastia, or testicular atrophy may also be seen. Jaundice is usually a late sign. Hepatomegaly occurs initially; however, the liver may not be palpable if the patient has advanced disease.

Gastric dilation (acute)

Left-upper-quadrant distention is characteristic of acute gastric dilation, but the presentation varies. The patient usually complains of epigastric fullness or pain and nausea (with or without vomiting). Physical examination reveals tympany, gastric tenderness, and a succussion splash. Initially, visible peristalsis may occur. Later, hypoactive or absent bowel sounds confirm ileus. The patient may be pale and diaphoretic and may exhibit tachycardia or bradycardia.

Heart failure

Irritable bowel syndrome

Irritable bowel syndrome may produce intermittent, localized distention — the result of periodic intestinal spasms. Lower abdominal pain or cramping typically accompanies these spasms. The pain is usually relieved by defecation or by passage of intestinal gas and is aggravated by stress. Other possible signs and symptoms include diarrhea that may alternate with constipation or normal bowel function; nausea; dyspepsia; straining and urgency at defecation; feeling of incomplete evacuation; and small, mucus-streaked stools.

Large-bowel obstruction

Dramatic abdominal distention is characteristic of large-bowel obstruction, a life-threatening disorder; in fact, loops of the large bowel may become visible on the abdomen. Constipation precedes distention and may be the only symptom for days. Associated findings include tympany, high-pitched bowel sounds, and the sudden onset of colicky lower abdominal pain that becomes persistent. Fecal vomiting and diminished peristaltic waves and bowel sounds are late signs.

Mesenteric artery occlusion (acute)

In acute mesenteric artery occlusion, a life-threatening disorder, abdominal distention usually occurs several hours after the sudden onset of severe, colicky periumbilical pain accompanied by rapid (even forceful) bowel evacuation. The pain later becomes constant and diffuse. Related signs and symptoms include severe abdominal tenderness with guarding and rigidity, absent bowel sounds and, occasionally, a bruit in the right iliac fossa. The patient may also experience vomiting, anorexia, diarrhea, or constipation. Late signs include fever, tachycardia, tachypnea, hypotension, and cool, clammy skin. Abdominal distention or GI bleeding may be the only clue if pain is absent.

Nephrotic syndrome

Ovarian cysts

Typically, large ovarian cysts produce lower abdominal distention accompanied by umbilical eversion. Because they’re thin walled and fluid filled, these cysts produce a fluid wave and shifting dullness — signs that mimic ascites. Lower abdominal pain and a palpable mass may be present.

Paralytic ileus

Paralytic ileus, which produces generalized distention with a tympanic percussion note, is accompanied by absent or hypoactive bowel sounds and, occasionally, extreme distress and vomiting. The patient may be severely constipated or may pass flatus and small, liquid stools.

Peritonitis

In peritonitis, a life-threatening disorder, abdominal distention may be localized or generalized, depending on the extent of peritonitis. Fluid accumulates first within the peritoneal cavity and then within the bowel lumen, causing a fluid wave and shifting dullness. Typically, distention is accompanied by sudden and severe abdominal pain that worsens with movement. Rebound tenderness and abdominal rigidity may be present.

Associated signs and symptoms usually include hypoactive or absent bowel sounds, fever, chills, hyperalgesia, nausea, and vomiting. Also, the skin over the patient’s abdomen may appear taut. Signs of shock, such as tachycardia and hypotension, appear with significant fluid loss into the abdomen.

Small-bowel obstruction

Abdominal distention, which is characteristic of small-bowel obstruction, is most pronounced during late obstruction, especially in the distal small bowel. Auscultation reveals hypoactive or hyperactive bowel sounds, whereas percussion produces a tympanic note. Accompanying signs and symptoms of this life-threatening disorder include colicky periumbilical pain, constipation, nausea, and vomiting; the higher the obstruction, the earlier and more severe the vomiting. Rebound tenderness reflects intestinal strangulation with ischemia. Associated signs and symptoms include drowsiness, malaise, and signs of dehydration. Signs of hypovolemic shock appear with progressive dehydration and plasma loss.

Toxic megacolon (acute)

Acute toxic megacolon is a life-threatening complication of infectious or ulcerative colitis. It produces dramatic abdominal distention that usually develops gradually and is accompanied by a tympanic percussion note, diminished or absent bowel sounds, and mild rebound tenderness. The patient also presents with abdominal pain and tenderness, fever, tachycardia, and dehydration.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal mass: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal aortic aneurysm

Bladder distention

A smooth, rounded, fluctuant suprapubic mass is characteristic of bladder distention. With extreme distention, the mass may extend to the umbilicus. Severe suprapubic pain and urinary frequency and urgency may also occur.

Cholecystitis

With cholecystitis, deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. However, with acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right-upper-quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

With cholelithiasis, a stone-filled gallbladder usually produces a painless right-upper-quadrant mass that’s smooth and sausage-shaped. However, passage of a stone through the bile or cystic duct may cause severe right-upper-quadrant pain that radiates to the epigastrium, back, or shoulder blades. Accompanying signs and symptoms include anorexia, nausea, vomiting, chills, diaphoresis, restlessness, and low-grade fever. Jaundice may occur with obstruction of the common bile duct. The patient may also experience intolerance to fatty foods and frequent indigestion.

Colon cancer

A right-lower-quadrant mass may occur with cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.

Crohn’s disease

With Crohn’s disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right-lower-quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.

Diverticulitis

Most common in the sigmoid colon, diverticulitis may produce a left-lower-
quadrant mass that’s usually tender, firm, and fixed. It also produces intermittent abdominal pain that’s relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, low-grade fever, and a distended and tympanic abdomen.

Gallbladder cancer

Gastric cancer

Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness, fatigue and, occasionally, coffee-ground vomitus or melena.

Hepatic cancer

Hepatic cancer produces a tender, nodular mass in the right upper quadrant or right epigastric area accompanied by severe pain that’s aggravated by jolting. Other effects include weight loss, weakness, anorexia, nausea, fever, dependent edema and, occasionally, jaundice and ascites. A large tumor can also cause a bruit or hum.

Hepatomegaly

Hydronephrosis

Enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.

Ovarian cyst

Pancreatic abscess

Renal cell cancer

Splenomegaly

The lymphomas, leukemias, hemolytic anemias, and inflammatory diseases are among the many disorders that may cause splenomegaly. Typically, the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but commonly include a feeling of abdominal fullness, left-upper-quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and low-grade fever.

Uterine leiomyomas (fibroids)

If large enough, a uterine leiomyoma (common, benign uterine tumor) can produce a round, multinodular mass in the suprapubic region. The patient’s chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal pain: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal aortic aneurysm (dissecting)

Dissecting abdominal aortic aneurysm, a life-threatening disorder, may initially produce dull lower abdominal, lower back, or severe chest pain. Typically, it produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Abdominal trauma

With abdominal trauma, generalized or localized abdominal pain occurs with ecchymoses on the abdomen, abdominal tenderness, vomiting and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

Adrenal crisis

With adrenal crisis, severe abdominal pain appears early, along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness; hypotension; tachycardia; oliguria; cool, clammy skin; and increased motor activity, which may progress to delirium or seizures.

Anthrax, GI

GI anthrax is an acute infectious disease that’s caused by eating meat contaminated with the gram-positive, spore-forming bacterium Bacillus anthracis. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

With appendicitis, a life-threatening disorder, pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, or vomiting may occur after the onset of pain. Pain localizes at McBurney’s point in the right lower quadrant and is accompanied by abdominal rigidity, increased tenderness (especially over McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

Cholecystitis

In cholecystitis, severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity, tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

A patient with cholelithiasis may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

Cirrhosis

With cirrhosis, dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, constipation, or diarrhea. Subsequent right-upper-quadrant pain worsens when the patient sits up or leans forward.
Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

Crohn’s disease

An acute attack of Crohn’s disease causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn’s disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding and, possibly, a palpable mass in a lower quadrant. Abdominal pain is usually relieved by defecation. Milder chronic signs and symptoms include right-lower-quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

Cystitis

With cystitis, abdominal pain and tenderness are usually suprapubic. Associated signs and symptoms include malaise, flank pain, low back pain, nausea, vomiting, urinary frequency and urgency, nocturia, dysuria, fever, and chills.

Diverticulitis

Mild cases of diverticulitis usually produce intermittent, diffuse left-lower-quadrant pain, which is sometimes relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, low-grade fever and, in many cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left-lower-quadrant pain, abdominal rigidity and, possibly, signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

Duodenal ulcer

With a duodenal ulcer, localized abdominal pain — described as steady, gnawing, burning, aching, or hungerlike — may occur high in the midepigastrium, slightly off-center, usually on the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again, but it also may produce weight gain. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

Ectopic pregnancy

Lower abdominal pain may be sharp, dull, or cramping, and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur, along with urinary frequency, a tender adnexal mass, and a 1- to 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

Endometriosis

With endometriosis, constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, the pain may be accompanied by constipation, abdominal tenderness, dysmenorrhea, dyspareunia, and deep sacral pain.

Escherichia coli O157:H7

Escherichia coli O157:H7 is an aerobic, gram-negative bacillus that causes food-borne illness. Most strains of E. coli are harmless and are part of the normal intestinal flora of healthy humans and animals. E. coli O157:H7, one of hundreds of strains of the bacterium, can produce a powerful toxin and cause severe illness. Eating undercooked beef or other foods contaminated with the bacteria causes the disease. Signs and symptoms include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. In children younger than age 5 and elderly adults, hemolytic uremic syndrome may develop and may ultimately lead to acute renal failure.

Gastric ulcer

In a patient with a gastric ulcer, diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 to 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

Gastritis

Gastroenteritis

With gastroenteritis, cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It’s accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

Heart failure

Right-upper-quadrant pain commonly accompanies these hallmarks of heart failure: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

Hepatitis

Herpes zoster

Intestinal obstruction

Short episodes of intense, colicky, cramping pain alternate with pain-free intervals in intestinal obstruction. Accompanying signs and symptoms of this life-threatening disorder may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as hypotension and tachycardia.

Irritable bowel syndrome

With irritable bowel syndrome, lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

Listeriosis

Listeriosis is a serious infection that’s caused by eating food contaminated with the bacterium Listeria monocytogenes. This food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems. Signs and symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; signs and symptoms include fever, headache, nuchal rigidity, and change in level of consciousness (LOC).

Mesenteric artery ischemia

Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmia, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

Ovarian cyst

Torsion or hemorrhage related to an ovarian cyst causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn’t. Pain is accompanied by slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass and, possibly, amenorrhea. Abdominal distention may occur if the patient has a large cyst. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

Pancreatitis

Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Pelvic inflammatory disease

Pelvic inflammatory disease causes pain in the right or left lower quadrant that ranges from vague discomfort that’s worsened by movement, to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, urinary discomfort, and abnormal vaginal bleeding or purulent vaginal discharge.

Perforated ulcer

With perforated ulcer, a life-threatening disorder, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

Peritonitis

With peritonitis, a life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

Pleurisy

Pneumonia

Pneumothorax

Pneumothorax is a potentially life-threatening disorder that can cause pain across the upper abdomen and costal margin that’s referred from the chest. Characteristic chest pain arises suddenly and worsens with deep inspiration or movement. Accompanying signs and symptoms include anxiety, dyspnea, cyanosis, decreased or absent breath sounds over the affected area, tachypnea, and tachycardia. Watch for asymmetrical chest movements on inspiration.

Prostatitis

With prostatitis, vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

Pyelonephritis (acute)

Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize acute pyelonephritis. Pain may radiate to the lower midabdomen or to the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

Renal calculi

Depending on the location of renal calculi, severe abdominal or back pain may occur. However, the classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant. Pain-induced agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria may occur.

Sickle cell crisis

Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain in sickle cell crisis. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice. Sickle cell crisis is the hallmark of sickle cell disease and tends to appear periodically after age 5.

Smallpox (variola major)

Initial signs and symptoms of smallpox include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Splenic infarction

Sudden, severe pain in the left upper quadrant occurs along with chest pain that may worsen on inspiration in splenic infarction. Pain commonly radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

Ulcerative colitis

Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom — recurrent and possibly severe diarrhea with blood, pus, and mucus — may relieve the pain. The abdomen may feel soft, squashy, and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Uremia

Characterized by generalized or periumbilical pain that shifts and varies in intensity, uremia causes diverse GI signs and symptoms, such as nausea, anorexia, vomiting, and diarrhea. Abdominal tenderness that changes in location and intensity may occur, along with vision disturbances, bleeding, headache, decreased LOC, vertigo, and oliguria or anuria. Chest pain may occur secondary to pericardial effusion. Localized or diffuse pruritus is common.

Other causes

Drugs

Salicylates and nonsteroidal anti-inflammatories commonly cause burning, gnawing pain in the left upper quadrant or epigastric area, along with nausea and vomiting.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Abdominal Pain: Principal Causes of Acute Abdominal Pain
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Neonates
1. Common
  1. Colic
  2. Necrotizing enterocolitis
2. Uncommon
  1. Gastrointestinal obstruction or perforationof any viscus
Infants
1. Common
  1. Colic
  2. Gastroenteritis
  3. Viral illness
  4. Incarcerated inguinal hernia
  5. Intussusception
  6. Trauma including child abuse
2. Uncommon
  1. Appendicitis
  2. Cow milk protein sensitivity
  3. Lactose intolerance
  4. Gastrointestinal obstruction includingvolvulus with malrotation
  5. Sickle cell pain episodes
  6. Lead poisoning
  7. Neoplasm
Preschool children
1. Common
  1. Constipation
  2. Gastroenteritis
  3. Viral illness
  4. Urinary tract infection
  5. Pneumonia
  6. Trauma
  7. Lactose intolerance
  8. Sickle cell pain episodes
2. Uncommon
  1. Food poisoning
  2. Diabetic ketoacidosis
  3. Gastrointestinal obstruction
  4. Henoch-Schönlein purpura
  5. Neoplasm
  6. Drugs and toxins
  7. Appendicitis
  8. Intussusception
  9. Hepatitis
School-aged children and adolescents
1. Common
  1. Gastroenteritis
  2. Viral illnesses
  3. Constipation
  4. Trauma
  5. Urinary tract infection
  6. Acute appendicitis
  7. Pneumonia
  8. Lactose intolerance
  9. Sickle cell pain episodes
  10. Functional abdominal pain
2. Uncommon
  1. Peptic ulcer disease
  2. Biliary tract disease
    1. Acutecholecystitis
    2. Biliary colic
  3. Pancreatitis
  4. Obstructive uropathy
  5. Urolithiasis
  6. Intraabdominal abscess
  7. Primary bacterial peritonitis
  8. Inflammatory bowel disease
  9. Lactose intolerance
  10. Hepatitis
  11. Intestinal obstruction
  12. Diabetic ketoacidosis
  13. Neoplasm
  14. Drugs and toxins
Adolescent girls
1. Common
  1. Primarydysmenorrhea
  2. Mittelschmerz
  3. Pelvic inflammatory disease
2. Uncommon
  1. Ovarian disorders
  2. Endometriosis
  3. Genital tract malformations with obstruction
  4. Complications of pregnancy

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Abdominal Masses: Principal Causes of Abdominal Masses
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Rightupper quadrant
1. Liver
  1. Hepatomegaly
  2. Hepatic cyst
  3. Primary hepatic neoplasms
2. Gallbladder
  1. Cholecystitis
  2. Hydrops of the gallbladder
3. Biliary tree
  1. Choledochal cyst
4. Intestine
  1. Pyloric stenosis
  2. Duodenal hematoma
  3. Duplication
Left upper quadrant
1. Spleen
  1. Splenomegaly
  2. Splenic cyst
  3. Neoplasm
Epigastric
1. Stomach
  1. Bezoar
  2. Duplication
2. Pancreas
  1. Pancreatic cyst
  2. Pancreatic pseudocyst
  3. Neoplasm
Right/left mid-abdomen
1. Kidney
  1. Unilateral
    1. Hydronephrosis
    2. Multicystic dysplastic kidney
    3. Renal vein thrombosis
    4. Congenital mesoblastic nephroma
    5. Wilms tumor
    6. Renal cyst
    7. Ectopic kidney
    8. Horseshoe kidney
    9. Renal or perinephric abscess
  2. Bilateral
    1. Hydronephrosis
    2. Multicystic dysplastic kidney
    3. Renal vein thrombosis
    4. Polycystic kidney disease
    5. Beckwith-Wiedemann syndrome
2. Adrenal
  1. Neonatal adrenal hematoma
  2. Neuroblastoma
Periumbilical
1. Intestine
  1. Mesenteric cyst
  2. Volvulus
  3. Duplication
  4. Neoplasm
Right lower quadrant
1. Intestine
  1. Abscess
  2. Intussusception
  3. Lymphoma
2. Ovary
  1. Cyst
  2. Torsion
  3. Neoplasm
Left lower quadrant
1. Intestine
  1. Constipation
2. Ovary (see right lower quadrant)
Hypogastrium
1. Bladder
  1. Distension/obstruction
2. Uterus
  1. Pregnancy
  2. Hydrometrocolpos

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Abdominal distention: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal cancer.Generalized abdominal distention may occur when the cancer—most commonly ovarian, hepatic, or pancreatic—produces ascites (usually in a patient with a known tumor). It's an indication of advanced disease. Shifting dullness and a fluid wave accompany distention. Associated signs and symptoms may include severe abdominal pain, an abdominal mass, anorexia, jaundice, GI hemorrhage (hematemesis or melena), dyspepsia, and weight loss that progresses to muscle weakness and atrophy.

Abdominal trauma.When brisk internal bleeding accompanies trauma, abdominal distention may be acute and dramatic. Associated signs and symptoms of this life-threatening disorder include abdominal rigidity with guarding, decreased or absent bowel sounds, vomiting, tenderness, and abdominal bruising. Pain may occur over the trauma site, or over the scapula if abdominal bleeding irritates the phrenic nerve. Signs of hypovolemic shock (such as hypotension and rapid, thready pulse) appear with significant blood loss.

Cirrhosis.In cirrhosis, ascites causes generalized distention and is confirmed by a fluid wave, shifting dullness, and a puddle sign. Umbilical eversion and caput medusae (dilated veins around the umbilicus) are common. The pa-tient may report a feeling of fullness or weight gain. Associated findings include vague abdominal pain, fever, anorexia, nausea, vomiting, constipation or diarrhea, bleeding tendencies, severe pruritus, palmar erythema, spider angiomas, leg edema, and possibly splenomegaly. Hematemesis, encephalopathy, gynecomastia, or testicular atrophy may also be seen. Jaundice is usually a late sign. Hepatomegaly occurs initially, but the liver may not be palpable if the patient has advanced disease.

Heart failure.Generalized abdominal distention due to ascites typically accompanies severe cardiovascular impairment and is confirmed by shifting dullness and a fluid wave. Signs and symptoms of heart failure are numerous and depend on the disease stage and degree of cardiovascular impairment. Hallmarks include peripheral edema, jugular vein distention, dyspnea, and tachycardia. Common associated signs and symptoms include hepatomegaly (which may cause right upper quadrant pain), nausea, vomiting, a productive cough, crackles, cool extremities, cyanotic nail beds, nocturia, exercise intolerance, nocturnal wheezing, diastolic hypertension, weight gain, and cardiomegaly.

Irritable bowel syndrome.Irritable bowel syndrome may produce intermittent, localized distention—the result of periodic intestinal spasms. Lower abdominal pain or cramping typically accompanies these spasms. The pain is usually relieved by defecation or by passage of intestinal gas and is aggravated by stress. Other possible signs and symptoms include diarrhea that may alternate with constipation or normal bowel function, nausea, dyspepsia, straining and urgency at defecation, a feeling of incomplete evacuation, and small, mucus-streaked stools.

Large-bowel obstruction.Dramatic abdominal distention is characteristic in this life-threatening disorder; in fact, loops of the large bowel may become visible on the abdomen. Constipation precedes distention and may be the only symptom for days. Associated findings include tympany, high-pitched bowel sounds, and the sudden onset of colicky lower abdominal pain that becomes persistent. Nausea, fecal vomiting, and diminished peristaltic waves and bowel sounds are late signs.

Mesenteric artery occlusion (acute). In this life-threatening disorder, abdominal distention usually occurs several hours after the sudden onset of severe, colicky periumbilical pain accompanied by rapid (even forceful) bowel evacuation. The pain later becomes constant and diffuse. Related signs and symptoms include severe abdominal tenderness with guarding and rigidity, absent bowel sounds and, occasionally, a bruit in the right iliac fossa. The patient may also experience vomiting, anorexia, diarrhea, or constipation. Late signs include fever, tachycardia, tachypnea, hypotension, and cool, clammy skin. Abdominal distention or GI bleeding may be the only clue if pain is absent.

Paralytic ileus.Paralytic ileus, which produces generalized distention with a tympanic percussion note, is accompanied by absent or hypoactive bowel sounds and, occasionally, mild abdominal pain and vomiting. The patient may be severely constipated or may pass flatus and small, liquid stools.

Peritonitis.Peritonitis is a life-threatening disorder in which abdominal distention may be localized or generalized, depending on the extent of the inflammation. Fluid accumulates within the peritoneal cavity and then within the bowel lumen, causing a fluid wave and shifting dullness. Typically, distention is accompanied by sudden and severe abdominal pain that worsens with movement, rebound tenderness, and abdominal rigidity.

The skin over the patient's abdomen may appear taut. Associated signs and symptoms usually include hypoactive or absent bowel sounds, fever, chills, hyperalgesia, nausea, and vomiting. Signs of shock, such as tachycardia and hypotension, appear with significant fluid loss into the abdomen.

Small-bowel obstruction.Abdominal distention is characteristic in small-bowel obstruction, a life-threatening disorder, and is most pronounced during late obstruction, especially in the distal small bowel. Auscultation reveals hypoactive or hyperactive bowel sounds, whereas percussion produces a tympanic note. Accompanying signs and symptoms include colicky periumbilical pain, constipation, nausea, and vomiting; the higher the obstruction, the earlier and more severe the vomiting. Rebound tenderness reflects intestinal strangulation with ischemia. Associated signs and symptoms include drowsiness, malaise, and signs of dehydration. Signs of hypovolemic shock appear with progressive dehydration and plasma loss.

Toxic megacolon (acute).Toxic megacolon is a life-threatening complication of infectious or ulcerative colitis. It produces dramatic abdominal distention that usually develops gradually and is accompanied by a tympanic percussion note, diminished or absent bowel sounds, and mild rebound tenderness. The patient also presents with abdominal pain and tenderness, fever, tachycardia, and dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal mass: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal aortic aneurysm.An abdominal aortic aneurysm may exist for years, producing only a pulsating periumbilical mass with a systolic bruit over the aorta. It may become life-threatening if the aneurysm expands and its walls weaken. In such cases, the patient initially reports constant upper abdominal pain or, less commonly, low back or dull abdominal pain. If the aneurysm ruptures, he'll report severe abdominal and back pain. After rupture, the aneurysm no longer pulsates.

Associated signs and symptoms of rupture include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock—such as altered mental status, tachycardia, and cool, clammy skin—appear with significant blood loss.

Cholecystitis.Deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. With acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right upper quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy's sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Colon cancer.A right lower quadrant mass may occur with cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.

Crohn's disease.With Crohn's disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right lower quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.

Diverticulitis.Most common in the sigmoid colon, diverticulitis may produce a left lower quadrant mass that's usually tender, firm, and fixed. It also produces intermittent abdominal pain that's relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, a low-grade fever, and a distended and tympanic abdomen.

Gastric cancer.Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness after eating, fatigue and, occasionally, coffee-ground vomitus or melena.

Hepatomegaly.Hepatomegaly produces a firm, blunt, irregular mass in the epigastric region or below the right costal margin. Associated signs and symptoms vary with the causative disorder but commonly include ascites, right upper quadrant pain and tenderness, anorexia, nausea, vomiting, leg edema, jaundice, palmar erythema, spider angiomas, gynecomastia, testicular atrophy and, possibly, splenomegaly.

Hernia.The soft and typically tender bulge is usually an effect of prolonged, increased intra-abdominal pressure on weakened areas of the abdominal wall. An umbilical hernia is typically located around the umbilicus and an inguinal hernia in either the right or left groin. An incisional hernia can occur anywhere along a previous incision. Hernia may be the only sign until strangulation occurs.

Hydronephrosis.Enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.

Ovarian cyst.A large ovarian cyst may produce a smooth, rounded, fluctuant mass, resembling a distended bladder, in the suprapubic region. Large or multiple cysts may also cause mild pelvic discomfort, low back pain, menstrual irregularities, and hirsutism. A twisted or ruptured cyst may cause abdominal tenderness, distention, and rigidity.

Splenomegaly.With splenomegaly,the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but usually include a feeling of abdominal fullness, left upper quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and a low-grade fever.

Uterine leiomyomas (fibroids).If large enough, these common, benign uterine tumors produce a round, multinodular mass in the suprapubic region. The patient's chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal aortic aneurysm
(dissecting).Initially, this life-threatening disorder may produce dull lower abdominal, lower back, or severe chest pain. Usually, a dissecting abdominal aortic aneurysm produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Abdominal cancer.Abdominal pain usually occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness, depression, and abdominal mass and distention.

Abdominal trauma.Generalized or localized abdominal pain occurs with ecchymoses on the abdomen, abdominal tenderness, vomiting and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

Adrenal crisis.Severe abdominal pain appears early, along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness; hypotension; tachycardia; oliguria; cool, clammy skin; and increased motor activity, which may progress to delirium or seizures.

Anthrax, GI.GI anthrax is caused by eating contaminated meat from an infected animal. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis.With appendicitis, a life-threatening disorder, pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, or vomiting may occur after the onset of pain. Pain localizes at McBurney's point in the right lower quadrant and is accompanied by abdominal rigidity, increasing tenderness (especially over McBurney's point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

Cholecystitis.Severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity, tenderness, pallor, and diaphoresis. Murphy's sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis.Patients may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

Cirrhosis.Dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, constipation, or diarrhea. Subsequent right upper quadrant pain worsens when the patient sits up or leans forward. Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

Crohn's disease.An acute attack in Crohn's disease causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn's disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding, and possibly a palpable mass in a lower quadrant. Abdominal pain is commonly relieved by defecation. Milder chronic signs and symptoms include right lower quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

Diverticulitis.Mild cases of diverticulitis usually produce intermittent, diffuse left lower quadrant pain, which is sometimes relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, a low-grade fever and, in many cases, a palpable abdominal mass that's usually tender, firm, and fixed. Rupture causes severe left lower quadrant pain, abdominal rigidity and, possibly, signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

Duodenal ulcer.Localized abdominal pain—described as steady, gnawing, burning, aching, or hunger like—may occur high in the midepigastrium, slightly off center, usually on the right. The pain usually doesn't radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again, but it may also produce weight gain. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

Ectopic pregnancy.Lower abdominal pain may be sharp, dull, or cramping and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur, along with urinary frequency, a tender adnexal mass, and a 1- or 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

Endometriosis.Constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, the pain may be accompanied by constipation, abdominal tenderness, dysmenorrhea, dyspareunia, and deep sacral pain.

Escherichia coli O157:H7 infection.Signs and symptoms of E. coli O157:H7 infection include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop, and this may ultimately lead to acute renal failure.

Gastric ulcer.Diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 or 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

Gastritis.With acute gastritis, the patient experiences a rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. Significant bleeding is unusual unless the patient has hemorrhagic gastritis.

Gastroenteritis.Cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It's accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

Heart failure.Right upper quadrant pain caused by liver congestion or enlargement commonly accompanies heart failure's hallmarks: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

Hepatitis.Liver enlargement from any type of hepatitis causes discomfort or dull pain and tenderness in the right upper quadrant. Associated signs and symptoms may include dark urine, clay-colored stools, nausea, vomiting, anorexia, jaundice, malaise, and pruritus.

Intestinal obstruction.Short episodes of intense, colicky, cramping pain alternate with pain-free intervals with an intestinal obstruction, a life-threatening disorder. Accompanying signs and symptoms may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as altered mental status, tachycardia, and hypotension.

Irritable bowel syndrome.Lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

Listeriosis.Signs and symptoms of listeriosis include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; signs and symptoms include fever, headache, nuchal rigidity, and change in the level of consciousness.

Mesenteric artery ischemia.Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmia, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 or 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

Norovirus infection.Abdominal pain or cramping is a symptom commonly associated with noroviruses. Transmitted by the fecal-oral route and highly contagious, these viruses that cause gastroenteritis may also produce acute-onset vomiting, nausea, and diarrhea. Less common symptoms include low-grade fever, headache, chills, muscle aches, and generalized fatigue. Individuals who are otherwise healthy usually recover in 24 to 60 hours without suffering lasting effects.

Ovarian cyst.Torsion or hemorrhage causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn't. Pain is accompanied by slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass and, possibly, amenorrhea. Abdominal distention may occur if the patient has a large cyst. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

Pancreatitis.Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner's sign (ecchymosis of the abdomen or flank) or Cullen's sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Chronic pancreatitisproduces severe left upper quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, maldigestion, and hyperglycemia are common.

Pelvic inflammatory disease.Pain in the right or left lower quadrant ranges from vague discomfort worsened by movement to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, urinary discomfort, and abnormal vaginal bleeding or purulent vaginal discharge.

Perforated ulcer.With perforated ulcer, a life-threatening disorder, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

Peritonitis.With peritonitis, a life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

Prostatitis.Vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop with prostatitis. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

Pyelonephritis (acute).Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize this disorder. Pain may radiate to the lower midabdomen or to the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

Renal calculi.Depending on the location of calculi, severe abdominal or back pain may occur. The classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant. Pain-induced agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria may occur.

Sickle cell crisis.Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice.

Smallpox (variola major).Initial signs and symptoms of smallpox include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Splenic infarction.Fulminating pain in the left upper quadrant occurs along with chest pain that may worsen on inspiration. Pain usually radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

Ulcerative colitis.Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom—recurrent and possibly severe diarrhea with blood, pus, and mucus—may relieve the pain. The abdomen may feel soft and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Other causes

Drugs.Salicylates and nonsteroidal anti-inflammatory drugs commonly cause burning, gnawing pain in the left upper quadrant or epigastric area, along with nausea and vomiting.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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Dr. Huntley's Diagnosis Checklist

Causes of Abdominal Cancer

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Abdominal Pain in Lower Quadrants: Differential Diagnosis (In a Page: Signs and Symptoms)

Abdominal Pain in Upper Quadrants: Differential Diagnosis (In a Page: Signs and Symptoms)

Abdominal Pain with Rebound Tenderness: Differential Diagnosis (In a Page: Signs and Symptoms)

Abdominal Masses: Differential Diagnosis (In a Page: Signs and Symptoms)

Abdominal Pain: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Abdominal Masses: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Abdominal distention: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Abdominal mass: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Abdominal pain: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Other causes

Introduction: Malignant Neoplasms: What causes cancer? (Professional Guide to Diseases (Eighth Edition))

Malignant spinal neoplasms: Causes and incidence (Professional Guide to Diseases (Eighth Edition))

Abdominal distention: Medical causes (Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal cancer

Abdominal trauma

Bladder distention

Cirrhosis

Gastric dilation (acute)

Heart failure

Irritable bowel syndrome (IBS)

Large-bowel obstruction

Mesenteric artery occlusion (acute)

Nephrotic syndrome

Ovarian cysts

Paralytic ileus

Peritonitis

Small-bowel obstruction

Toxic megacolon (acute)

Abdominal mass: Medical causes (Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm

Bladder distention

Cholecystitis

Cholelithiasis

Colon cancer

Crohn’s disease

Diverticulitis

Gallbladder cancer

Gastric cancer

Hepatic cancer

Hepatomegaly

Hydronephrosis

Ovarian cyst

Pancreatic abscess

Pancreatic pseudocysts

Renal cell carcinoma

Splenomegaly

Uterine leiomyomas (fibroids)

Abdominal pain: Medical causes (Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm (dissecting)

Abdominal cancer

Abdominal trauma

Adrenal crisis

Anthrax, GI

Appendicitis

Cholecystitis

Cholelithiasis

Cirrhosis

Crohn’s disease

Cystitis

Diabetic ketoacidosis

Diverticulitis

Duodenal ulcer

Ectopic pregnancy

Endometriosis

Escherichia coli O157:H7

Gastric ulcer

Gastritis

Gastroenteritis

Heart failure

Hepatic abscess

Hepatic amebiasis

Hepatitis

Herpes zoster

Dr. Huntley's
Diagnosis
Checklist

Abdominal Pain in Lower Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Abdominal Pain in Upper Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Abdominal Pain with Rebound Tenderness: Differential Diagnosis
(In a Page: Signs and Symptoms)

Abdominal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

Abdominal Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Abdominal Masses: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Abdominal distention: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Abdominal mass: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Abdominal pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Introduction: Malignant Neoplasms: What causes cancer?
(Professional Guide to Diseases (Eighth Edition))

Malignant spinal neoplasms: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Abdominal distention: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal mass: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Chronic/Recurrent Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Acute Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal pain: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)