Recognizing Common Abdominal Disorders

Core Concepts

Appendicitis: the RLQ classic

Appendicitis is inflammation of the appendix, a small pouch attached to the cecum in the right lower quadrant. The classic pattern: pain begins as a vague ache around the umbilicus (visceral pain), then shifts to the right lower quadrant and becomes sharp and localized as inflammation spreads to the parietal peritoneum. It is typically accompanied by anorexia (loss of appetite), nausea, and often a low-grade fever. On exam, tenderness is maximal at McBurney's point (roughly halfway between the umbilicus and the right anterior superior iliac spine), with guarding or rigidity as inflammation worsens. The pattern is classic — but not universal: older adults, young children, and pregnant people may have atypical presentations with vague pain. Any patient with worsening RLQ pain and fever needs prompt provider evaluation; a perforated appendix causes peritonitis and is a surgical emergency.

Gallbladder disease: the fatty-meal RUQ pain

Cholelithiasis (gallstones) is extremely common; many people have gallstones without symptoms. When a stone blocks the cystic duct, the gallbladder becomes inflamed — cholecystitis — producing pain in the right upper quadrant that often begins after a fatty meal (because fat triggers gallbladder contraction). The pain may radiate to the right shoulder or scapula, and is often accompanied by nausea and vomiting. Murphy's sign — arrested inspiration when the examiner presses under the right costal margin during a deep breath — is a classic finding, typically elicited and interpreted by the provider. Fever and tenderness suggest worsening inflammation; the RUQ location plus the fatty-meal trigger plus shoulder radiation is the pattern to recognize.

Pancreatitis: epigastric pain to the back

Pancreatitis is inflammation of the pancreas, an organ that sits deep behind the stomach. Its signature is severe epigastric pain that radiates to the back, often with nausea, vomiting, and a distressed, hunched-over patient who finds lying flat unbearable. The causes are many (gallstones and alcohol use are among the most common), but the nurse does not need the cause to recognize the severity: pancreatitis is often a serious, sometimes life-threatening illness requiring hospitalization, monitoring, and intravenous support. Because the pancreas is retroperitoneal (behind the peritoneum), the pain is deep and poorly localized compared with the sharp, localized pain of peritonitis.

Bowel obstruction: the blocked tube

A bowel obstruction is a blockage of the intestine, and its symptoms follow directly from the "one long tube" model from Topic 1. The classic presentation is the four Cs: crampy (colicky) abdominal pain, constipation (inability to pass stool or flatus — obstipation), copious vomiting (which may become feculent, or stool-like, in late small-bowel obstruction), and distention. Bowel sounds may be high-pitched and tinkling early (the bowel working hard against the blockage) or absent later (the bowel exhausted). Causes include adhesions from prior surgery, hernias, tumors, and volvulus. A complete obstruction is a surgical emergency — bowel tissue can become ischemic and die.

GERD and peptic ulcer disease: the upper-GI pair

GERD (gastroesophageal reflux disease) occurs when stomach contents reflux into the esophagus, causing heartburn (a burning sensation behind the sternum), regurgitation, and sometimes a chronic cough or sore throat — often worse after meals or when lying down. Peptic ulcer disease (PUD) is a break in the lining of the stomach or duodenum, typically felt as a burning or gnawing epigastric pain that may be related to meals. The danger signs for both are bleeding: vomiting blood (hematemesis), passing black, tarry stools (melena, indicating upper-GI bleeding that has been digested), or dark blood in stool. Any of these red flags — especially in an older adult — warrants prompt evaluation.

IBD and IBS: inflammatory versus functional

Inflammatory bowel disease (IBD) — Crohn's disease and ulcerative colitis — involves chronic inflammation of the intestine, with symptoms such as diarrhea (often with blood), abdominal cramping, weight loss, and fatigue, in a relapsing and remitting course. Irritable bowel syndrome (IBS) is a functional disorder: the bowel looks normal, but the person experiences chronic cramping, bloating, and altered bowel habits (diarrhea, constipation, or both) related to gut-brain signaling, stress, and diet. The key distinction: IBD has visible inflammation and can cause tissue damage; IBS does not. Both are chronic, both deserve person-first language ("a person with Crohn's disease"), and recognizing the difference changes expectations about treatment and monitoring.

Hernias and peritonitis: two more patterns

A hernia is a protrusion of an organ or tissue through a weakness in the abdominal wall, felt as a bulge that often appears with coughing, straining, or standing and may disappear when lying down (reducible). Danger signs are a bulge that cannot be pushed back (incarcerated) and one that is painful, tender, and red (strangulated — blood supply compromised, a surgical emergency). Peritonitis is inflammation of the peritoneum, most often from a perforated organ or spreading infection. Its signs are the most serious in this topic: rigid, board-like abdomen; severe pain worsened by any movement or pressure; rebound tenderness; fever; and a patient who looks acutely ill and lies very still. Peritonitis is a life-threatening emergency requiring immediate surgical evaluation.

The recognition checklist

When you encounter abdominal pain, run a quick mental checklist: Where is it (quadrant)? How does it behave (crampy vs constant; acute vs chronic)? What came with it (fever, vomiting, appetite, bowel changes, bleeding)? Is the patient stable (vitals, distress, rigid abdomen)? Then document objectively and escalate according to severity. Never assume severe pain is "nothing" in an older adult, who may have blunted symptoms; never give food, drink, heat, or laxatives for undiagnosed abdominal pain without orders; and never let a rigid abdomen wait. Scope of practice varies by state or provincial regulations and facility policy.

Common Confusions