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.