Solid organs include the liver, spleen, pancreas, kidneys, and ovaries. Kidneys, ovaries, and pancreas are retroperitoneal. Trauma to these can create bleeding, which leads to shock. The spleen is part of the lymphatic system and plays a role in relation to red blood cells and the immune system. It assists in filtration of blood, recycles iron, and is a blood reservoir. It also produces antibodies to help the body fight off disease and infection. Hollow organs include the gallbladder, stomach, small intestine, large intestine, and urinary bladder. If there is a perforation in these organs, they will leak and contaminate the abdominal cavity.
The GI system is responsible for the digestion process. It begins when food is put in the mouth and the salivary glands secrete saliva and begin to break down the food. When swallowed, it travels down the esophagus to the stomach. The stomach is the main organ. Absorption of nutrients occurs at various places along the digestive tract. Sugars start to be absorbed in the mouth. Most of the digestion takes place in the stomach where gastric juices break down food. The liver secretes bile, which aids in the digestion of fats, also filters toxic substances produced by digestion, creates glucose stores, and produces substances necessary for blood clotting and immune function. The gallbladder is a hollow pouch located beneath the liver that acts as a reservoir for bile.
From the stomach, food travels down into the small intestine, which contains three parts: the duodenum, jejunum, and ileum. The duodenum is where digestive juices from the pancreas and liver mix together. The jejunum’s major role is the absorption of digestive products. The ileum also absorbs the rest of the nutrients. It also absorbs bile acids so they can be returned to the liver for future use and vitamin B12 for making nerve cells and red blood cells. The pancreas secretes juice containing enzymes that help break down starches, fats, and proteins. Amylase breaks down starches into sugar. Bicarbonate, insulin, and glucagon are also produced. Bicarbonate neutralizes the stomach acid in the duodenum. Insulin and glucagon help regulate the levels of glucose in the bloodstream. The food that was not broken down and used as nutrients then moves into the colon, or large intestine, as waste products. A wavelike contraction of smooth muscle called peristalsis moves the waste matter through the intestines. The stool passes through the rectum to the anus where it is defecated.
The urinary system controls the discharge of certain waste materials filtered from the blood by the kidneys. Ureters, bladder, and urethra are hollow organs. One system can directly affect the other. If the prostate gland in the male genital system enlarges, then the urethra will narrow, impairing the bladder. The body contains two kidneys, which lie on the posterior muscular wall of the abdomen behind the peritoneum (a membrane lining the abdominal cavity—the parietal peritoneum—and covering the abdominal organs—the visceral peritoneum). Kidneys play an important role in the regulation of the acid-base balance and blood pressure. Blood pressure regulation is associated with the kidney’s ability to remove sodium chloride from the body. Kidney disease is a common cause of secondary hypertension. Kidneys also rid the body of toxic wastes and control the body’s balance of fluid and electrolytes. Nearly 20% of the output of blood from the heart passes through the kidneys each minute. The kidney is attached directly to the aorta and the inferior vena cava. Kidneys constantly absorb filtered urine by reabsorbing the water as it passes through a system of specialized tubes which unite to form the renal pelvis. A ureter passes from the renal pelvis of each kidney along the surface of the posterior abdominal wall behind the peritoneum to drain into the urinary bladder. Peristalsis occurs in these tubes to move the urine to the bladder. The urinary bladder is located immediately behind the pubic symphysis in the pelvic cavity and is composed of smooth muscle with a specialized lining membrane.
Peritonitis is any foreign material, such as blood, pus, bile, pancreatic juice, or amniotic fluid, that can cause irritation of the peritoneum. It often causes ileus, or the paralysis of the muscular contractions that normally propel material through the intestine. The retained gas and feces cause abdominal distention. Distention usually begins after the muscular contractions cease. Nothing that can be eaten can pass through the stomach, which results in emesis. Symptoms are typically associated with nausea and vomiting. Tachycardia and hypotension can be accompanied by hemorrhage. Fever may or may not be present. Patients with diverticulitis (inflammation in small pockets at weak areas in the muscle walls of the intestines) or cholecystitis (inflammation of the gallbladder) may have a substantial elevation in body temperature. Acute appendicitis may have temperature within normal limits until the appendix ruptures and contaminates the peritoneal cavity.
Acute abdomen is a term for sudden onset of abdominal pain which is severe and progressive problem that requires medical attention. If not treated, it can be fatal. Abdominal pain can have different qualities because two different types of nerves supply the peritoneum. The nerves from the spinal cord that supply the skin of the abdomen can also supply the parietal peritoneum. Sensations can feel pain, touch, pressure, heat, and cold, which can easily identify and localize a point of irritation.
The visceral peritoneum is supplied by the autonomic nervous system. These nerves are far less able to localize sensation, which means the patient will not be able to describe exactly where the pain is located. It is stimulated when distention or contraction of the hollow abdominal organs stretch receptors. Other painful sensations that occur because of irritated visceral peritoneum may be perceived at a distant point on the surface of the body, such as the back or shoulder. This phenomenon is called referred pain. Referred pain is the result of connections between the body’s two separate nervous systems, somatic nervous system and autonomic nervous system. Acute cholecystitis may cause pain in the right shoulder because the autonomic nerves serving the gallbladder lie near the spinal cord at the same anatomic level as the spinal sensory nerves that supply the skin of the shoulder.
Appendicitis – right lower quadrant (direct); around navel (referred); rebound tenderness (pain felt on the rebound after palpation). An inflammation or infection in the appendix is called appendicitis. This eventually causes the tissues to die and rupture, causing an abscess, peritonitis, or shock. Initially, the pain caused by appendicitis is generalized, dull, and diffuse and may center in the umbilical area. Later it is localized in the right lower quadrant of the abdomen. The patient may report nausea and vomiting, anorexia, fever, and chills. There is also rebound tenderness as a result of peritoneal irritation. It can be assessed by pressing down gently and firmly on the abdomen and then quickly releasing the pressure. The patient will feel pain when the pressure is released.
Cholecystitis (gallbladder) – right upper quadrant; right shoulder (referred). The gallbladder is a storage pouch for digestive juices and waste from the liver. Gallstones can form blocking the outlet of the gallbladder, causing pain. If they do not clear on their own, there is severe inflammation of the gallbladder called cholecystitis. It may cause the gallbladder to rupture, causing inflammation to spread and irritate surrounding structures such as the diaphragm and bowel. Constant severe pain in the right upper or midabdominal region and may refer to the right upper back, shoulder area, or flank. Commonly produces symptoms about 30 minutes after a particularly fatty meal and usually at night. Other symptoms include general GI distress such as nausea and vomiting, indigestion, bloating, gas, and belching.
Ulcer – upper midabdominal or upper part of back. The stomach and duodenum are subjected to high levels of acidity. To prevent damage to these organs, protective layers of mucus line both organs. In peptic ulcer disease (PUD), the protective layer is eroded, allowing the acid to eat into the organ itself. Mostly a result of infection of the stomach with Helicobacter pylori bacteria. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. Alcohol and smoking can also affect this by increasing gastric acid. Pain is normally in the upper abdomen but sometimes may be found below the sternum. Pain occurs immediately after eating. Nausea, vomiting, belching, and heartburn are common symptoms. If erosion is severe, gastric bleeding can occur resulting in hematemesis (vomiting blood) and melena (black, tarry stools containing blood). Some ulcers will heal without medical intervention, but with bleeding or perforation (a hole through the wall of the stomach). More serious ulcerative conditions can cause severe peritonitis and an acute abdomen.
Diverticulitis (weak pockets in muscle walls of the intestine) – left lower quadrant. Amount of fiber consumed as part of the diet decreases and stool becomes more solid. Hard stool requires more intestinal contractions, subsequently increasing pressure within the colon. Small defects within the colonic wall that would otherwise never pose a problem now fail, resulting in bulges in the wall. Eventually these turn into pouches called diverticula where feces may become trapped within these pouches. When bacteria grow there, they cause localized inflammation and infection. The most common cause of lower GI bleeding in the US is diverticulosis. Pain typically in the lower left side of the abdomen. Signs of infection include fever, malaise, body aches, chills, nausea, and vomiting. Bleeding is rare. The narrowing diameter of the colon results in constipation and bowel obstruction. In severe cases outcroppings may burst, causing perforation of the affected segment of colon, leading to peritonitis, severe infection, and septic shock.
Cystitis (inflammation of the bladder) – lower midabdominal (retropubic). Bladder inflammation is caused by a bacterial infection and can be referred to as a urinary tract infection (UTI). The patient may report blood in the urine. If infection is severe, the urethra can become inflamed, causing urinary retention. The patient may report tenderness when you are palpating the abdomen over the bladder (just above the pubic bone).
Kidney infection – costovertebral angle. When kidneys fail, the patient loses the ability to excrete waste from the body, leading to a condition called uremia. Kidney failure can occur from hemorrhage, dehydration, trauma, shock, sepsis, heart failure, medication, drug abuse, and kidney strokes.
Kidney stone – right or left flank, radiating to the genitalia. Chemicals may crystallize in the urine and form kidney stones. When the stone passes into the ureter, it can cause a blockage. Pressure will build up behind the kidney stone and cause swelling in the kidney. Pain is intense and radiates to the groin, nausea, and vomiting. Chronic kidney disease (CKD) is irreversible and is often caused by diabetes or hypertension. Eventually the patient requires dialysis or a kidney transplant to remove waste products from the bloodstream. Missed treatments lead to altered level of consciousness, seizures, coma, lethargy, nausea, headaches, cramps, and edema in the extremities and face because of fluid imbalances. Heart disease and tendency to bleed easily.
Pancreatitis – upper abdomen (both quadrants); back. The pancreas forms digestive juices and is also the source of insulin and glucagon. Inflammation of the pancreas is called pancreatitis, which can be caused by obstructing gallstone, alcohol abuse, and other diseases. Severe pain may present in the upper left and right quadrants and may often radiate to the back. Pain may be worse after eating. Tachycardia and fever. Complications such as sepsis or hemorrhage can occur.
Hernia – anywhere in the abdominal area. A hernia is a protrusion of an organ or tissue through a hole or opening into a body cavity where it does not belong. A congenital defect, as around the umbilicus. A surgical wound that has failed to heal properly. A natural weakness in an area, such as in the groin. When a hernia is incarcerated, it becomes seriously compressed by the surrounding tissue, eventually compromising the blood supply. This situation, called strangulation, is a serious medical emergency which requires immediate surgery to remove any dead tissue and repair the hernia.
Gastrointestinal hemorrhage is bleeding within the GI tract and is a symptom of another disease. All complaints of bleeding should be considered serious. GI hemorrhage can occur in the upper or lower GI tract. Upper GI tract occurs from the esophagus to the upper small intestine. In the esophagus, problems might be esophagitis secondary to liver failure or a Mallory-Weiss tear, which results from excessive retching or vomiting. Hematemesis, or vomiting blood, is frequently seen in patients with upper GI bleeding. Blood is either bright red or has the appearance of coffee grounds. Upper GI bleeding often manifests as melena, or dark tarry stools, as a result of partial digestion of the blood. Lower GI bleeding occurs between the upper part of the small intestine and the anus. Bowel inflammation, diverticulosis, diverticulitis, cancer, and hemorrhoids are common causes of bleeding in the lower GI tract. When bleeding originates in the lower GI tract, the stools are often bright red or maroon in color.
Esophagitis – this occurs when the lining of the esophagus becomes inflamed by infection or from acids in the stomach. Gastroesophageal reflux disease (GERD) is a condition in which the sphincter between the esophagus and the stomach opens, allowing for stomach acid to move up into the esophagus. It can be referred to as acid reflux disease. The condition can cause a burning sensation in the chest (heartburn). Feels like an object is stuck in his or her throat. Additional symptoms include heartburn, nausea, vomiting, and sores in the mouth. In the worst cases, bleeding can occur from the small capillary vessels within the esophageal lining or the main blood vessels.
Esophageal varices – occurs when the pressure within the blood vessels surrounding the esophagus increases, frequently as a result of liver failure. The esophageal blood vessels eventually drain their blood into the liver. If the liver becomes damaged and blood cannot flow through it easily, blood begins to back up into these portal vessels, dilating the vessels and causing the capillary network of the esophagus to begin leaking. If pressure continues to build, the vessel walls may fail, causing massive upper GI bleeding and quickly afterward hematemesis. Can occur through either viral hepatitis or alcohol consumption. Initially shows signs of liver disease: fatigue, weight loss, jaundice, anorexia, edema in the abdomen, abdominal pain, nausea, and vomiting. Eventually extreme discomfort. The rupture of the varices is far more sudden. The patient may report sudden-onset discomfort in the epigastric region or sternum and have severe difficulty swallowing, vomiting bright red blood, hypotension, and signs of shock.
Mallory-Weiss tear – is a tear in the junction between the esophagus and the stomach causing severe bleeding and potentially death. Primary risk factors include alcoholism and eating disorders. Violent coughing or vomiting is the principal cause. In women, severe vomiting related to pregnancy. The extent of the bleeding can range from minor bleeding to severe bleeding and extreme fluid loss. In some cases patients may experience signs and symptoms of shock, upper abdominal pain, hematemesis, and melena.
Gastroenteritis – acute gastroenteritis comprises a family of conditions revolving around an infection combined with diarrhea, nausea, and vomiting. Bacterial and viral organisms can cause this condition and typically enter the body through contaminated food or water. Patients may experience an upset stomach and diarrhea as soon as several hours or several days after contact with contaminated matter. May be a reaction to certain toxins or chemotherapy. Diarrhea may contain blood or pus and may have foul odor or be odorless.
Hemorrhoids are caused by swelling and inflammation of the blood vessels surrounding the rectum. Common problem with almost half the population having at least one hemorrhoid by age 50 years. Results in increased pressure on the rectum or irritation of the rectum. May be internal and not visible. They present as bright red blood during defecation. Bleeding is minimal and easily controlled. Patients may experience itching and a small mass in the rectum.
End-stage renal disease, also referred to as chronic renal failure, is treated with either peritoneal dialysis (PD) or hemodialysis. In these processes, the patient’s blood is filtered and cleansed of the toxins and then returned to the body. The treatment eliminates waste, normalizes the blood chemistry, and reduces excess fluid. If the patient misses treatments, weakness and pulmonary edema can be the first in a series of conditions that can become progressively more serious if normal balance is not returned to the patient’s body. In PD, fluid circulates within the peritoneal cavity. Urea and other toxins diffuse across the peritoneum into the dialysis fluid, which is then drained from the peritoneum, allowing the peritoneum to essentially function as a kidney. Patients will have a tube in the abdomen. PD carries a very small risk of peritonitis due to bacteria contaminating the dialysis site. A patient with peritonitis may have hypotension, fever, nausea, diarrhea, and cloudy dialysis fluid. In hemodialysis, the patient’s blood circulates through a dialysis machine that functions in much the same way as normal kidneys. Most patients undergoing long-term hemodialysis have some sort of shunt or fistula, a surgically created connection between a vein and an artery. Adverse effects of dialysis include hypotension, dysrhythmias, chest pain, muscle cramps, nausea and vomiting, altered mental status, electrolyte imbalances, hemorrhage from the access site, and infection at the access site.
| Condition | Location | Key Clues |
|---|---|---|
| Appendicitis | RLQ (late), Periumbilical (early) | Rebound tenderness |
| Cholecystitis | RUQ → Right shoulder | After fatty meal |
| Pancreatitis | Upper abdomen → Back | Worse after eating |
| Diverticulitis | LLQ | Fever |
| Ulcer | Epigastric | Worse after eating |
| Cystitis | Suprapubic | UTI symptoms |
| Kidney infection | CVA tenderness | Fever |
| Kidney stone | Flank → Groin | Severe colicky pain |
| Hernia | Variable | Bulge present |
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