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Causes of Mittelschmerz

Mittelschmerz Causes: Book Excerpts

• Differential Diagnosis - Abdominal Pain in Lower Quadrants
• Differential Diagnosis - Abdominal Pain in Upper Quadrants
• Differential Diagnosis - Abdominal Pain with Rebound Tenderness
• Differential Diagnosis - Abdominal Pain
• Medical causes - Abdominal pain
• Medical causes - Abdominal pain
• Differential Overview - Chronic/Recurrent Abdominal Pain
• Differential Overview - Acute Abdominal Pain
• Medical causes - Abdominal pain
• Medical causes - Abdominal pain
• Principal Causes of Acute Abdominal Pain - Abdominal Pain
• Medical causes - Abdominal pain

Mittelschmerz as a symptom:

Conditions listing Mittelschmerz as a symptom may also be potential underlying causes of Mittelschmerz. Our database lists the following as having Mittelschmerz as a symptom of that condition:

• Mittelschmerz

Related information on causes of Mittelschmerz:

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

• Hidden causes of Mittelschmerz

Causes of Mittelschmerz: Online Medical Books

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

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 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 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.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third 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

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, which rapidly evolve into grouped vesicles.

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.

» READ BOOK EXCERPT ONLINE »

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

» READ BOOK EXCERPT ONLINE »

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.

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 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

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 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

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 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

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 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

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

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.

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.

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.

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, poor digestion, 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. 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

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 develop 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

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

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 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

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 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.

» READ BOOK EXCERPT ONLINE »

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

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 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

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

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

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

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, which rapidly evolve into grouped vesicles.

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.

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

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

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 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.

» READ BOOK EXCERPT ONLINE »

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)

1. Neonates
   1. Common
      1. Colic
      2. Necrotizing enterocolitis
   2. Uncommon
      1. Gastrointestinal obstruction or perforationof any viscus
2. 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
3. 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
4. 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
5. 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

» READ BOOK EXCERPT ONLINE »

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

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.

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.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.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

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