Causes of Abdominal Complaints

Due to the extreme complexity of the human body, there are multiple
problems that can occur with it, particularly within the abdominal cavity.
Some of the more likely presentations you will come across in the
prehospital setting are:
● nausea and vomiting
● appendicitis
● pancreatitis
● gastroenteritis
● inflammatory bowel disease
● bowel obstructions
● ectopic pregnancy
● kidney stones

You will notice the common theme that provisional diagnoses can be
difficult, and transport to hospital should be considered in all cases!
Nausea and Vomiting
Nausea and vomiting are symptoms of an underlying illness and not a
specific disease. 'Nausea' is the sensation that the stomach wants to empty
itself (an inclincation to vomit), while 'vomiting' (emesis) is the act of
forcible emptying of the stomach contents. 'Retching' on the other hand, is
the gastric and oesphageal movements and sensation of vomiting, without
the expulsion of any actual vomitus. There are numerous causes of
nausea and vomiting and these symptoms may be due to the following:
Acute gastritis​ - caused by something that irritates the lining of the
stomach such as an infection, peptic ulcers, GORD and alcohol and
smoking.
Central causes​ - in which signals from the brain directly cause nausea and
vomiting. E.g. headache, inner ear issues (labrynthitis, vertigo), increased
ICP (trauma, tumours, infection), pregnancy (hormone changes), and
noxious stimulants (certain smells or sounds).
Other illnesses​ - not due to stomach problems, and include heat-related
illness, diabetes, sepsis, eating disorders, cardiac complications, and
digestive organ diseases (e.g. pancreatitis, crohn's disease, renal issues,
bowel obstructions).
Medications and medical treatments​ - many medications may irriate the
stomach, and commonly result in nausea and/or vomiting, and include
opioids, anti-inflammatory drugs, steroids, and antibiotics. Anti-cancer
medications and radiotherapy frequently cause abdominal complaints.

Essentially nausea and vomiting can be as a result of many different

disease processes and the paramedic should be able to determine between
which require urgent intervention, and which are less serious. The patient
may require an anti-emetic, fluid therapy and analgesia and receive
follow-up from a health care professional, regardless of how insignificant
the cause may appear. You should also consider your own PPE to avoid
catching something contagious from an infective patient!

Appendicitis
Appendicitis is an inflammation of the appendix, an 8cm long pouch of
tissue that extends from the large intestine. It is caused by either an
infection (possibly spread from elsewhere), or an obstruction (from foreign
body or faeces carrying bacteria). Left untreated, an inflamed appendix will
eventually perforate, spilling infectious materials into the abdominal cavity.
This can lead to peritonitis (inflammation of the peritoneum) which can be
fatal unless it is treated quickly with antibiotic therapy. Appendicitis is a
medical emergency that requires prompt surgical intervention to remove
the inflamed appendix. There is no way to prevent appendicitis. However,
appendicitis is less common in people who eat foods high in fibre.

Symptoms of Appendicitis:
● Pain - Appendicitis pain often occurs in the LRQ of the abdomen. The
first sign, however, is typically discomfort near the umbilicus, which
then moves to the lower abdomen. The pain may also get worse on
movement, coughing and sneezing. Once the pain is in the lower part of
the abdomen, it can be very intense and increase in severity quickly.
● Rebound tenderness - occurs when you push on the lower-right part of
your abdomen and then experience pain when releasing the pressure (a
classic sign).
● Rovsing's Sign - named after the Danish surgeon Niels Thorkild Rovsing.
If palpation of the left lower quadrant of a person's abdomen increases
the pain felt in the right lower quadrant, the patient is said to have a
positive Rovsing's sign and may have appendicitis. In acute appendicitis,
palpation in the left iliac fossa may produce pain in the right iliac fossa.
● Low-grade fever and chills
● Nausea and vomiting
● Loss of appetite
● Constipation or diarrhoea
● Gas and bloating

Diagnosing appendicitis can be difficult, as the symptoms are frequently

vague or similar to other ailments, including gallbladder problems, bladder
or urinary tract infection, Crohn's disease, gastritis, intestinal infection, and
ovary problems. Surgery to remove the appendix (appendectomy) is fairly
routine, and doctors may perform this if any suspicion of appendicitis
exists, and follow-through with the procedure even if the appendix looks
normal during surgery. The following tests are usually used to rule out
other complications and make a diagnosis:
● Abdominal exam to detect inflammation
● Urine test to rule out a urinary tract infection
● Rectal exam
● Blood test to see if your body is fighting infection
● CT scans and/or ultrasound

REVIEW​: A
​ ppendicitis Fact Sheet​

In the prehospital setting paramedics may be called for debilitating

abdominal pain and fever. You should consider appendicitis when the
patient has multiple symptoms as above (ask if they have had their
appendix out in the past or look for a small scar in the RLQ), and transport
to hospital. Your treatment may include analgesia
(methoxyflurane/morphine) and an antiemetic (maxolon/ondansetron).
Pancreatitis
Pancreatitis is inflammation of the pancreas and occurs when pancreatic
enzymes (mainly trypsin) that digest food are activated in the pancreas
instead of the duodenum. It is either classed as acute (develops over days
and often subsides) or chronic (persistent and causes scarring) - up to
10% of cases of severe acute pancreatitis are fatal. More than 80% of
cases are caused by gallstones (most common for acute) and alcohol (most
common for chronic). Infectious agents and some medications may also
cause pancreatitis and include corticosteroids, anti-cancer and HIV drugs,
cholesterol-lowering statins and anti-hyperglycaemic agents.

Signs and symptoms include:

● Severe upper abdominal (LUQ) pain
● Burning abdominal pain radiating to the back
● Nausea and vomiting which worsens with eating
● Fever
● Jaundice
● Swollen abdomen
● Weight-loss (when digestion is hindered)
● Possible indications of internal bleeding

Detecting pancreatitis involves blood tests to show high amylase or lipase

levels, and an abdominal ultrasound or CT scan. Either of these coupled
with the characteristic pain and symptoms as above result in a diagnosis.
Mild cases are managed in hospital with strong analgesia, whereas severe
cases require admission to an ICU for continual fluid therapy and treatment
of the underlying cause.
REVIEW​: P
​ ancreatitis Fact Sheet

In the prehospital setting it is difficult to create a provisional diagnosis, as

with many abdominal complaints, and all patients with suspcted
pancreatitis should be transported to hospital with the appropriate
symptom management as required.
Gastroenteritis
Gastroenteritis is a nonspecific term for various pathologic states of the
gastrointestinal tract, mainly inflammation of the mucous membranes. The
primary manifestation is diarrhoea, but it may be accompanied by nausea,
vomiting, and abdominal pain. The micro-organisms that cause
gastroenteritis are found in the faeces and vomit of infected people and
can contaminate food, water and objects. People can become infected by
eating or drinking items contaminated with the organisms, or by touching
contaminated surfaces or objects and then playing hands in their mouth.
Symptoms usually begin about 24 to 48 hours after exposure to the source
of infection but can appear as early as 6 hours after exposure. The severity
of illness may vary from mild and inconvenient to severe and life
threatening. Symptoms include:
● nausea and vomiting
● diarrhoea
● bloody stools/faeces (in some cases)
● stomach pain/cramps
● fever
● generally feeling unwell, including lethargy and body aches

G​astroenteritis diagnosis is generally based on symptoms, a physical exam

and sometimes on the presence of similar cases in the community. A
well-taken history, considering important epidemiologic factors, can help to
identify not only the cause of gastroenteritis symptoms, but also the
patient at risk for complications. The history should also identify risk factors
for unusual causes of acute gastroenteritis and possible reasons to suspect
noninfectious aetiologies. Indications of dehydration or sepsis should also
be sought. Differential diagnoses include appendicitis, inflammatory bowel
disease, bowel obstruction, and salmonella infection.

Things to consider:
● The presence of high fever generally suggests that an invasive organism
is the cause of diarrhoea.
● Vomiting implies proximal bowel involvement​.
● The location and character of pain may be indicative of the area of
infection.
● Cramps may be caused by an electrolyte imbalance.
● Pain, especially in patients older than 50 years, should raise the
suspicion of an ischaemic process.
● Large volumes of stool are usually associated with enteric infection,
whereas colonic infection results in many small stools.
● The presence of blood may indicate colonic ulceration (bacterial
infection, inflammatory disease, ischaemia).
● A history of any nonintestinal illnesses that can lead to diarrhoea should
be obtained. Vomiting and/or diarrhea may be a manifestation of that
illness or a result of its treatment. Obtaining a history of recent surgery
 or radiation, food or drug allergies, and endocrine or gastrointestinal
disorders is extremely important. The patient should always be
questioned regarding prior episodes.
● Malaria, Whipple disease, irritable bowel, incomplete bowel obstruction,
inflammatory bowel disease, nutritional disease, and carcinoid and
malabsorption syndromes can all result in diarrhea and are examples of
the numerous possible noninfectious cases.
● The young and the elderly are at risk of severe dehydration which may
be associated with significant electrolyte imbalances.
● A number of historical questions may provide clues to the aetiology of
the illness, including foreign travel, recent camping, recent antibiotic
use, daycare attendance, ingestion of raw foods, as well as similar
illnesses in family or friends.

Treatment depends on the cause but in general people with gastroenteritis

should drink plenty of fluids (gastrolyte etc), and initially avoid
anti-diarrhoeal agents (to rid the bug causing the symptoms). Over time
people may need to be managed with medications to stop vomiting and
diarrhoea to prevent dehydration, and depending on the cause, antibiotics
may be prescribed.

In the prehospital setting any patient who experiences both vomiting and
diarrhoea is deemed to have gastroenteritis and should be managed as
such, including wearing appropriate PPE because it is highly contagious.
Depending on the severity of the patient's condition the paramedic must
decide whether the patient is better managed in the comfort of their own
home (proximity to toilet), or requires hospitalisation (risk of
cross-infection). Patients will routinely receive anti-emetics and fluid
therapy.
Bowel Disease
Crohn’s Disease and Ulcerative Colitis are collectively known as
inflammatory bowel disease (IBD). Both conditions affect the bowel, but in
slightly different ways. Crohn’s disease causes inflammation of the full
thickness of the bowel wall, in any part of the digestive tract from the
mouth to the anus. Ulcerative colitis is inflammation of the inner lining of
the large bowel (colon and rectum). The causes of these diseases are
unknown, but is most likely due to an autoimmune issue, or from an
infection. IDB has not been linked to stress or diet.
Every person responds differently to IBD and the severity of symptoms will
vary from time to time and from person to person. IBD is not a progressive
disease (it does not necessarily get worse over time). Rather, flare-ups can
range from mild to severe and back to mild again. Some people will
experience periods of relief from symptoms in between flare-ups. IBD
interferes with a person’s normal body functions and signs and symptoms
can include:
● pain in the abdomen
● weight loss
● diarrhoea (sometimes with blood and mucus)
● tiredness
● constipation
● malnutrition
● nausea
● delayed or impaired growth in children.

Diagnosis is usually through blood tests and a endoscopy/colonoscopy after

multiple prolonged symptoms. Flare-ups and acute episodes are usually
managed by medication (to control inflammation and pain) and steroids,
and in severe cases surgical intervention to remove sections of diseased
bowel is performed. Some people with Crohn's Disease may have multiple
bowel resections which eventuates in a colostomy procedure.

Bowel Obstruction
A bowel obstruction is the significant mechanical impairment or complete
arrest of the passage of contents through the intestine. Mechanical
obstruction is divided into obstruction of the small bowel (including the
duodenum) and obstruction of the large bowel, and may be classified as
partial or complete. Common causes of bowel obstruction include previous
surgery with the formation of adhesions, hernias, abnormal twisting of the
GI tract (volvulus), tumors, and especially inflammatory bowel disease
(IBD).
When an obstruction occurs, ingested food, liquids and digestive secretions
accumulate above the blockage, the bowel section involved in the blockage
becomes distended and the segment can collapse. The normal functions of
the bowel wall are compromised and the distended section gets
progressively worse. A completely blocked large bowel is a medical
emergency as it may lead to ischaemia. Signs and symptoms of a bowel
obstruction are:
● abdominal pain
● abdominal distension
● nausea and vomiting (faecal vomit)
● constipation
● inability to pass wind
● decreased or no bowel sounds on auscultation

In addition to the evidence of these symptoms, a bowel obstruction may be

diagnosed by abdominal CT scan or X-ray, or a barium enema to highlight
any blockages. Treatment involves the aspiration of stomach contents,
clearing blockages by colonoscopy, or by surgery intevention like in IBD.

Paramedics in the prehospital setting need to obtain an appropriate history

and perform a thorough assessment to determine any chances/risks of
bowel disease or obstruction. Patients' symptoms should be managed, but
with extreme caution when considering analgesia and anti-emetics due to
the affect they have on the GIT. Again, all patients should be transported
for further assessment.
Ectopic Pregnancy
An ectopic pregnancy (EP) is a condition in which a fertilised egg settles
and grows in any location other than the inner lining of the uterus. The
vast majority of ectopic pregnancies are so-called tubal pregnancies and
occur in the Fallopian tube (98%); however, they can occur in other
locations, such as the ovary, cervix, and abdominal cavity. An ectopic
pregnancy occurs in about one in 50 pregnancies. In rare cases, an ectopic
pregnancy may occur at the same time as an intrauterine pregnancy
(termed heterotopic pregnancy), and the incidence has risen due to the
increasing use of IVF and other assisted reproductive technologies (ARTs).
The major health risk of ectopic pregnancy is rupture leading to internal
bleeding. The survival rate from ectopic pregnancies is improving even
though the incidence of ectopic pregnancies is also increasing. The major
reason for a poor outcome is failure to seek early medical attention. Ectopic
pregnancy remains the leading cause of pregnancy-related death in the
first trimester of pregnancy.
Risk factors for an ectopic include:
● Prior history of an EP (greatest risk factor)
● Disruption to anatomy of fallopian tubes (surgery leading to scarring)
● Endometriosis, pelvic infections (narrowing of the fallopian tubes or
damage to cilia disrupting egg transportation)
● Multiple sexual partners (increases risk of pelvic infections)
● Cigarette smoking
● Use of intrauterine devices (IUDs)

The classic signs and symptoms of ectopic pregnancy are the triad of:
● abdominal pain,
● the absence of menstrual periods (amenorrhea), and
● vaginal bleeding or intermittent bleeding (spotting).

The patient may also experience general symptoms of pregnancy (nausea,

breast discomfort), and signs of hypovolaemia and shock may also be
present in a ruptured EP, which is a medical emergency. As only 50% of
cases will present with the classic triad above, paramedics need to
determine differential diagnoses for this type of presentation. Some
conditions which may present similarly are:
● Appendicitis
● Salpingitis (inflammation of fallopian tubes)
● Ruptured corpus luteum cyst or ovarian follicle
● Spontaneous abortion or threatened abortion
● Ovarian torsion
● Urinary tract disease

If an ectopic pregnancy is suspected, the combination of blood hormone

pregnancy tests and pelvic ultrasound can usually help to establish the
diagnosis. Some ectopic pregnancies will resolve on their own without the
need for any intervention, while others will need urgent surgery due to
haemorrhage. Some may also receive medical therapy (methotrexate) to
induce a miscarriage without damage to the reproductive system.
Paramedics should transport all potential cases of an ectopic pregnancy
(bearing in mind the patient may not believe she is pregnant) and treat
associated symptoms as they arise. Reassessment should occur to detect
any signs of hypovolaemia and shock, with IV fluid and rapid transport
instigated in this situation.
Kidney Stones
The kidneys filter blood and remove waste and fluid as urine. Occassionally
these wastes can form crystals that clump together to make small stones
(in varying shapes and sizes). Whilst in most cases there is no known
reason why a stone is formed, they can be causes by excessive levels of
certain substances in the urine (e.g. calcium and uric acid), some
medications, and even medical conditions. There are four main types of
stones:
● Stones formed from calcium combined with oxalate or phosphate
(calcium oxalate most common type)
● Struvite stones (from excess magnesium and often horn-shaped and
quite large)
● Uric acid stones (often softer than other forms)
● Cystine stones (rare and hereditary and appear as crystals)

WATCH​: 'Inside Kidney Stone Disease' (a very detailed animation!)

The signs and symptoms of kidney stones are:
● Severe 'gripping' pain in the back below the ribs (renal colic)
● Severe pain in flanks and groin (likened to intensity of child birth)
● Haematuria
● Nausea and vomiting
● Shivers, sweating and fever
● Cloudy pungent urine (if associated infection)
● ‘Gravel’ in the urine, which is made of small uric acid stones
● Urgency to urinate

Many stones are found by chance during tests for other conditions, but
may be diagnosed by ultrasound, CT scan, and X-rays (by injection of a
dye). Differential diagnoses based on the above symptoms are almost
endless, but could include:
● Acute Glomerulonephritis
● Appendicitis or Pancreatitis
● Bowel obstruction or Diverticulitis
● Cholecystitis
● Duodenal Ulcers
● Epididymitis
● Gastritis and Peptic Ulcer Disease
● Gastroenteritis
● GIT foreign body
● Pelvic Inflammatory Disease
● Renal Arteriovenous Malformation and Carcinoma
● Testicular Torsion
● Urinary Tract Infection (UTI)

Most stones can be treated without surgery (90% of stones will pass in
urine), and only analgesia may be required. However if a stone doesn’t
pass and blocks urine flow or causes bleeding or an infection then it may
need to be managed by:
● Extracorporeal Shock-Wave Lithotripsy (ESWL) - ultrasound waves are
used to break the kidney stone into smaller pieces, which can pass out
with the urine (used for stones less than 2cm in size).
● Endoscope Removal - an instrument is inserted into the urethra, passed
into the bladder then to where the stone is located (for removal or to
break it into smaller pieces).
● Surgery - requires an incision into the patient's back to directly access
the kidney and ureter to remove the stone.

Abdominal Assessment
Regardless of the condition a patient may be complaining of, you should
have a systematic way to conduct your assessment and gather a patient
history, directing your focus to the main issue they present with. In
addition to the usual AMPLE mnemonic, any pain assessment can follow a
common process, similar to that of a chest pain assessment (e.g. DOLOR,
PQRST). Specific questions to ask a patient complaining of any pain
include:
● where is the pain exactly?
● when did it start?
● can you describe the pain to me (nature/character)?
● what is the severity of the pain (0-10)?
● does it radiate anywhere?
● have you ever had it before?
● have you taken anything for it?

When focusing your questioning on abdominal complaints, consider asking

the following:
● when did you last eat or drink?
● do you feel nauseous?
● have you vomited?
● have you opened your bowels? Consistency?
● are you passing urine normally? no pain/strange smells or blood?
● are you pregnant/sexually active?

You should be familiar with what conditions can cause certain symptoms,
and what can be the cause of pain in different regions of the abdomen.
Bearing in mind that most symptoms unfortunately overlap, and some
individuals may have atypical presentations...making your job even harder!
REVIEW​: C
​ auses by region diagram
READ​: Bickley, L.S. (2012) B ​ ates’ Guide to Physical Examination and
History Taking ​(11th ed.). Lippincott Williams & Wilkins, Philadelphia, pp.
436-446.

As well as thorough history taking, you must conduct a physical

assessment of the patient which includes palpation and often auscultation
of the abdomen. Percussion can be of some assistance but may be difficult
due to the noisy prehospital environment. Feel over all the regions of the
abdomen with the palm of your hand - is it soft? is there guarding? any
palpable masses? And with your stethoscope can you hear bowel sounds
and normal peristalsis?
READ​: Bickley, L.S. (2012) B ​ ates’ Guide to Physical Examination and
History Taking ​(11th ed.). Lippincott Williams & Wilkins, Philadelphia, pp.
454-456.
Essentially you must be considering all the possible causes of abdominal
pain and linking this with the patient presentation - is the patient
presenting in a way in which you would expect? Are the vital signs what
you would anticipate, and does the story you have obtained correlate with
all the other information? Use the information gathered, coupled with your
understanding of the underlying anatomy and physiology, to begin to
determine a cause for any complaints. Then use your knowledge of
paramedic drugs and interventions (as well as guidelines) to begin
appropriate treatment!