Chapter 23: Abdominal and stuff

vascular structures

Abdominal aorta and inferior vena cava are the large blood vessels found in the abdominal cavity. Portions of the descending aorta and the inferior vena cava are in the abdominal cavity. Rupture or injury to either vessel can result in major bleeding, rapid blood loss, and a probable quick death.

types of abdominal pain

Abdominal pain can be classified as visceral pain, parietal (somatic) pain, or referred pain. The type of pain characteristcally depends on what organ is involved. For the other abdominal viscera, if an organ is torn, the pain does not result from the tearing of the organ but from blood irritating the peritoneum.

Parietal pain (somatic pain)

also called somatic pain, is associated with the irritation of the peritoneal lining. Remember, the peritoneum has a larger number of highly sensitized nerve endings. Thus, you would expect the pain to be more severe and more localized (easier to point to with one finger). Parietal pain is more localized, intense, usually found on one side or the other, sharp, and typically constant. You typically find the patient lying supine with the knees flexed up toward the chest. This reduces the stretch of the abdominal muscles and exerts less pull on the peritoneum. The patient is usually lying still and breathing shallowly. When the patient breathes deeply, the diaphragm moves lower and pushes on the peritoneum and abdominal organs, causing more pain.

thrombophilia and deep vein thrombosis

an abnormal clotting condition that is completely opposite to that of hemophilia. In thrombophilia, which is also known as hypercoagulability or prothrombotic state, the blood coagulates and creates a clot inside a blood vessel known as a thrombosis (stationary clot). Thrombophilia can be congenital, meaning that the patient is born with the disorder, or acquired.

pelvic inflammatory disease (PID)

an infection of the female reproductive tract. Pelvic infections are caused by bacteria, fungi, or viruses. Most of these infections are caused by the same bacteria that lead to sexually transmitted diseases. Approximately one million women develop PID each year. Although this condition is spread most often during sex, it can also result from a gynecologic procedure, insertion of an intrauterine device, childbirth, or an abortion.

retroperitoneal organs

some organs or portions of organs are located behind the peritoneal space. This area is referred to as the retroperitoneal space. The kidneys, ureters, pancreas, and abdominal aorta are in the retroperitoneal space.

hollow organs

stomach, intestines, gallbladder, urinary bladder, appendix, fallopian tubes, uterus, ureters contain some type of substance that might leak into the abdominal cavity if the organ is perforated or injured. When a hollow organ is perforated or injured, any substance that leaks into the abdominal cavity can lead to chemical or bacterial peritonitis. Hollow organs typically do not have the same amount of blood supply as solid organs; therefore, they tend not to bleed as much as solid organs.

immunocompromised patients

tend to have a poor inflammatory response to abdominal conditions; therefore, they might not access EMS or seek medical treatment until later in the progress of the disease or condition. This leads to a higher mortality rate for these patients. When conducting a history, it is important to ask about fever, vomiting, diarrhea, similar episodes in the past, and any recent changes in medications or treatment. Be sure to ask any transplant patient about the date and location of the surgery.

urology

the branch of medicine that studies the urinary system in females and the genitourinary system in males. The organs of the female reproductive system are separate from those in the female urinary system; however, in males, some of the structures are shared. Because of this, the term genitourinary system is referred to in males. Patients with genitourinary or renal conditions frequently experience abdominopelvic pain.

abdominal quadrants and regions

the navel, or umbilicus, as the central reference point. For names of the quadrants, right and left refer to the patient's right and left. Left upper quadrant (LUQ). Contains most of the stomach, the spleen, the pancreas, and part of the large intestine. The left kidney is behind the abdominal lining. Right upper quadrant (RUQ). Contains most of the liver, the gallbladder, and part of the large intestine. The right kidney is behind the abdominal lining. Right lower quadrant (RLQ). Contains the appendix (a worm-shaped structure extending from the beginning of the large intestine), part of the large intestine, and the female reproductive organs. Left lower quadrant (LLQ). Contains part of the large intestine and the female reproductive organs. figure 23-2

UTI

urinary tract infection (bacteria)

bariatric surgery patients

Post-bariatric-surgery patients are at risk for ulcers, perforations, and obstruction of the bowel. Within 1 year of their surgery, 20 percent of post-bariatric-surgery patients are admitted to the hospital; within 3 years, 40 percent are hospitalized. Thus, abdominal complaints in post-bariatric-surgery patients could be an indication of a serious condition.

abdominal cavity

The abdomen, or abdominal cavity, is located below the diaphragm and extends to the top of the pelvis. The abdominal cavity is lined with the peritoneum. Like the thoracic pleura, the abdominal peritoneum has two layers: the visceral peritoneum and the parietal peritoneum. The visceral peritoneum is the innermost layer and is in contact with the abdominal organs, whereas the parietal peritoneum is the outer layer. The two layers are separated by a space that contains serous fluid that acts as a lubricant.

intraperitoneal organs

The abdominal cavity contains many vital organs. Most abdominal organs—including the stomach, spleen, liver, gallbladder, pancreas, small intestine, and part of the large intestine—are enclosed by the visceral peritoneum. Hence, they are termed intraperitoneal.

solid organs

Liver, Spleen, Pancreas, Kidneys, ovaries are vascular (contain many vessels and a large amount of blood). Some are covered by a thick fibrous capsule (liver and spleen). When a solid organ is ruptured or injured, it tends to bleed, potentially leading to severe shock.

male reproductive system

include the testes, epididymis, vas deferens, prostate gland, and penis. The testes are the primary male reproductive organs. They produce sperm cells, which are necessary for reproduction and are stored in a small sac called the epididymis. For the sperm to leave the body, it passes through the two ducts called the vas deferens. The sperm then mixes with fluid from the prostate gland before it can be ejaculated from the body. The prostate gland surrounds the male urinary bladder and houses the first part of the male's urethra. The penis is the male organ used for sexual intercourse and urination.

sexually transmitted diseases

infectious diseases spread from person to person through sexual contact Chlamydia and gonorrhea are the most commonly reported STDs

acute abdomen

Acute abdominal pain, sometimes called acute abdomen, or acute abdominal distress, is a common condition that can be severe. Some causes of acute abdominal pain are obvious, but most causes are not that apparent. Medical texts cite approximately 100 different causes of abdominal pain. Acute abdominal pain can arise from the cardiac, pulmonary, gastrointestinal, hematologic, genital, urinary, reproductive, or other body system.

sickle cell crisis

Bone crisis. This type typically involves the bones in the back and the large long bones in the arm (humerus) and leg (femur and tibia), causing sudden severe pain. Acute chest syndrome. This involves a sudden onset of chest pain, possibly with dyspnea, hypoxia, and cough, which can be nonproductive, or the patient coughs up blood. A low-grade fever can be present. Abdominal crisis. This causes sudden, constant abdominal pain that can be general or localized. There might also be nausea, vomiting, and diarrhea. Joint crisis. This presents with an acute onset of one or more painful, stiff joints.

urinary catheter

Foley or indwelling catheters are the most common. These catheters have a balloon that is inserted into the urinary bladder via the urethra (Figures 23-18a and 23-18b). The urine drains from the bladder into the catheter and is deposited into a bag. Suprapubic catheters work in a similar way, but instead of being inserted through the urethra they are placed into the urinary bladder directly through the patient's abdominal wall. Patients with catheters are prone to infections and device malfunctions.

pediatrics

Has the child been more irritable than normal recently? Can you console the child when crying or upset? Has child had poor feeding habits recently?

kidney failure

Kidney failure, or renal failure, occurs when the kidneys fail to function adequately. During this condition, the kidneys cannot able to filter the wastes and maintain homeostasis as they normally would. Kidney failure is normally classified as either acute or chronic. Acute kidney injury (AKI) normally occurs over a period of days and often results from a significant decrease in urine elimination. Some causes of acute renal failure are decreased blood flow to the kidneys from trauma, cardiac failure, surgery, shock, sepsis, and urinary tract obstruction. This condition is sometimes reversible, but many patients require dialysis Chronic renal failure (CRF) normally occurs over a period of years, and the symptoms range from mild at first to severe kidney failure. The causes of chronic renal failure are numerous; however, diabetes and hypertension are linked to many of the cases. Chronic renal failure results in an accumulation of waste products and fluids that can affect almost every organ system in the body. This condition is permanent and life threatening. Patients with this type of kidney failure ultimately require dialysis or a kidney transplant for survival.

kidney stones

Kidney stones, or renal calculi, are crystals of substances such as calcium, uric acid, struvite, and crystine that are formed from metabolic abnormalities. They most frequently occur in men between the ages of 20 and 50. Other risk factors associated with renal calculi include family history, hyperparathyroidism, recurrent UTIs, sedentary lifestyle, dehydration, and obesity. Renal calculi are believed to originate in the kidneys and must pass through the rest of the urinary system to be eliminated from the body. Severe pain can occur with renal calculi, especially if the stone is large and is passing through a ureter.

abdominal pain results from these three

Mechanical forces (stretching) Inflammation Ischemia (organ and tissue hypoxia, or oxygen deficiency) Pain from stretching a solid organ is usually a steady type of pain. Inflammation of a hollow organ can irritate the lining of the walls of the organ, causing a crampy (colicky, intermittent) type of pain. Pain associated with ischemia (hypoxia) to an abdominal organ will be steady and severe and continue to worsen as the organ becomes more ischemic.

menstrual pain

When the endometrial lining of the uterus is sloughed off during menses, it can be accompanied by strong uterine cramps that cause the severe pain during menstruation called dysmenorrhea. Dysmenorrhea is normally caused by hormonal imbalances or other gynecologic conditions. Occasionally, a patient experiences abdominopelvic pain in the middle of her menstrual cycle. This pain is called mittelschmerz (German for "middle pain"). It is caused by irritation of the peritoneum by the small amount of bleeding associated with the rupture of ovarian tissue that occurs with release of the mature ovum. Remember that abdominopelvic pain, regardless of the cause, should be treated as an emergency.

intestinal obstruction

a blockage that interrupts the normal flow of the intestinal contents within the intestines. This condition can occur in both the small and the large intestines and can be either partial or complete. Blockages occurring in the small intestine are usually the result of adhesions (a sticking together of the sides of the intestines), gallstones, or a hernia. Blockages of the large intestine are commonly caused by tumors or fecal impaction. If left untreated, intestinal obstructions can lead to sepsis, perforation, intestinal infarction, and peritonitis. Patients over the age of 50 are at increased risk for having an intestinal obstruction. This condition is likely to reoccur in patients who have a history of a previous bowel obstruction. Abdominal pain, moderate to severe, depending on location of obstruction—typically described as crampy and colicky Nausea and vomiting Constipation (difficulty in passing stool and flatus is the classic finding in intestinal obstruction) Abdominal distention and tenderness Abnormally prominent, high-pitched bowel sounds with auscultation in early stages (Bowel sounds can be diminished or absent in some later cases.)

Hemophilia

a blood disorder that affects clotting. When a person with hemophilia is injured, it takes longer for the bleeding to stop because clots cannot form properly. Bleeding that would be considered minor for a nonhemophiliac, such as a nosebleed, is a major emergency for the hemophiliac. Bleeding tends to occur in major joints (knees, hips, shoulders, or elbows) in the hemophiliac patient. Normal bleeding control procedures should be applied to the hemophiliac; however, stopping the blood loss will be more difficult and your attempts to do so less effective. The missing clotting factor must be restored by infusion.

esophageal varices

a bulging, engorgement, or weakening of the blood vessels in the lining of the lower part of the esophagus. These abnormalities are common to heavy alcohol drinkers or patients with liver disease and are caused by increased pressure in the venous blood supply system of the liver, stomach, and esophagus, known as portal hypertension. Esophageal varices are usually identified with painless bleeding in the digestive tract. Bleeding can be profuse, leading to shock. Emergency medical care is the same as for any other abdominal pain or distress; however, airway and breathing management can be more challenging. Large amounts of bright red hematemesis (vomiting of blood) Absence of pain or tenderness in the abdomen Rapid pulse Breathing difficulty Pale, cool, clammy skin Other signs and symptoms of shock Jaundice (yellowing) of the skin or sclerae of the eyes from liver disease (can be seen in some cases)

endometriosis

a condition in which endometrial tissue grows outside the uterus. The most common sites for endometrial tissue implantation are the abdomen and pelvis, but the tissue can be implanted anywhere in the body. This endometrial tissue can bleed into the surrounding area and result in inflammation, scarring, pain, and adhesions. Endometriosis is most commonly diagnosed in women who are 25 to 35 years of age.

sickle cell anemia

a hereditary blood disorder most often afflicting African Americans and black Africans but also those of Mediterranean, South and Central American, Caribbean, and Middle Eastern origin. In sickle cell anemia, some red blood cells have abnormal hemoglobin that does not carry adequate oxygen. As a result, the cells take on a crescent (sickle) shape and become fragile, stiff, and rigid. The sickled cells begin to stack up, blocking capillary blood flow. Cells and tissues become ischemic and can die. Patients with this disease often suffer infections from damaged red blood cells blocking the spleen.

hernia

a protrusion or thrusting forward of a portion of the intestine through an opening or weakness in the abdominal wall. Hernias are most commonly associated with chronic increases in pressure in the abdominal cavity during heavy lifting or straining, causing the peritoneum to be pushed into the weakness or opening. Others are caused by previous surgical incisions or at the umbilicus. Most hernias are not life threatening and can be easily treated. In some cases, however, they can become incarcerated or strangulated, causing the portion of the intestine to be pinched or cut off, producing obstruction. Sudden onset of abdominal pain (usually after heavy lifting or straining) Fever Rapid pulse Tender mass at point of hernia Others similar to intestinal obstruction

Anemia

a reduction of the number of red blood cells in the circulating blood volume. It is unlikely that a patient will call EMS for anemia unless it is the result of acute blood loss; however, the anemia can worsen other conditions the patient is experiencing. Acute anemia can result from a sudden decrease in red blood cells resulting from a source of bleeding. Chronic anemia results from a slow source of blood loss, such as a gastrointestinal bleed, lack of production or maturity of red blood cells, increased destruction of red blood cells, or issues with the structure of the hemoglobin on the surface of the red blood cell. The patient with chronic anemia often appears pale, fatigues easily, and experiences shortness of breath on exertion. In both acute and chronic anemia, the lack of the availability of red blood cells and hemoglobin to carry oxygen in the blood leads to a faster onset of hypoxia.

Abdominal Aortic Aneurysm (AAA)

a weakened, ballooned, and enlarged area of the wall of the abdominal aorta. The aneurysm can eventually rupture and is one of the most lethal causes of abdominal pain. Although it can happen at any age, this condition, which generally results from atherosclerosis, is most common in men over the age of 60. Another condition involving the aorta is an aortic dissection or a dissecting aorta, which begins with a small tear of the inner vessel structure, which enables blood to leak between the walls of the aorta. The process of dissection continues with increasing pressure until, finally, the outer wall is damaged and blood leaks out behind the peritoneum or into the abdominal cavity.

sexual assault

any intentional sexual attack against another person Do not allow the patient to change clothes, bathe, comb, or clean any part of her body. If the clothing were changed, collect it, bag it separately, and take it with you. Do not cut through any holes or tears in the patient's clothing. Handle the clothing as little as possible. Do not touch or change anything at the crime scene unless it impedes emergency medical care. Do not clean wounds, if possible. Treat wounds as you would other soft tissue injuries. Do not examine the genital area unless there is a life-threatening hemorrhage. Minor bleeding can be absorbed by a pad. Make sure all bloody articles are collected and transported with the patient. When caring for a patient who has been sexually assaulted, it is important to remain nonjudgmental and objective. Provide a safe environment for the patient. Always maintain patient confidentiality and ask only questions that are pertinent to assessment and emergency medical care. When interviewing the patient, it is not necessary to question her about the specific details of the crime, because your treatment will be based on your assessment findings and your patient's current presentation

dialysis

artificial process used to remove water and waste substances from the blood when the kidneys fail to function properly. It generally works through osmosis and filtration of fluid across a semipermeable membrane. In general, the blood containing waste products passes on one side of the membrane while a dialysate (special fluid used for dialysis) passes on the other side. When this occurs, the water and waste products travel from the blood across the membrane and into the dialysate thus removing the waste from the patient. There are two major types of dialysis: hemodialysis and peritoneal dialysis. In hemodialysis, a dialysis machine containing the dialysate is connected to an access site on the patient. The access site can be a shunt, fistula, port, or graft (Figure 23-16). The patient's blood, which is heparinized, is pumped through the access site and into the machine to have the waste removed. The access site should be treated with care because dialysis cannot occur without it. The EMT should not take the blood pressure of a dialysis patient on the side of the patient's access site. Hemodialysis is commonly performed at an outpatient dialysis facility but can be performed in other locations. In peritoneal dialysis, the dialysate is run through a tube into the patient's abdomen (Figure 23-17). The peritoneal membrane functions as the semipermeable membrane during peritoneal dialysis. The fluid remains in the abdomen for several hours so that it can absorb the wastes, and then it is drained out of the body through a different tube. Peritoneal dialysis is commonly performed at home and is often performed while the patient is sleeping at night. This form of dialysis has fallen into disfavor and is less commonly seen.

hematuria

blood in the urine

gastrointestinal bleeding

can occur anywhere within the gastrointestinal tract and can be attributed to numerous causes. Gastrointestinal bleeds are usually classified as upper or lower, based on the location of the bleeding. Upper gastrointestinal bleeds are frequently caused by peptic ulcers, gastric erosion, and varices. They are more prevalent in adult males. Lower gastrointestinal bleeds are frequently caused by diverticulitis, ateriovenous malformations, or tumors and occur more in women. Gastrointestinal bleeding most commonly affects people in their 40s to 70s, but children and younger adults can experience it, too. Most deaths resulting from gastrointestinal bleeding occur in patients over 60 years of age. Abdominal pain or tenderness Hematemesis (vomiting blood, which can be bright red or look like coffee grounds) Hematochezia (bright red blood in the stool normally signifying a rapid onset) Melena (dark tarry stools containing decomposing blood normally from the upper gastrointestinal system) Altered mental status, weakness, or syncope Tachycardia Signs of shock

female reproductive structures and functions

composed of the external genitalia and internal organs and structures. The female external genitalia, also called the vulva, consist of vascular tissues called the perineum, mons pubis, labia, and clitoris. The vulva provides accessory functions to the internal organs that are used primarily for reproduction. The internal organs of the female reproductive system are the vagina, uterus, ovaries, and fallopian tubes. The vagina functions as the birth canal during childbirth, receives the penis during sexual intercourse, and serves as a passageway for menstrual flow. The ovaries are the primary sex glands located on each side of the uterus. They excrete hormones and develop and release eggs that are needed for reproduction. The fallopian tubes extend from near each of the ovaries to the uterus. Fertilization of the egg normally occurs here. The uterus is the pear-shaped muscular organ that provides an appropriate site for egg implantation and fetal development during pregnancy. The uterus is lined by the endometrium, which is sloughed off during menses, or the menstrual period.

Ovarian Cysts

fluid-filled sac that forms inside or on an ovary. It is formed during ovulation when a follicle containing the egg fails to open as it is supposed to. Ovarian cysts can cause abdominopelvic pain if they rupture, twist, or break open and leak their contents into the abdomen; however, most ovarian cysts are asymptomatic

Elderly (Geriatric)

elderly patients have a decreased perception of abdominal pain and present with vague symptoms; therefore, the abdominal condition can be missed or the severity overlooked. Elderly patients also tend to wait longer to seek medical care for their complaints, which might allow the abdominal disease or condition to progress and become much worse.

duodenum

first part of the small intestine connecting to stomach

appendicitis

inflammation of the appendix that commonly causes an acute abdomen. Appendicitis is usually caused by a blockage in the intestines and results in inflammation and irritation. If left untreated, the inflammation eventually causes the tissue to die and rupture. This results in abscess formation (local pus collection), peritonitis, or shock. Appendicitis is common in children because their appendix wall is thinner. This is also true for elderly patients who are prone to perforation. Definitive care for this condition is surgical intervention, ideally before rupture of the appendix contents into the peritoneal cavity. Abdominal pain or cramping—Initially this can be dull, diffuse, and located around the umbilicus because of the distention of the appendix. Later this pain is usually localized to the RLQ medial to the iliac crest (pelvic wing), also called the McBurney point, because of peritoneal irritation. Nausea and vomiting Low-grade fever and chills Lack of appetite (anorexia) Abdominal guarding Positive Markle ("heel drop" or "heel jar") test

endometritis

inflammation of the endometrium. It is most commonly caused by an infection; however, it can also occur from childbirth, abortions, gynecologic procedures, or intrauterine devices. If left untreated, endometritis can lead to peritonitis, abscess formation, septicemia, shock, and infertility.

Cholecystitis

inflammation of the gallbladder, is commonly associated with the presence of gallstones. This condition is more common in women than men and frequently occurs between the ages of 30 and 50. It rarely occurs in children. In some cases of cholecystitis, the gallstones actually block the opening of the gallbladder to the small intestine. This blockage causes an increase in pressure inside the gallbladder, which can cause severe pain. Definitive care for this condition is hospitalization and sometimes surgical intervention to remove the gallbladder, stones, or blockage. If left untreated, tissue death, perforation, or pancreatitis can occur. Sudden onset of abdominal pain located from the middle of the upper quadrants (epigastric area) to RUQ areas (Pain is present more commonly at night and associated with ingestion of fatty foods. Pain can also be referred to the right scapula.) Tenderness upon palpation of the RUQ Belching or heartburn Nausea and vomiting (contents can be greenish)

pancreatitis

inflammation of the pancreas, can cause severe pain in the middle of the upper quadrants (epigastric area) of the abdomen. This abdominal pain sometimes radiates to the mid to lower back. Pancreatitis can be triggered by a variety of causes including the ingestion of alcohol, gallstones, or infection. Complications that can result from pancreatitis include abscesses, sepsis, hemorrhage, tissue death, hypoglycemia or hyperglycemia, and organ failure. Abdominal pain Nausea and vomiting Abdominal tenderness and distention Mild jaundice (depending on cause) Severe abdominal pain with radiation from the umbilicus (navel) to the back and shoulders Fever, rapid pulse, and signs of shock (in extreme cases)

gastroenteritis

inflammation of the stomach and small intestines, is commonly associated with the presence of abdominopelvic pain. This condition can be chronic or acute. Acute gastroenteritis is normally caused by viruses and bacteria and is commonly diagnosed in children. If left untreated, it can result in the breakdown of the mucosal layers in the gastrointestinal tract. This breakdown can lead to dehydration, hemorrhage, ulceration, and perforation. Hematemesis, hematochezia, or melena can be present in severe acute cases. In these severe cases, signs and symptoms of shock are present. Abdominal pain or cramping Nausea, vomiting, and diarrhea Abdominal tenderness Fever and dehydration In severe cases, signs and symptoms of shock and hemorrhage can be present

peritonitis

irritation and inflammation of the peritoneum, occurs when blood pus bacteria or chemical substances leak into the peritoneal cavity Abdominal pain or tenderness Nausea, vomiting, or diarrhea Fever and chills Lack of appetite (anorexia) Positive Markle (heel drop or heel jar) test

referred pain

is visceral pain (pain from an organ) that is not felt in the organ itself but instead is felt elsewhere in the body. The pain is usually poorly localized but is felt consistently in the part of the body it is referred to. Referred pain occurs when organs share a nerve pathway with a skin sensory nerve. The brain becomes confused in the interpretation of the impulse and causes the patient to feel pain at a location that can be totally unrelated to the organ involved. For example, a patient who experiences inflammation of the gallbladder (cholecystitis) typically feels referred pain in his right shoulder and scapular (shoulder blade) area.

urinary system

kidneys, ureters, urinary bladder, and urethra. The urinary system produces, stores, and eliminates urine from the body. The kidneys are bean-shaped organs located in the retroperitoneal space. The kidneys filter the blood and excrete waste products in the urine. They also play a role in homeostasis by regulating the body's pH (acid/base levels) and electrolytes, controlling the blood volume, promoting hemoglobin production, and regulating the blood pressure. The ureters are the tubes that carry urine from the kidneys to the urinary bladder. The urinary bladder houses the urine until it is eliminated from the body via a duct called the urethra. In women, the urethral opening is anterior to the vagina and excretes urine; however, in men the urethra is located at the tip of the penis and eliminates both urine and male reproductive fluid.

vaginal bleeding (nontraumatic)

may be caused by cancerous lesions, pelvic inflammatory disease, hormonal imbalances, spontaneous abortion (miscarriage), ectopic pregnancy or labor in girls age 10 or older menarche, or the onset of menses could be the cause of bleeding The most common cause of nontraumatic vaginal bleeding other than menses is a spontaneous abortion or miscarriage.

visceral pain

occurs when an abdominal organ is involved. Most organs do not have many highly sensitive nerve fibers; therefore, organ (visceral) pain is usually less severe, is poorly localized (the patient cannot point to the pain with one finger; it is more general in nature), is dull or aching or oppressive, and can be constant or intermittent. Although the pain might not be severe, a serious condition can still exist. This is one of the most important lessons to learn from the differences in the types of pain. Mild and intermittent pain does not mean a mild or insignificant condition. Visceral pain is also associated with nausea and vomiting.

ulcers

open wounds or sores within the digestive tract, usually in the stomach or the beginning of the small intestine. Ulcers are associated with a breakdown of the lining that normally protects the intestine from the digestive fluids contained inside the digestive tract. This breakdown can cause damage to the stomach or intestine and, in some instances, massive bleeding or perforation. This can result in hematemesis, hematochezia, or melena depending on the location and severity of the bleed. The type of abdominal pain is also affected by the location and severity of the ulcer. Patients with severe ulcerative disease can develop signs and symptoms of shock and signs of peritonitis from erosion through the stomach or duodenum that are life threatening. Most patients are usually aware of their ulcers and provide you with this information during the history. In some cases, the patient takes over-the-counter antacids or prescribed medications for this condition. Gradual onset of abdominal pain normally in the LUQ and epigastric area, usually described as a burning or gnawing-type pain before meals or during stressful events. An acute onset may indicate perforation. Nausea and vomiting Hematemesis, hematochezia, or melena or coffee-ground emesis in some cases Signs or symptoms of shock in cases of massive bleeding or perforation Peritonitis with a rigid abdomen in cases of perforation