Wild Side of Medicine: The Belly Goes Bad

By Buck Tilton
Reprinted from The Leader, Fall 2000, Vol. 16, No. 1

The Dirty Devil: remote, magnificent in its sculpted majesty, its hollow cathedrals of soaring sandstone. Too bad the woman, age 22, your responsibility, distracts your contemplation with complaints of "a really bad stomachache."

She doesn't act like it's too bad. You give her a quick assessment which reveals the discomfort is general to her mid-abdominal area, nothing of major significance, and she completes the day's hike. By evening, however, her discomfort has increased, and she complains of nausea. Before dinner she vomits, and reports some relief of pain.

She declines food, "I'm not hungry" and soon complains the pain is back and worse than before. The pain now centers in her lower right quadrant, pain she describes as "a sharp pain when I breathe deep." She calls the pain a 6 on a scale of 1-10. Examination and palpation of the belly reveal guarding and an increase to an "8" on the pain scale when the lower right quadrant is pressed and when the pressure is suddenly released. How long has her belly been causing pain? She started "feeling bad" last night, about 24 hours ago.

Diarrhea? Nope. Urine output? She's not sure of the amount (who is?), but it looked only slightly yellow, and she claims adherence to the hydration ritual. Last bowel movement? This morning, and it looked "normal." Fever? 101 F. Is there any chance she could be pregnant? "Absolutely not!"

No other symptoms. No allergies. No medications. She is sure she's never hurt like this before. She thinks she's been eating and drinking the same stuff as the other students. Are you worried? Yes. An unending list of possible diagnoses associated with abdominal pain includes quite a few that could spell serious trouble.

You cannot--and you have no reason to--memorize the list. But you should be able to recognize a serious belly. Evacuate anyone when: 1. The pain is associated with the signs and symptoms of shock; 2. The pain persists for longer than 12 to 24 hours; 3. The pain localizes, and especially if the pain involves guarding, tenderness, or abdominal rigidity; 4. Blood appears in the vomit, feces, or urine; 5. nausea, vomiting, or diarrhea persist for longer than 24 to 72 hours; 6. The pain is associated with a fever above 102 degrees F; 7. The pain is associated with signs and symptoms of pregnancy.

In the meantime, you know the routine: Keep your patient well hydrated. This one needs a doctor's care. You call for an evacuation. Several hours later her appendix lies in a silver basin on the operating room floor.