HIV Infection

  Definition

HIV infection is a disease caused by the human immunodeficiency virus (HIV). The condition gradually destroys the immune system, which makes it harder for the body to fight infections.

Cause & Risk Factor

The human immunodeficiency virus (HIV) can be spread by the following:

• Contaminated blood transfusions and blood products
• Intimate sexual contact
• The use of contaminated needles and syringes

The virus may also spread from a mother to her baby, either at birth or through breastfeeding.
People who become infected with HIV may have no symptoms for up to 10 years, but they can still pass the infection to others. After being exposed to the virus, it usually takes about 3 months for the HIV ELISA blood test to change from HIV negative to HIV positive. HIV has spread throughout the US. The disease is more prevalent in urban areas, especially in inner cities. 

Symptoms & Signs

Symptoms related to HIV are usually due to an infection in part of the body. Some symptoms related to HIV infection include:

• Diarrhea
• Fatigue
• Fever
• Frequent vaginal yeast infections
• Headache
• Mouth sores, including fungal (candida) infection
• Muscular stiffness or aching
• Rash of various types, including seborrheic dermatitis
• Sore throat
• Swollen lymph glands

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Medical Causes Related To Abdominal Pain

• Abdominal aortic aneurysm (dissecting): Initially, abdominal aortic aneurysm—a lifethreatening 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 lifethreatening 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 confusionalso 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 foodborne 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).
• 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 lifethreatening 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 acuteonset 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 leftupper- 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.

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Abdominal Pain

Abdominal pain usually results from a GI disorder, but it can also be caused by a reproductive,
genitourinary (GU), musculoskeletal, or vascular disorder; drug use; or ingestion of toxins. At
times, such pain signals life-threatening complications.

Abdominal pain arises from the abdominopelvic viscera, the parietal peritoneum, or the capsules of the liver, kidney, or spleen. It may be acute or chronic and diffuse or localized. Visceral pain develops slowly into a deep, dull, aching pain that’s poorly localized in the epigastric, periumbilical, or lower midabdominal (hypogastric) region. In contrast, somatic (parietal, peritoneal) pain produces a sharp, more intense, and well-localized discomfort that rapidly follows the insult. Movement or coughing aggravates this pain.

Pain may also be referred to the abdomen from another site with the same or similar nerve
supply. This sharp, well-localized, referred pain is felt in skin or deeper tissues and may coexist
with skin hyperesthesia and muscle hyperalgesia.

Mechanisms that produce abdominal pain include stretching or tension of the gut wall, traction
on the peritoneum or mesentery, vigorous intestinal contraction, inflammation, ischemia, and sensory nerve irritation.

Abdominal Pain: Types and Locations

 History and Physical Examination

If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has
had this type of pain before. Have him describe the pain—for example, is it dull, sharp, stabbing,
or burning? Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests the patient may have an obstruction of a hollow organ.

If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient

where the pain is located and if it radiates to other areas.

Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens

or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient the date of her last menses and if she has had changes in her menstrual pattern or dyspareunia.

Also ask about appetite changes and the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was his last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth. Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness.

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