Abdominal pain
Among the adventures for your primary care physicians is managing the complaint of abdominal pain. And while it is very different if you’re 2 or 12 or 20 or 50 or 80, the problems range from nothing to dangerous. But unlike the complaint of chest pain, dropping over dead from it is not very often the case, so there is time to assess the situation.
The abdomen is full of organs and they all behave differently, and you may be able to zero in on what the problem might be with a few tips. Here are some thoughts on what organs act like when they are hurting:
Appendicitis. The appendix is a little worm-shaped finger-sized blind loop of intestine that hangs down off the beginning of the colon, and is famously present in the lower right abdomen, or the “right lower quadrant” (RLQ). In the condition of acute appendicitis there is an obstruction at the pore where it attaches to the colon there, with poop material, etc., and it begins to swell. Eventually it will pop (“perforate”), and this is bad because rupture of any part of the colon spills the germs that live there (part of normal bowel “flora”) out into the abdominal cavity, and if this is allowed to fester for some days the infection in the belly cavity gets large and out of control and threatening. Yet while it seems like at least a quarter of the appendicitis cases we see are perforated, I cannot recall any cases where the person died from it, but it is possible. Hence, it is worth getting evaluated for if the pain is down on that side of the belly.
The condition is unusual in the elderly and littler kids, but I have seen it in all ages. The peak age is young teenagers. A typical story is waking up with pain around the belly button and loss of appetite. By noon the pain seems to localize in the RLQ, and that night there is a general surgeon in your life. Appendectomy is a minor procedure taking less than an hour usually, and nowadays is done with a fiberoptic tool.
It is difficult to tell who has appendicitis by examination, and years back we had to “sell” a surgeon on the idea that he or she needed to see the patient in the emergency department, and things like abnormal labs, fever, and the exam itself are unreliable. Hence, they used to train surgeons to find that at surgery only half of patients actually had appendicitis, to make sure they were operating aggressively enough.
Even though we don’t feel good about CT scan radiation dose, if you’ve got an appendicitis story we’re breaking out the scanner. An ultrasound can sometimes be useful but is not as good. There aren’t many cases that hide from the scanner, so a normal study is pretty reassuring. Generally, with appendicitis you’re getting worse by the hour, so if things seem to be improving you can consider waiting. If you’re on to day two I’d worry less, but I’ve seen lower grade cases develop slowly like that. But remember, if there’s an infection thing like that in your belly, you should be able to push on it and find tenderness, and any time you can find something like that in the abdomen you’d better be careful. Tenderness (i.e., hurts to push on) is a key warning sign in abdominal pain complaints of any kind. And there is the term “rebound tenderness”, where shaking the belly cavity and moving things around in there will make an inflamed thing hurt. If there’s rebound, you’re getting worse.
Barbers used to do minor surgeries, and hung bloody rags outside to dry, and after this practice ended they just made those whirly red signs to mimic the rags. Their scalpels were used by surgeons of a later day. But yes, barbers used to do appendectomies.
Other conditions: Upper abdominal pain
Pain in the upper abdomen is common and there are several organs up there that can hurt for one reason or another. There is the stomach, the gall bladder, the early loops of the small bowel (the duodenum), and very importantly, the pancreas, and it can be hard to tell them apart based on the hurt, and whether it’s tender there or not to push on. They all cause nausea and vomiting, and can affect and be affected by eating. They all tend to hurt through to the back. For bad enough complaints, a series of labs, an ultrasound, or even a CAT scan can tell you what’s wrong usually.
Do I have a stomach ulcer? The stomach is in the upper mid-abdomen region called the “mid-epigastrium”, and deep-hurt, organ-type pain in this location, often felt radiating through to the back, may signal the stomach is hurting. Ulcers develop gradually, so the complaint is typically weeks of discomfort, usually worse when the stomach is empty, like in the middle of the night, when there is nothing but acid gnawing away at the stomach lining. The pain at times becomes intolerable, and vomiting is not unusual. Food often makes things feel better, presumably by diluting the acidic juices.
The stomach manufactures acid to a very low pH (high acid is low pH), and in so doing injures the stomach itself, and also the first part of the small bowel it empties into (the duodenum). Furthermore, the reflux of its contents injures the esophagus, resulting in the zillion-dollar antacid business. And we don’t eat a lot of rough foods like we used to, so all this acid seems increasingly unnecessary. Since the advent of acid suppressors like histamine blockers (Zantac, Pepcid, Tagamet) and proton pump inhibitors (Prilosec, Nexium, Prevacid, others), we just don’t see stomach ulcers like we used to. However, with the introduction of the over-the-counter (OTC) anti-inflammatories like ibuprofen and naproxen, we still see ulcers, and these medications are now the main cause. Alcohol and especially cigarettes are famous causers for stomach ulcers as well.
Upper GI Bleeding
Another consequence of stomach or duodenal ulcer is bleeding and hemorrhage from the organ, a life-threatening situation. There are big arteries up there and when there is bleeding it is typically massive. Blood is cathartic, so before long it is coming out the bottom of you. And after traveling through the digestive system it is metabolized to black, and the term for the black, tarry, unbelievably foul-smelling “end-product” is “melena” (pronounced MELL-ena). Many times people have no idea the black stuff is blood, and may report “black diarrhea”. But it is the drop in circulating blood volume that makes people collapse or feel weak or dizzy especially on standing, and this is what brings them to the medical system. It is the low blood pressure, fast heart rates, and loss of color that leads us to suspect that the condition of “upper GI” (for gastro-intestinal) bleeding is occurring. Resuscitation with IV fluid is critical, and often more “intensive care” is needed for stabilization. If the circulatory system loses pressure it can be very hard to get it back, presenting a potentially fatal situation. And these are very frequent emergencies.
Vomiting blood, and passing “bright red blood” from below, is scary, right? Well, it is in fact less often dangerous when compared to upper GI hemorrhage and melena. Bleeding from “below” that is red is usually from the colon, which doesn’t bleed like the stomach and duodenum do. Vomiting can tear esophageal tissue a little bit and scare people, especially young people, but without melena or signs of blood loss (low blood pressure, fast heart rates, poor color), these red pukes rarely add up to something serious. Reassuring people is another story however.
Early in my career, in the early 80s, fiberoptic tools were just being invented. Now, you name the area of the body, and there’s a scope for it. Besides looking at and biopsying tissue, they also can be used to stop bleeding and open obstructions. They are very helpful managing intestinal bleeding and revolutionized care immensely. And they have allowed for the gastroenterologists of the world to live in very large homes.
The Pancreas
This digestive organ resides on the left side of the upper abdomen, but the hurt generated when there’s something wrong can be anywhere in the upper abdomen and generally toward the midline. It can even hurt on the right of the upper abdomen, the area typically reserved for the gallbladder, so it’s hard to tell. The pancreas is a vital organ, and when something’s wrong with it, it stops you in your tracks. The pain is intolerable, and there is often vomiting, and one knows this is more than your average bellyache. The most common cause of pain in the organ is injury caused by alcoholism. Occasionally medications and high fat levels in the bloodstream can injure and inflame the organs, the condition of “pancreatitis”.
The leaf-shaped pancreas coalesces into a single duct that connects with the bile duct coming down from the liver, and they form one duct that empties into the upper part of the small intestine, so stones and sludge from the gallbladder can get loose and travel down the piping and plug up the pancreas duct. The resulting backup injures the pancreas and this can be life-threatening (“gallstone pancreatitis”). And the bile backup turns you yellow.
They say there are three rules of surgery: eat when you can, sleep when you have to, and don’t ever mess with the pancreas. It is a flimsy, fragile organ and is profoundly unforgiving. Recovery can be long, with incapacitation and starvation, since eating flares it all up again. Once they start, these problems can recur.
Haunting ERs everywhere: the patient with chronic pancreatitis. They rarely deviate from the profile of 30s to 40s, former drunks and usually drug addicts, from bad childhoods, now broken down to chronically depressed chronic pain patients. They orbit into the ER every so often with “a flare-up”, and there’s usually not enough narcotics in the box to give them relief, and they’re always wide awake and hoping, usually pleading, for more. Their labs are unreliable, and yes you can see abnormalities on CT scans, but then where are you? Usually you have validated their ghastly plight, that this little organ can make you so miserable. Even when we can’t find anything wrong with it.
As with all chronic pain patients. antipsychotics with a little narcotic is usually the key to the temporary relief we hope to provide.
The Gallbladder
The liver sits in the right UPPER quadrant of the abdomen (RUQ). Beneath it, hanging on some ductwork emerging out of the bottom of the liver is the gallbladder. This small pouch of an organ a few inches long stores bile. This residue of metabolism (bile) is dumped into the small intestine where it aids in digestion of fats in the diet. It is also responsible for the color of poop. The “gall” (bile) can sludge and form stones, and these can cause intermittent pain and lead to surgical removal for relief.
The stomach itself secretes a hormone called CCK (cholecystokinin, or “make the gallbladder move”), which finds it’s way through the blood to the gallbladder and makes it contract, and this all happens when you eat. If there are stones in the gallbladder, a right upper abdominal pain may follow a meal an hour or so later. The hurt is bad but tolerable, and people put up with it for years. But a diseased, stone-filled gallbladder can get swollen, infected, rupture even, and good luck surviving all that. And this is not to mention the possibility of sending one of those stones down the duct system and injuring the pancreas.
It’s a small industry regarding the gallbladder in the management of belly pain complaints. Usually with classic symptoms and an ultrasound that shows stones, the local surgeon can remove it with a few cool tools of the modern era and you’re home tomorrow with a small scar. But what if the tests are normal? Well, they’ll often take it out anyway, and then what if the pain doesn’t go away? Is this just some sort of chronic pain? Are narcotics involved, or psychiatric behavior? Welcome to my shift.
The Colon
The colon starts in the Right Lower Quadrant, where the appendix is. It goes from there up toward the RUQ (the ascending colon), then goes across the upper abdomen behind the stomach (the transverse colon), turns downward there on the left side of the abdomen (the descending colon), makes an ess heading back toward the sacrum (the sigmoid colon), then goes straight down as the rectum (a word that means straight), and then the anal structures form the exit.
The rectum is usually empty, and when it’s not you can tell gas vs liquid vs solid, and you knew that. There is an involuntary muscle there which relaxes when any of these substances come in contact with it, and then only the voluntary external sphincter allows for fecal continence. And you knew that also.
Constipation: The job description for the colon is to remove water and “form” stool. Low food intake, dehydration, and narcotics along with other medications can result in drying and stool retention, what we call constipation. If firm stool makes it into the rectum and down to where the relaxation tissue is (a toothy looking structure called the dentate line), stool and stool liquid leak out, and this is called stool “impaction”. Often the only help is to manually disimpact the colon with the (gloved) finger. Soap suds enema, delivered with the long hose and quart of soapy water inserted a few feet up into the descending colon, is the best treatment, and nurses love you for ordering this. But constipation and impaction are awful for the sufferers, and we do well to help out. Cathartic agents (things you can drink that clean you out) like Magnesium Citrate bottles, available over the counter, are reliable relievers of constipating conditions.
The ER is famous for poop stories, and the most notorious top 100 are all from narcotic withdrawal. And without question, with narcotics being the reliable personality destroyers that they are, it makes sense that these people become “full of sh–”, which they generally are figuratively to have fooled themselves into this catastrophic addiction. When they get overmedicated or even frankly overdosed, and are rescued with the narcotic reverser naloxone, they wake up in a pile of…themselves.
Diverticulitis: The colon has 3 bands of longitudinal muscles with areas where the colon is “bare” between them, and over the years as much as 1/3 of people develop small balloon pouches we call diverticuli. And while they may never cause problems, they famously get infections in them and cause the acute abdominal pain from the condition called diverticulitis. This almost always involves the descending and sigmoid colon, and so is a left-sided abdominal pain complaint unfolding gradually over several days. It is treated with antibiotics, and is usually diagnosed by CT scan. And like appendicitis, these things can rupture (though rarely), they can obstruct the bowel, and can bleed profusely (often when they are not inflamed as in acute diverticulitis). I have been surprised in my career how common diverticular disease actually is in our society. But as opposed to appendicitis, there is no rush to go to the hospital before one ruptures. Still, if you’re hurting and tender over there, you should check into it. When one does rupture, the surgical repair is much more than an appendectomy, often resulting in temporary colostomy.
Crohn’s disease and Ulcerative colitis: This pair of conditions involve inflammation of the bowel as the result of auto-immunity. In Crohn’s disease any part of the bowel from the esophagus to the rectum can be involved, and in Ulcerative colitis it is the colon that is under attack. In both cases there is lots of abdominal cramping and diarrhea over months, and periods of bloody diarrhea. The diagnosis is made by biopsy and the care is necessarily delivered by the specialist in the field, the “gastroenterologist”. They are treatable conditions, and may remit for years. The typical age of onset is people in their 20s and 30s.
GERD
Gastroesophageal reflux disease (GERD). GERD treatment is a zillion dollar industry. There is a large, well-controlled muscle (the pyloris, a word that means fire) at the end of the stomach that allows the stomach to be the reservoir we need it to be so we don’t have to eat all day long. After a meal, the pyloris will open briefly every 20 minutes or so, and the stomach (a muscle) will contract and squish a small amount of foodstuff into the small bowel, and then it closes up again. Holding things at the esophagus end of the stomach is a relatively much smaller muscle, the lower esophageal sphincter (LES). It predictably loses the battle against the pyloris, and as a result, food, now acidified, refluxes into the esophagus. This may range from a little “heartburn” to full-blown GERD, where there is damage to the esophagus resulting in scarring and eventually narrowing. Over time, there can be enough scar buildup, often without even noticing it has gone on, that food gets hung up there requiring a trip to the ER. The gastroenterologist is called in, and a fiberoptic tool used to clear the thing. I have worked most of the Thanksgivings of my adult life, and I believe on every one of them somebody came in with “esophageal impaction”.
In the late 80s, the new class of acid stoppers mentioned earlier (proton pump inhibitors like prolosec, Nexium) came on the market and are great at turning off the acid, and while the reflux disease continues the injury is not nearly as bad, and the long-term consequences less. So with much of these symptoms, people should feel free to medicate themselves with these drugs, previously very expensive and now affordable, and safe in the long term.
Nausea, vomiting and diarrhea, and dehydration:
Microbes attack the intestine on regular occasion as we inoculate ourselves after coming in contact with other people. When it’s a virus there is sudden onset of nausea, vomiting, and lots of watery diarrhea. Each germ seems to have its own personality, with some causing more nausea and vomiting and some being more of a diarrhea result. Some invade and enter the bloodstream bringing fever and the “achy” feeling, referred to as “myalgias and arthralgias”, or muscle and joint aches. Sometimes the germs get into the nervous system causing the non-dangerous form of meningitis called “aseptic” (viral meningitis).
Dehydration: Everybody seems to think they’re “dehydrated”, with no real sense of what that means. Certainly we have an ability to run a little wet or dry, and you can usually tell by the darkness of your urine. But look at dehydration like this: there are three degrees of dehydration: 5%, 10%, and the max, 15% dehydrated. So, from hot summer days to intestinal viruses, you may dry out. For 5% dehydrated, maybe you’re a little lightheaded and dry mouthed, and your heart runs a little. In 10% dehydrated you’re quite flat and need to be laying down mostly, along with dry membranes, and dizziness on standing resulting from decreased blood volume. But when we test you your labs are fairly normal, and while a little IV fluid helps, you’re handling the situation, and eventually the stomach will settle and you can start drinking again, and wouldn’t have died. But at say 15% dehydrated, the blood pressure might be in the 70s, the heart rate in the 130s or higher, and lab testing will show that the kidneys are failing, and electrolytes like potassium and sodium are rising to dangerous levels. IV fluid “resuscitation” is probably essential for survival in these situations. So, often it is the most excellent RN who manages IV access for the life-saving of it all. While I mouseclick a bunch of notes and orders and other nonsense.
And lastly, the rear end: The most common of rearend problems are hemorrhoids, fissures, and infections. Hemorrhoids are hemorrhages into the skin of the anus itself, which is a tender and soft mucous membrane. They are managed acutely with lots of soapy water soaking and a variety of salves with limited benefit. They generally must run a course of 3 or 4 weeks, when the clot solidifies and resorbes to some degree. Fissures are slits in the anal muscle from trauma and are associated with a wicked spasm after bowel movements lasting an hour. The best treatment is to aggressively apply “Calmoseptine”, a relative of the zinc oxide the surfers and lifeguards use.
And then there are infections. Pain, redness and swelling or abscess formation in the outskirts of the anus are the typical and unmistakable complaints and findings. They may require a surgeon to slice and drain them open, a painful experience. In fistula formation, a tunnel has dissected from the rectum around the anal muscles and emerging a short distance away. They drain a foul smelling combo of poop juice and infection. Again, a surgeon can “work on” these things for you, and thank goodness for that.