Search for tag: "stomach"

Interviewer: Three symptoms that don't seem serious but could be. We'll talk about that next on The Scope.

Announcer: This is, From the Front Lines with emergency room physician Dr. Troy Madsen, on The Scope.

Interviewer: Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. Today, three symptoms that don't seem serious but could be. We're talking about signs that you might have a serious medical condition that a lot of people ignore because we're kind of numb to these things.

What are the big three? Let's start with number three. In no particular order, or is this in order?

Dr. Madsen: This is in no particular order at all.

Interviewer: Okay.

Dr. Madsen: Just the three things I thought of as we talked about this that people often don't take very seriously but when they come in sometimes we can find serious things going on.

First one on the list is headaches. And when we're talking about headaches, I think a lot of us are used to headaches. We work, we get tension headaches, sometimes we just don't feel quite right, a little nauseated. But I oftentimes find that people with headaches just feel like "I've just got to tough it out," just get through it and it will go away.

Interviewer: Right, it's a headache, everybody gets them.

Dr. Madsen: Exactly. And, sometimes headaches are a sign of something very serious going on. A lot of times, the red flags with headaches are, headaches that come on very suddenly, very severe, maybe make you feel more nauseated then maybe you've been with previous headaches, certainly if you're passing out because of headaches. Another interesting thing with headaches that's more serious is if it wakes you up in the morning, like you get a headache and you wake up and this headache is the thing that woke you up.

Interviewer: Okay.

Dr. Madsen: And that's often a sign of something going on in the brain, maybe a brain tumor or something like that that can be a more serious thing. So a reason to, certainly if it's a sudden onset severe headache, get to the ER, if it's a headache that's waking you up in the morning, something to talk to your doctor about, they may want you to come to the ER or get some sort of imaging of your brain to see what's going on there.

Interviewer: And it might not be a bad idea if you just kind of always have headaches to talk to your doctor about it because that's not a fun way to live.

Dr. Madsen: Yeah, you're exactly right. We do see cases like that, too, of people who come in the ER who say "I just get migraines all the time" and they could be on medication to prevent that, to prevent that ER visit and make their life much more comfortable.

Interviewer: All right, number two on three things that don't seem serious but could be.

Dr. Madsen: Yeah, so number two is back pain. And back pain is another one of these things you figure "Tough it out, I get pain in my back, maybe I was doing some lifting, something like that." But one of the really, really serious things with back pain is an aortic aneurysm, or a tear in the aorta. And classically with that, people will have pain that starts in their chest and goes though to their back and it's like a tearing pain, maybe it's down in their abdomen and they feel some pain in their back as well with that.

Interviewer: So upper or lower back it sounds like.

Dr. Madsen: Exactly.

Interviewer: Doesn't have to be just back from where the heart is.

Dr. Madsen: No it doesn't.

Interviewer: Even though it's a heart thing you're describing.

Dr. Madsen: Well it's related to the heart. The aorta is the main vessel that delivers blood from the heart to the body. So yeah, it is related to the heart. The heart is squeezing blood through there, so people sometimes just have just severe back pain with an aortic aneurysm or a tear in the aorta and that's something that's extremely serious, you've got to get to the ER, get that checked out. And typically with that, they just have sudden onset severe pain. That's how they describe it. Just a sudden onset pain feels like a tearing or a ripping sort of pain.

You know with back pain as well, you can have issues like cancer, tumors in the spine, things there that will cause you pain that's often more severe when you're lying down or certain positions. It's a little more rare, but that would be something to see your doctor about. They could get an x-ray of your back, sometimes they'll get an MRI to take a look there and see what's going on.

Interviewer: So if it's something you've lived with for a while, there again, go see a physician because why should you live with that. If it's something that comes on very suddenly, for no real apparent reason, that's the trip to the ER time.

Dr. Madsen: Exactly.

Interviewer: All right. Number one on the list of three symptoms that don't seem serious but could be.

Dr. Madsen: And number one is abdominal pain. And we see lots and lots and lots of people with abdominal pain, and we see lots of people with abdominal pain who don't have anything wrong. But then we see people with abdominal pain who come in and say "I've had this pain in the right lower side of my abdomen for five days now. I just figured it was gas and it would go away." We get a CT scan and they have a ruptured appendicitis. And that's just not good.

So there are things in the abdomen that can go very wrong, and it generally happens over time. Typically in the abdomen, it's not something that's going to happen all of the sudden, but if you're having abdominal pain and it's not going away after a few hours, it's progressing, especially on the right side of your abdomen. If you're a typical young, healthy person, the right lower side is your appendix, the right upper side is your gall bladder.

Those are the most common things I see in young healthy people who are just like "I've had abdominal pain before. This will go away." They come in, they have a ruptured appendicitis, or they have a very serious case of cholecystitis, which is an infection of the gall bladder, and they have to go to the operating room to get these things repaired, which they would otherwise but often it's a much more complex case because the infection there is so advanced.

Interviewer: So it sounds like the first two, sudden symptoms. The third one, symptoms that have lasted for a while.

Dr. Madsen: Exactly. Things that came on more gradually and then progressed but people just keep thinking "This will go away" and it's not going away.

Interviewer: That's for the abdominal pain. How many days, if I kind of have a consistent abdominal thing going on, what should my line be, where I'm like "I better go see somebody"? Five days? Is that it, or sooner than that?

Dr. Madsen: I would do sooner than that. With the appendix, with the gallbladder, most things if you got a little bit of food poisoning or some gas in your stomach it's going to get better within six hours. If it's going on beyond that, if you're getting more toward 12 hours with this sort of thing, that's definitely I think a reason to at least see your doctor about it.

Interviewer: And I think it's also interesting too because I know a lot of people from some previous podcasts talk about very sudden abdominal pain like waking up in the middle of the night, sudden abdominal pain. From what you just told me, that doesn't sound like necessarily the thing to worry about. It's if it continues over time.

Dr. Madsen: Well, and again it becomes challenging because I mention that thing to you about the aortic aneurysm, like the back pain, that's also in the stomach that is a sudden thing, so it comes a little bit more challenging.

Interviewer: How do I know if something happens suddenly if I should be concerned? I mean, how do I parse this out?

Dr. Madsen: I think you have to base it on the severity of the pain, how it compares to your previous pain. But these are things where people kind of ease into it, it's like "Oh this isn't so bad. I've got a little pain in the right side of my abdomen. I'm used to having a little bit of abdominal pain." But then they gradually get worse and worse. Maybe some of these other serious things in the abdomen, they come on suddenly, and they're severe.

And so, you base it on the severity, and then those things that aren't so severe, you base it on well, what's it been doing over time, has it just been gradually getting worse, that's a sign often of something more serious.

Interviewer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: Inflammatory Bowel Disease treatment options. We'll talk about those next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. John Valentine is an expert in treating inflammatory diseases of the intestinal tract including inflammatory bowel disease. Dr. Valentine, after you've been diagnosed or you've diagnosed someone, I should say, with IBD, is there a standard treatment order that you follow or what can the person expect at that point?

Dr. Valentine: Well, there used to be a misconception that you'd start with the milder medications and work your way up, but people were failing. I think the better concept is to treat to the disease severity. If somebody has mild disease, see if you can get by with some of the milder medications. If somebody has obviously severe disease, you're wasting your time starting slow and the patient's going to get into other kinds of problems. It also makes a difference if you're talking about ulcerative colitis or Crohn's disease.

Let's start with ulcerative colitis. I would like to see everybody fail a class of drugs called mesalamine back in the '50s, '60s, and '70s, a drug was called sulfasalazine. That still exists, but they all deliver the same medication to the colon. Most patients will respond well to that. There is a proportion, 30-40% of those, that that class of drugs isn't enough. Then they need to get into medications to suppress their immune system.

We may use steroids such as prednisone in patients just to get them better quicker while you want to see if the mesalamine drugs will be effective for them. But if they're not effective, then steroids can give some prompt relief, but they're not good for your long run. They are full of complications.

Then we get into what we call steroid sparing therapies, which could include azathioprine, methotrexate, or anti-TNF medications, infliximab. Vedolizumab is a newer so-called biologic, but that blocks the signal that sends the inflammatory cells to the intestine.

Interviewer: Are there any drawbacks to those medications?

Dr. Valentine: Well, with the mesalamine medications, they are very safe. Every drug has potential side effects to it, including aspirin, but these drugs, like I've said, have been around since the '50s in one form or the other. So they have a long track record and they're very well tolerated for the most part. When you start getting into the medications that suppress the immune system or blocking a key component that we have for a reason, given what we're doing to the immune system, I think there are also surprisingly well-tolerated. But you do need to be aware of potential complications.

So we avoid chronic steroids because of effects on mood. You can get depressed, trouble sleeping, get irritable. It can push you over to be diabetic if you're prone to that already, weight gain, acne, other cosmetic changes can occur, as well as osteoporosis from long-term use. So we need to avoid long-term use of steroids.

The other medications, methotrexate, azathioprine is a therapy and we'll start with those. They can reduce your white counts so you need blood monitoring. Abnormal liver tests can occur with both of those so you need to monitor the liver enzyme. Look for irritation of the liver. There's also an increased risk of skin cancers and lymphoma with patients on azathioprine. Now, it's not dramatic, but there is an increased rate and patients need to be aware of that.

So then, you get into the anti-TNF medications. These are monoclonal antibody or biologic drugs that bind the protein in your immune system called tumor necrosis factor, which is very stimulating to the immune system. While there appears to be less of a risk of malignancy with those medications, it's not zero. You need to screen patients for exposure to tuberculosis because putting somebody who has been exposed but not been treated can let the TB run wild. Screening for TB and for Hepatitis B is very important for that class of drugs.

Interviewer: Sounds like some of these cures are just about as not fun as inflammatory bowel disease is.

Dr. Valentine: Well, if you don't need to be on those medications, you shouldn't be. But I think if you need them, the benefits outweigh the risks.

Interviewer: Got you.

Dr. Valentine: While these complications can occur, they're not very common.

Interviewer: That's good. When it comes to the treatments, it's all about just managing the symptoms or is it about actually suppressing the disease?

Dr. Valentine: It's suppressing the disease. You might be able to manage the symptoms with pain medications, antidiarrheal medications, but the inflammation is still there and problems will occur.

Interviewer: Yeah, all right. So let's talk about if you're diagnosed with Crohn's Disease, then. How do the treatments differ?

Dr. Valentine: So since Crohn's Disease likes to, or commonly affects, the small intestine, the mesalamine drugs don't work very well because they're designed to deliver to the colon. In addition, with Chon's Disease, rather than being just the lining of the bowel that's inflamed, the whole thickness of the bowel wall is inflamed so you need more potent medication. Mesalamine medications don't work very well for Crohn's Disease. Very mild, colonic Crohn's, I've seen it'd be effective. But if you have more severe disease, you need to move on.

The only thing to move on now is to immunosuppressant medications. The same ones I mentioned before. The azathioprine, methotrexate, the anti-TNF drugs, infliximab, adalimumab, certolizumab, and then the vedolizumab, the one that blocks the lymphocyte traffic, has also been approved. There have not been head-to-head comparisons, but it doesn't appear to work as well as the anti-TNF medications. So because you need to get into more aggressive medication, and because of the complications with Crohn's, you don't want to let that drag out too long.

Interviewer: What's somebody's eating or their lifestyle, or are there any changes they could make there that will help inflammatory bowel disease, or is that not even related?

Dr. Valentine: There are some things you could do to help the symptoms. So when you're bowel's inflamed, especially the colon, the job of the colon is to absorb water and to hold your stool until it's a convenient time to get rid of it. When it's inflamed, it's having a hard time doing that so certain foods that pull more water into your colon are going to give you more symptoms. So we advise people with the inflammation of their colon to avoid raw fruits and vegetables, high fiber foods until we get the inflammation under control.

Once it's under control, you can add that stuff back to your diet and tolerate just like before your diagnosis. In Crohn's disease involving the small intestine, but when the whole thickness of the bowel wall is inflamed, the lumen, the center part of the intestine, actually gets narrowed. So again, bulkier, fibrous foods may have a harder time getting through the narrowing, which give symptoms of abdominal pain, distention, and if bad enough, nausea and vomiting. So again, avoiding those until we get the inflammation under control is often recommended.

Interviewer: But it doesn't actually treat the problem, which as you indicated, if untreated, could cause bigger problems?

Dr. Valentine: Correct. I firmly believe we need better dietary studies in inflammatory bowel disease, but the studies that have been done to date haven't really identified any particular diet or lack of things in your diet that causes inflammatory bowel disease.

Interviewer: Are there any other common things that patients say to you that they wonder if it will help as opposed to taking some of the medications that you recommend? And what do we know about those?

Dr. Valentine: Diet comes up a lot and I think patients are frustrated and disappointed when I can't tell them how to change their diet. Probiotic supplements also come up frequently and in the test tube, they do have anti-inflammatory activity. But there are thousands of different species and strains of bacteria within the gut.

Most of the probiotic supplements have between one to 10 species of bacteria and we don't know which ones and how many and which ones you need for which disease processes. So they won't be harmful, but I really would have difficulty going to the medical journals and finding clinical trials of probiotic supplements showing they're of great benefit.

Interviewer: What can a patient expect for the rest of their life, then, since this is something that you manage and treat throughout the rest of your life as far as dealing with inflammatory bowel disease?

Dr. Valentine: Well, the need to stay on chronic medication and keep regular follow-ups with the gastroenterologist is important. Because we can't cure this, chronic treatment is needed. Then, if you have inflammation in your colon, after you've had the disease for about 10 years, you need to get into colon cancer screening surveillance programs because of the higher rate of colon cancer that's found in these patients.

So typically, it's a colonoscopy every two to three years after 10 years, and then current guidelines recommend a yearly colonoscopy after 20 years of inflammation in the colon. So if you have Crohn's disease only in the small intestine, the rate of colon cancer is not increased. That's another reason why to determine where in the bowel the inflammation is occurring.

Interviewer: As far as my lifestyle, if I'm on the medications that are managing the symptoms, it's taking care of the inflammation, which is the root cause, life relative is normal beyond that point?

Dr. Valentine: Except for having to remember to take your medication.

Interviewer: Yes.

Dr. Valentine: That is easy to do when you feel bad, but then when you're feeling well, you have to remember to take it.

Interviewer: Take that medication and you'll be fine.

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Interviewer: What will an emergency room physician do if you have a severe stomachache? Can you go into the ER? That's next on The Scope.

Announcer: This is "From the Front Lines" with emergency room physician, Dr. Troy Madsen, on The Scope.

Interviewer: One of our most popular pieces on TheScopeRadio.com is "I have a severe stomachache, ER or not?" And in that particular episode, we were told that if you have a severe stomachache, you should go to the ER and have a look at because it could be a couple of things. One of the comments on that is what do emergency room doctors do if you go in with a bad stomachache? Dr. Troy Madsen is an emergency room physician at University of Utah Health. Bad stomachache somebody comes in, what do you start doing?

Dr. Madsen: This is a really great question because you may think to yourself, "Okay, my stomach hurts. I'm going to go to the ER and they're going to look at me and say, 'Why are you here?' They're going to send me home."

So the first thing I'm going to do of course is find out more about the stomachache, when did it start, where does it hurt. Have there been any other symptoms with it like fever or any pain elsewhere, nausea, vomiting, diarrhea, pain with urination, any blood in the urine or in the stool. So these are all kind of things I'm doing to try and figure out, "Okay, what could be causing this sort of pain?"

The next thing often that I'm doing is, not often always, is a physical examination. So I'm examining this person trying to push on their abdomen and I really focus on certain areas because these areas will make me think of different things. If I push on the right lower side of their abdomen and it hurts, I'm thinking of appendicitis.

On the right upper side I'm thinking of the gallbladder, maybe a gallstone or an infection there. Just in the upper part of the abdomen, just kind of down below the ribs there where you feel a little notch that little bone there. Thinking about the pancreas there. It could be causing some symptoms.

And then in the left lower side of the abdomen. In older people you can have an infection in the intestines there called diverticulitis, that often causes pain there. So those are some of the things that are going through my mind as I'm pushing around saying, "Hey, does it hurt here? If I let go, does it hurt worst when I let go?" That can be a sign of a more severe infection. Is the pain just everywhere or does it really localize to one spot?

Typically in the ER, you'll get an IV. We'll put an IV in, which is giving you medications. So if you're having severe pain we'll give you a pain medication. If you're having nausea we'll treat that. Often times we're giving fluid for dehydration, especially if a person has been vomiting a lot, "I've had a lot of diarrhea." And then I'm thinking about testing. What do I need to do to figure this out?

In some cases someone may come in, I may push on their abdomen and in doing that I pretty much have an idea of what's going on, but those cases are rare. A lot of times with abdominal pain we are sending tests and so typically there I'm doing blood work, looking at their white blood cell count, that's going to show me signs of infection.

Also, looking at their liver function test to see if there's anything there that suggests a liver problem. Look at something called the lipase, which is something that they have an issue in the pancreas. I'm going to see things that are abnormal there. Looking at the kidneys, electrolytes. So all sorts of different blood tests.

And then beyond that I may do an ultrasound, an ultrasound to look at the gallbladder. Maybe we end up getting a CT scan to look at the appendix or the other organs in the abdomen. So it's going to be more testing guided by where this person hurts.

There may be cases where we do an examination, push on the abdomen and we don't have to do tests. Maybe we'd say, probably gastroenteritis, probably a virus or something like that. But often times we are doing some sort of testing in the ER.

Interviewer: So a lot of the times it sounds like it's a very complicated thing. That's even difficult for a physician to figure out what the real problem is?

Dr. Madsen: It really is and this is one of the most common things we see in the ER is abdominal pain. So you've always got to be thinking of all these different things. There's really not just a certain way we go about it. We're going to be guiding that by how their symptoms started, where they hurt, but typically it does involve some blood work, may involve an ultrasound, maybe a CAT scan. Trying to sort through this and rule out the bad stuff to see what's going on.

Interviewer: To most people that come in, have a pretty good sense of the difference between kind of regular stomach pain that might be caused from something they ate or a gas bubble and one of these issues you've talk about?

Dr. Madsen: It's tough. At the end of the day the large majority of the time we send people home saying, "We're not finding anything really serious. It's probably something you ate, probably a virus or a gas bubble or something." So it is really tough for an individual to tease that out and so I can't say that most people really are sure exactly what's going on.

Interviewer: If the pain subsides after five minutes or so, would you recommend somebody still going to the ER? Is it that more pain that lasts longer that should worry somebody or not really?

Dr. Madsen: Yeah, I think probably pain that lasts longer and it depends on the individual and what other medical issues they might have. But typically if it's something that comes on and goes away, you can watch it, see what happens, see if things come back if they get worse. Most things that are serious, in pretty much all cases if it's going to be something that's really significant, it's going to get worse. It's not just going to come on and then go away and then you feel fine.

Interviewer: But it sounds like that it can be a difficult thing to figure out and if in doubt, really you should go see somebody.

Dr. Madsen: Sure, absolutely. Have someone at least take a look at you, examine you, see where you hurt. Get a better sense of what's going on.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 22, 2018
originally published: April 22, 2016

Announcer: Is it bad enough to go to the emergency room or isn't it? Find out now. This is ER or Not on The Scope.

Interviewer: Dr. Scott Youngquist with the University of Utah Hospital, are you ready for ER or Not?

Dr. Youngquist: I'm ready.

Interviewer: All right. Here we go. Here's the situation. You wake up and you can't stand up straight because your stomach hurts so much. ER or not?

Dr. Youngquist: In most cases ER.

Interviewer: Really?

Dr. Youngquist: Yes. The reason is there could be some very bad things causing that abdominal pain. So in some way it depends. If this is a chronic issue obviously it may not require any treatment in the emergency department at all, and some people unfortunately suffer from abdominal pain on a daily basis. But I'm going to assume this is new, you've never had this before and you woke up with abdominal pain so severe that you couldn't stand up. So what could it be?

If you're a young and otherwise healthy person, the most likely cause is appendicitis. And usually if you've got appendicitis you've started with some mild abdominal pain; it's often located around the belly button and then tends to migrate to the right lower quadrant of your abdomen and gets severe over time. It can perforate if it's not treated surgically and cause a large intra-abdominal infection or sepsis or even death from infection.

Interviewer: It's nasty because it releases all that nasty stuff into your body that it would normally contain in the appendix.

Dr. Youngquist: Absolutely. People don't feel well when they've got it. They feel sick all over and it's all coming from their appendix.

Now the other things that can cause this particularly in middle aged older people are gallbladder disease. So you could have a gallstone that is obstructing the common bile duct or even causing perforation or infection of the gallbladder. And that also requires emergency treatment sometimes and removal of the gallbladder or at least antibiotics.

Interviewer: Got you. I'd be afraid that I was just a little bloated or gassy or had some sort of a weird cramp.

Dr. Youngquist: It could be, but that should resolve in a matter of minutes, seconds to minutes.

Interviewer: Okay.

Dr. Youngquist: It shouldn't last hours.

Interviewer: Okay.

Dr. Youngquist: So if you want to wait a little bit and see if it goes away that's probably fine. But if it's lasting for minutes/hours, then you need to come in and see somebody about it.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: June 28, 2018
originally published: June 29, 2014