Heart Attack (See Page 50)

The symptoms of a heart attack can include pain that is located in the epigastrium, rather than in the chest. If the victim has a history of heart disease and complains of dull epigastric pain, nausea, shortness of breath, and weakness, consider the possibility of a heart attack. If you suspect a heart attack, even minimally, plan for immediate rescue or evacuation.

Ulcer (See Also Page 223)

An ulcer is an erosion in the lining of the stomach (gastric ulcer) or duodenum (peptic ulcer) that penetrates the protective mucous layer and allows acid and digestive juices to erode deeper into the tissues (Figure 96). This causes extreme pain and can lead to bleeding from leaking blood vessels in the ulcer crater. Symptoms include constant burning pain in the epigastrium that is made worse by pressing and is often associated with nausea and/or belching. In a minor case, the pain may be relieved by a meal. In a severe case, when the ulcer has eroded into a blood vessel or has perforated the wall of the stomach or bowel, the victim will vomit red blood or dark brown clotted blood (“coffee grounds”) and complain of pain that may radiate to his back. Rebound tenderness and peritonitis may be present. Dark black tarry bowel movements (melena) are caused by blood that has made its transit through the bowel. Bright red blood or blood clots with a bowel movement can be caused by brisk bleeding from an ulcer, but more commonly originate from bleeding that is occurring within the large intestine (colon) or rectum, or from hemorrhoids (see page 220). Mild bleeding from an ulcer may actually transiently decrease the pain, because blood acts as an antacid. Some ulcers are caused by bacterial (usually, Helicobacter pylori) infection. To eradicate the bacteria and allow the ulcer to heal, a physician must prescribe specific, intense antibiotic therapy.

Figure 96 Ulcers. A, Location of ulcer craters in the duodenum and stomach. B, Epigastric region of the abdomen, where ulcer pain is often noted.

Gastroenteritis

Gastroenteritis is often called the “stomach flu” (see the discussion of diarrhea on page 207). Symptoms include waves of crampy upper and/or lower abdominal pain, followed by loose bowel movements. Nausea and vomiting may be present. Occasionally, the victim has symptoms of an upper respiratory infection, with cough, runny nose, sore throat, headache, and fever. The treatment for viral gastroenteritis consists of an adequate liquid diet (hydration is the key to recovery—see page 208) and medicine for intractable vomiting (see page 222). When a victim vomits green bile, this should be taken as a sign that the problem is more serious than straightforward gastroenteritis, although bilious vomiting can occur with repetitive retching, when the stomach has been emptied and duodenal contents are all that is left for regurgitation.

Heartburn

See page 221.

Pancreatitis

The pancreas is an organ situated in the posterior upper abdomen that secretes a number of enzymes used to digest food. The pancreas also secretes insulin, the hormone that allows us to use and store glucose. The digestive enzymes travel from the pancreas through a duct, from which they are released through a small opening into the duodenum (the first portion of the bowel after the stomach). If the pancreas becomes inflamed, either by alcohol abuse (heavy drinking is far and away the most common cause), viral infection, or blockage of the main secretory duct by a gallstone, severe epigastric pain is the rule. Sometimes the victim will have diffuse abdominal pain with radiation to the back. Pain is accompanied by nausea and vomiting (which may contain bile). The victim may be restless and prefer to sit and lean forward for pain relief. A person with pancreatitis needs to be hospitalized, because the most effective treatment is to eliminate oral intake for a time (to decrease stimulation of the pancreas). Out of the hospital, allow the victim clear liquids and antacids only, and pain medicine if pills can be kept down. Seek immediate physician care. If a person with severe abdominal pain has blue discoloration around the umbilicus or of the flanks, this may indicate internal bleeding.

Injured Liver

If a fall or blow to the abdomen, right flank, or right lower chest is followed by abdominal pain that is worsened by pressing on the right upper quadrant, a torn or bruised liver should be considered. The victim is at risk for severe internal bleeding and should be observed for signs of shock (see page 60). Evacuate him as soon as possible.

Hepatitis

See page 224.

Gallstones (Cholelithiasis)

Gallstones are formed in the gallbladder, which lies under the liver in the right upper quadrant of the abdomen. The gallbladder stores bile (manufactured in the liver), which is released into the duodenum to aid in digestion following each meal (Figure 97). An attack of gallbladder inflammation (cholecystitis) occurs when the outlet from the gallbladder or the main bile duct into the duodenum becomes obstructed (usually by a gallstone) and the gallbladder cannot empty. This causes stretching of the gallbladder, inflammation, and painful contraction against an impenetrable passage. There is often an element of infection.

Figure 97 Gallbladder with gallstones. A, The stones are formed in the gallbladder and travel through a narrow passageway (cystic and common ducts), which is easily blocked. B, Location of the gallbladder adjacent to the liver in the right upper quadrant of the abdomen.

A typical attack occurs immediately after a meal and is sudden in onset. The pain is colicky and located in the right upper quadrant or epigastrium. It may be associated with nausea, vomiting, and fever. Occasionally, it radiates to the back or right shoulder. Examination of the abdomen demonstrates tenderness in the right upper quadrant. Occasionally, you can feel a tennis-ball-sized tender mass—the swollen gallbladder.

The definitive treatment for cholecystitis is removal of the gallbladder, although many surgeons prefer to “quiet down” the situation first with antibiotics, pain medicine, and intravenous fluids. The victim of a gallbladder attack should be transported to a hospital for evaluation. Pain medicines can be given safely, although certain narcotics may increase spasm of the bile passage and, paradoxically, briefly worsen pain. Solid foods (particularly fats) are prohibited during an attack. Maintain the victim on clear liquids and begin antibiotic therapy with ciprofloxacin, ampicillin, amoxicillin, or amoxicillin-clavulanate combined with metronidazole, if pills can be kept down.

Pneumonia

See page 48.

Injured Spleen

If a fall or blow to the abdomen, left flank, or left lower chest is followed by abdominal pain that is worsened by pressing on the left upper quadrant, consider a torn or bruised spleen. The victim is at risk for severe internal bleeding and should be observed for signs of shock (see page 60). Evacuate the victim as soon as possible.

Gastroenteritis

See page 122.

Pancreatitis

See page 123.

Pneumonia

See page 48.

Appendicitis

The appendix is a small (average length 9 cm) sausage-shaped outpouching of the cecum (which is a part of the small bowel), with no modern physiological function, that is located near the transition point where the small bowel becomes the large bowel (colon) (Figure 98). When it becomes obstructed or infected/inflamed (acute appendicitis), the victim typically has a history of crampy pain that begins in the central abdomen (often around the umbilicus), and then moves, over the course of a few hours, to become constant in the right lower quadrant. He may also suffer loss of appetite, constipation or diarrhea, vomiting, fever, and weakness. Pain nearly always precedes any other symptoms. There may be burning on urination if the appendix rests against a ureter carrying urine from the kidney to the bladder. Sometimes, if one presses on the left lower quadrant of a victim of appendicitis, there is pain noted in the right lower quadrant. If an inflamed appendix lies close to the obturator or psoas muscles, there may be pain when the right leg is internally rotated (obturator) or pulled away from the midline (psoas) of the body.

Figure 98 Appendicitis. Pain is felt in the right lower quadrant of the abdomen.

Examination of the abdomen demonstrates tenderness in the right lower quadrant. Frequently, the victim will resist any movement of the body or legs, because such movement causes abdominal pain. Rebound tenderness is associated with a swollen appendix that is ready to burst or has already ruptured. After the appendix ruptures, the pain may diminish considerably for a few days while an abscess forms. Untreated appendicitis may cause the victim to develop peritonitis, rapid breathing and heart rate, and low blood pressure. If you suspect appendicitis, transport the victim to a hospital for surgical evaluation. If transport will take more than 24 hours and the victim can tolerate oral fluids (is not actively vomiting), allow clear liquid intake to prevent dehydration. An antibiotic (cephalexin, amoxicillin-clavulanate, cefixime, or cefpodoxime) should be administered if more than 24 hours will elapse before arrival at a hospital. If the victim is allergic to these agents, a combination of ciprofloxacin and metronidazole can be substituted.

If a woman of childbearing age develops right lower quadrant pain, the diagnosis of ectopic pregnancy (see page 133) should always be considered. It is useful to carry a “home” urine pregnancy test kit in the first-aid kit.

Kidney Stone

See page 135.

Ovarian Infection (and Other Disorders of the Female Reproductive System)

See page 131.

Colitis

See page 218.

Bowel Obstruction

If the intestine becomes obstructed by scar tissue, cancer, injury, or feces, the victim rapidly becomes quite ill. Symptoms include nausea and vomiting, frequently of green bile or feculent (feces-like) material. The victim has waves of cramping pain associated with waves of bowel motion (contractions) that may be visible through the abdominal wall, which is often distended by the dilated loops of bowel. Occasionally, the victim will have small, squirting bowel movements, as a little liquid slips past the obstruction. If a bowel obstruction is suspected, the victim should be immediately evacuated to a hospital.

An ileus is functional inactivity (no food or fluid absorption, lack of normal peristalsis) of the bowel that leads to intestinal dilation, vomiting, and abdominal pain. It commonly follows an intraabdominal injury or physiological catastrophe (such as extensive burns, disseminated infection, or shock).

Hernia

If the intestine slips through the muscles of the abdominal wall, usually in the groin or around the umbilicus (navel), a hernia is formed (Figure 99). Symptoms include a visible bulge, abdominal pain, and pain at the site of the hernia. The victim should be made to lie quietly on his back with his knees drawn up; place cold packs directly on the bulge. Give pain medicine to control the discomfort. If sufficient relaxation is obtained, the hernia may slip back through the wall, and the bulge will disappear. Afterward, the victim should wear a support (truss or belt) to prevent recurrence until the problem can be corrected surgically. Straining and heavy lifting should be avoided.

Figure 99 Inguinal (groin) hernia. A, A loop of bowel bulges through a defect in the lower abdominal wall. B, Location of external bulge. In some cases, the swelling extends into the scrotum.

If a victim has a painless hernia (bulge) that cannot be corrected, he should avoid straining, particularly when holding his breath, and seek the advice of a physician.

If the intestine will not slip back through, the hernia is trapped (incarcerated). This is an emergency, because if the blood supply to the bowel is pinched off, the tissue can be severely damaged or die, and/or a bowel obstruction (see page 127) can be created. An incarcerated hernia is extremely painful, and if the bowel is injured, the overlying skin frequently becomes reddened or dusky in appearance. Because the aforementioned maneuvers for reduction of a hernia will not be successful and pain will increase, the victim should be rapidly evacuated to a hospital.

Diverticulitis

Diverticula are small outpouchings that develop at weak points along the wall of the colon (large bowel), probably because of high pressures associated with muscle contractions during the passage of stool. When these sacs become obstructed and/or inflamed (most frequently in middle-aged or elderly individuals), they enlarge and create pain and fever. Usually, the left lower quadrant is involved, because diverticula tend to form in the left-side portion of the colon (descending colon) more frequently than in the right-side portion (ascending colon) or horizontal connecting section (transverse colon). A ruptured diverticulum can cause a clinical picture much like that of a ruptured appendix (see page 126), with pain in the left side of the abdomen instead of the right side. The victim should seek medical attention, and his diet should be limited to clear fluids. Antibiotics (metronidazole, metronidazole combined with doxycycline, amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, cefixime, ciprofloxacin, or cefpodoxime) should be administered if help is more than 24 hours away.

Colitis

See page 218.

Kidney Stone

See page 135.

Ovarian Infection (and Other Disorders of the Female Reproductive System)

See page 131.

Bowel Obstruction

See page 127.

Hernia

See page 128.

Abdominal Aortic Aneurysm

An aneurysm is a dilated blood vessel that has been weakened by the ravages of age, high blood pressure, and atherosclerosis (Figure 100). At a certain point, the wear and tear become too much and the blood vessel rips, causing either a slow leak or rapid, massive bleeding that leads to sudden collapse and death. This generally occurs spontaneously only in the elderly, unless there is a congenital defect; traumatic tears of the aorta occur in all age groups.

Figure 100 Abdominal aortic aneurysm. A, Age, high blood pressure, and disease ravage the dilated aorta. B, Location of the aorta in the abdomen. Leaking or rupture causes pain in the abdomen, back, and flank.

The aorta is the large artery that carries blood from the left ventricle of the heart to the body. The symptoms of a ruptured abdominal aortic aneurysm are intense, unrelenting, ripping pain in the abdomen that may radiate to the back or chest; weakness; discoloration of the legs with mottling; and rapid collapse. Gentle examination of the abdomen may demonstrate a pulsating, expanding mass. Abdominal rigidity is due to the rapid accumulation of blood.

Any elderly person who suddenly develops abdominal pain or back pain associated with weakness, a fainting spell, decreased sensation and/or abnormal color in the legs or feet (even if transient) or shortness of breath should be immediately rushed to a hospital. In the best of circumstances, this is a highly critical situation. Be prepared to treat the victim for shock (see page 60).

Ovarian Infection

The ovaries and fallopian tubes (Figures 101 and 102), which carry eggs from the ovaries to the uterus, may become infected, commonly with the bacteria that cause gonorrhea (a form of venereal disease) or by other infectious agents, such as Chlamydia trachomatis. Symptoms include abdominal pain in the lower quadrants (greatest on the side of the affected ovary), fever, shaking, chills, nausea, vomiting, and weakness. Occasionally, the victim will complain of a yellow-greenish vaginal discharge. If you suspect an infection, take the victim to a hospital immediately. If more than 24 hours will pass before a doctor can be reached, the victim should be started on tetracycline 500 mg four times a day, amoxicillin-clavulanate 500 mg 2 to 3 times per day, or doxycycline 100 mg two times a day, for 14 days (doxycycline and tetracycline are effective against Chlamydia). Azithromycin 1 g in a single dose is also effective against chlamydial infection. If you suspect gonorrhea, administer cefixime 400 mg orally twice a day (for single-dose therapies for gonorrhea, see page 299). To treat gonorrhea and chlamydial infection at the same time (the two germs often “travel” together), administer azithromycin in a 2 g single dose (again, see page 299). If the victim is pregnant or allergic to penicillin and gonorrhea is suspected, administer azithromycin 2 g in a single dose or erythromycin base 250 mg four times a day for 14 days. Another treatment regimen that may be used is ofloxacin 400 mg twice a day or levofloxacin 500 mg once a twice for 14 days, either of these with the addition of metronidazole 500 mg twice a day for 14 days, noting that this regimen may be less effective than the others noted because of bacterial resistance to fluoroquinolone drugs.

Figure 101 Female reproductive tract.

Figure 102 Location of female reproductive tract within the pelvis.

Ovulation, Ovarian Cyst, and Torsed (Twisted) Ovary

Some women suffer sudden, intense abdominal pain at the time of ovulation (when the egg is released from the ovary) (see Figure 101). This is caused by a small amount of blood and ovarian fluid, which irritates the lining of the abdomen. Symptoms include pain that suddenly develops in the right or left lower quadrant, and is worsened by movement or deep palpation of the area. Treatment is pain medicine and rest. A ruptured ovarian cyst (which releases tissue fluid or blood) or torsed (twisted) ovary causes similar but much more severe symptoms, which may include excruciating pain, nausea and vomiting, and a rigid (to the pressing hand) abdomen. Any of these conditions may be difficult to distinguish from appendicitis (see page 126) if the right ovary is involved. Treatment for a torsed ovary may require surgery. Any sudden abdominal discomfort in a woman of childbearing age should be promptly evaluated by a physician.

Bleeding from the Vagina

If bleeding from the vagina accompanied by abdominal pain is not clearly part of a normal menstrual period, a woman should seek prompt medical attention. If the bleeding is clearly part of a normal menstrual period, and the pain is unquestionably due to menstrual cramps, the victim may benefit from the administration of a nonsteroidal antiinflammatory drug.

If abnormal (in amount or character) pain and/or bleeding occurs during or between menstrual periods, the cause should be determined by a physician. Until the evaluation is performed, exertion should be kept to a minimum. If periods have been missed (or if the victim is known to be pregnant) and copious vaginal bleeding develops, place the victim at rest and transport her rapidly—by litter, if possible—to a physician. If the bleeding is spotty, the victim may walk with assistance. A ruptured tubal (ectopic) pregnancy can rapidly become life threatening. In this situation, a pregnancy situated in a fallopian tube (rather than in the uterus) causes the tube to rupture. The symptoms include vaginal bleeding, lower abdominal pain (which can become severe), and signs of shock (see page 60). This is a true medical emergency.

Vaginitis, Vaginal Discharge, and Vaginal Infections

The most common causes of female genital tract discharge are infection, reaction to a foreign object, injury, or allergic reaction. In the healthy vagina, bacteria (lactobacilli) produce lactic acid and promote an environment (pH of 3.8 to 4.5) that resists infection, although there are other microorganisms (such as Staphylococcus, Ureaplasma, and Mycoplasma) present.

Vaginitis is a condition of irritation and inflammation of the vagina, commonly noted as a secondary condition that follows administration of an antibiotic, such as ampicillin, to a woman. The antibiotic alters the normal bacterial population of the vagina and allows overgrowth of the causative (for vaginitis) agent, which is often yeast. With a Candida albicans yeast (candidiasis or moniliasis) infection, the victim notes a thick, white, and creamy or curdy (“cottage cheese”) discharge, vulvar and vaginal itching and redness, and burning pain on urination. She should use clotrimazole (Gyne-Lotrimin). Administer vaginal 100 mg tablets once a day for 7 days, or twice a day for 3 days; a vaginal 500 mg tablet for 1 day (single dose); or 1% cream in a 5 g dose for 7 to 14 days. An alternative drug is miconazole nitrate (Monistat); administer 100 mg vaginal suppositories once a day for 7 days, 200 mg vaginal suppositories once a day for 3 days, 1,200 mg vaginal suppository in one dose, or 2% cream in a 5 g dose for 7 days. Other acceptable treatments are a single fluconazole (Diflucan) 150 mg tablet by mouth; tioconazole 6.5% (Vagistat-1) ointment in a single 5 g application; butoconazole nitrate 2% (Femstat) cream in a 5 g dose for 3 days; and terconazole (Terazol) vaginal cream 0.8% in a 5 g dose once a day for 3 days, vaginal cream 0.4% in a 5 g dose once a day for 7 days, or vaginal suppositories 80 mg once a day for 3 days.

Bacterial vaginosis is caused by a shift in vaginal bacterial flora from lactobacilli-dominant to mixed flora, and is characterized by a milky (white or gray), sticky, homogeneous, and sometimes thin discharge with an abnormal (“fishy,” particularly after intercourse) odor, as well as occasional itching and pain. It is definitively diagnosed by measuring the vaginal pH at a value greater than 4.5 and noting a specific type of cell (“clue cell”) when the discharge is examined with a microscope. Treatment is either metronidazole 500 mg by mouth twice a day for 7 days or 0.5% or 0.75% metronidazole vaginal gel (such as MetroGel-Vaginal) once a day for 5 days; or clindamycin phosphate 300 mg by mouth twice a day or 1 applicator (5 g) of 2% vaginal cream at bedtime for 7 consecutive nights; or 2% extended-release clindamycin cream, one application intravaginally.

If the infection is due to trichomoniasis (caused by Trichomonas vaginalis), the victim will suffer a copious, occasionally frothy, and white-gray or yellowish discharge and may also have abdominal pain and fever. In such a case, the antibiotic of choice is tinidazole 2 g in a single dose, metronidazole 2 g in a single dose, or metronidazole 250 mg three times a day, or 375 mg two times a day, for 7 days. Do not drink alcohol while taking tinidazole or metronidazole or for 3 days thereafter. The male sex partner should be treated with tinidazole or metronidazole 2 g in a single dose.

On return to civilization, an appropriate gynecological exam should be sought to exclude other causes of vaginal infection, which include herpes simplex virus, Neisseria gonorrhoeae (the causative agent of gonorrhea), and Chlamydia trachomatis.

Genital herpes is caused by herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2). HSV-1 is transmitted predominantly by oral-genital sexual contact and HSV-2 by genital-genital contact. After exposure, the incubation period is 2 to 12 days, with an average of 4 days. Early symptoms include a red rash and small bumps, followed by a blistering rash with ulcers. Other symptoms may include pain at the site of the rash, tender local lymph nodes, fever, headache, fatigue, and muscle aching. If the blisters and ulcers occur on external skin, they heal in 9 to 12 days after a crusting phase; if they occur on mucous membranes (e.g., inside the vagina or the mouth), they heal without first crusting. After the first episode of genital herpes has resolved, recurrent episodes may be preceded by tingling or sharp pain in the buttocks, legs, or hips from a half hour to 5 days before the rash erupts. Antiviral treatment can shorten the first episode or a recurrent episode, or can be used to suppress the onset of an eruption. The following are recommended doses of medications:

Emergency Contraception

In the event that emergency contraception is desired (e.g., for unprotected sexual intercourse or contraceptive failure), levonorgestrel tablets 0.75 mg (Plan B) are available over-the-counter and approved for women age 18 years and older. A prescription is required for a woman age 17 years or younger. This medication does not protect against infection with human immunodeficiency virus (HIV) and other sexually transmitted diseases. The medication provides a short burst of hormones that affects the lining of the uterus and alters sperm transport, which prevents sperm from meeting the egg to achieve fertilization. Levonorgestrel is effective if given within 5 days (120 hours) of intercourse, but is most effective if given within the first 24 hours after intercourse. The dose is one pill by mouth, followed by a second pill 12 hours after the initial pill.

Bladder Infection

See page 294.

Colitis

See page 218.

Bowel Obstruction

See page 127.

Abdominal Aortic Aneurysm

See page 130.

Kidney Stone

A “kidney stone” originates in the urine-collecting system of the kidney, and most commonly causes pain when it travels down the ureter (ureteral stone) to the bladder (Figure 103). After traversing the bladder, it may enter the urethra and continue to wreak havoc. The most common compositions of stones are calcium-derived (80%), struvite (15% to 20%; magnesium ammonium phosphate), uric acid (5% to 10%), and cysteine (less than 1%).

Figure 103 Kidney with kidney stones. A, The stones are formed in the kidney and travel through the ureter, bladder, and urethra before they are passed in the urine. B, Location of the genitourinary (urogenital) system.

The pain of a kidney stone is usually sudden in onset and often becomes intolerable. The location of the pain is related to the location of the stone. If the stone is high in the ureter, the pain localizes to the victim’s back (on the affected side), with some radiation to the abdomen. Lightly tapping over the flank and lower ribs on the back of a victim with a kidney stone will often cause extreme pain. If the stone is passing through the lower ureter, the victim will have extreme pain in the back, abdomen, and genitals. When the stone is not moving, the pain (renal “colic”) may disappear as quickly as it began. A small (less than or equal to 2 mm in diameter) stone may take 7 to 10 days to pass; a 2 to 4 mm stone may take up to 2 weeks; and a stone larger than 4 mm may take up to 3 weeks.

A victim who is passing a kidney stone finds no relief from remaining motionless, and will appear quite agitated, constantly changing positions. Associated symptoms include nausea, vomiting, bloody urine, an urge to urinate, pain on urination, and sweating.

If the diagnosis of a kidney stone appears relatively certain, give the victim the strongest pain medicine that is necessary and available, and encourage him to drink copious amounts of fluid. Ketorolac (10 mg by mouth every 4 to 6 hours, not to exceed 5 days) has been recommended as a pain medication for kidney stone because it may decrease spasm in the ureter; it may be given along with a narcotic drug, such as hydrocodone, to enhance the analgesic effect. Another useful drug if ketorolac is not available is diclofenac 50 mg by mouth 2 or 3 times a day. Some urologists recommend adding tasmulosin (Flomax) 0.4 mg by mouth once a day for a few days after the onset of pain associated with passing a kidney (ureteral) stone. Seek physician evaluation as soon as possible. If the victim is elderly, consider the diagnosis of ruptured aortic aneurysm (see page 130). If you have any suspicion that the victim might have an aneurysm, evacuate him immediately.

Kidney Infection

See page 295.

Pneumonia

See page 48.