2016, September/October Adirondac Adirondoc
There are entire textbooks for physicians describing the diagnosis and treatment of the patient with abdominal pain. Distilling these for a one-page wilderness medicine column is obviously impossible. Yet, most of us occasionally develop a bellyache while camping, and the vast majority of the time these resolve uneventfully. Let me simply mention a few specific causes, in no particular order, and highlight some of the features that demand further evaluation and concern.
Appendicitis is probably the condition about which most everyone frets, yet it is actually uncommon. The condition affects about a quarter percent of folks annually, with the peak age in the 10- to 19-year range. Few patients have “classic” findings of appendicitis, but typically the disorder begins with abdominal pain that then becomes associated with nausea and appetite loss. A low-grade fever then develops. There is tenderness when the abdomen is pressed, especially on the lower right side. Walking and movement are painful and difficult. Definitive diagnosis and therapy requires hospitalization.
Gastritis is a non-specific term for irritation of the lining of the stomach. It has many causes, including infection, increased stomach acid, stress, and dietary factors. It typically causes a steady burning discomfort between the bottom of the breast bone and the belly button. On camping trips, dietary changes are the most likely cause. It generally responds to chewable antacids such as Tums®. Over-the-counter acid blockers such as Prevacid® or Zantac® are effective but take longer to work than antacids. Remember that some of the pain medications frequently used on hikes, such as Motrin®, are common causes of gastritis.
Gastroenteritis is an infection, usually caused by a virus, that affects the entire intestinal tract. It can cause diffuse abdominal pain, usually accompanied by diarrhea and/or vomiting. Most episodes of viral gastroenteritis are self-limited, but can make a visit to the backcountry miserable. The only real first aid is ensuring adequate hydration. In the wilderness, plain water is usually the only option; it should be given in frequent but low-volume increments. Soup or bullion can provide both water and salt. While over-the-counter anti-diarrheals such as Imodium® may decrease the frequency of stooling somewhat, they do nothing to hasten recovery or prevent dehydration. Finally, keep in mind that viral gastroenteritis is extremely contagious, and ensure adequate hand sanitation among the camping group to prevent spreading to others.
Constipation, in my experience of decades of taking groups and individuals on backcountry expeditions, is the most common cause of abdominal pain. Dietary change and reduced fluid intake are the usual culprits, although many Americans live with mild constipation daily anyway. Discomfort and straining with stooling, rather than the actual number of bowel movements, is the usual feature. Increasing fluid intake and introducing some dietary fiber, such as dried fruits and beans, may be the only option in the wilderness. I have recently begun carrying a stool-bulking agent, MiraLax®, in my camping first aid kit.
Although most belly pain in the wilderness is benign, here are some red flags that should merit immediate termination of a trek:
• alteration of consciousness ( confusion, lethargy) may be a sign of severe dehydration or systemic infection;
• blood from any orifice (vomit, stool, urine, or non-menstrual vaginal bleeding);
• persistent pain that interferes with sleep or walking; • pain that follows an injury, such as falling onto the abdomen;
• persistent lower abdominal pain in a woman of childbearing age in whom there is even a remote chance of early pregnancy.
~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com. Triathlete and gastroenterologist Marcus Rivera, MD, reviewed this column and provided helpful advice.General First Aid