You have recent unintended weight loss or a history of cancer. You could have a tumor in your spine. Such tumors may start in the spine but more frequently spread there from another location, like the lung, breast, kidney, and prostate. A tumor can weaken a vertebra, leading to fracture and pain, and it can also compress the spinal cord or its branches, leading to weakness, incontinence, and many other problems. If you have a known history of cancer or very strong risk factors (for example, you have been smoking a pack per day since kindergarten), get an urgent evaluation. Your doctor will likely order an X-ray and/or CT scan of your spine.
You have known osteoporosis (or risk factors, like age over sixty-five and/or long-term use of steroid pills) and have sudden-onset back pain. You may have fractured one of your vertebrae. Such fractures can occur after traumatic events, like falling down, or seemingly insignificant events, like coughing hard or lifting a heavy object. One case report even described a woman with osteoporosis fracturing her spine in multiple places while going over a speed bump! Your doctor will recommend over-the-counter pain medications (see the Quick Consult). If the pain is really severe and doesn’t improve with medications, you may need a procedure in which cement is injected into the fractured vertebra to improve its height and strength (known as vertebroplasty or kyphoplasty).
You have severe lower back pain only during your period. The pain is likely coming from your uterus or surrounding organs, rather than from your spine. The two most common culprits are endometriosis and fibroids. In endometriosis, a clump of cells that look and behave just like the ones in the wall of the uterus gets stuck somewhere outside of the uterus, including near the spine. During your period, the extra tissue swells and bleeds, producing pain. Meanwhile, fibroids are tumors in the wall of the uterus that aren’t malignant (meaning they don’t spread to other parts of the body) but can cause significant pain and heavy periods. Endometriosis and fibroids are both diagnosed with physical exam and ultrasound of the pelvis. The treatments include over-the-counter pain relievers (see the Quick Consult), hormone therapies, and (in some cases) surgical removal.
Get to the E.R.
Over the course of hours to days your legs have become weak, and either you can’t pee or you keep peeing in your pants. You could have compression of your spinal cord from a tumor or infection, causing dysfunction of the nerves that travel to your legs and/or bladder. You need an emergency assessment to avoid permanent paralysis.
You have severe pain and can’t get out of bed. If you can’t get out of bed because your legs literally won’t move, then you may have spinal cord compression and need to get to the E.R. as soon as possible. If your legs work fine but your back pain is disabling, you’re likely in less trouble but may still need help. Take a pain reliever (see the Quick Consult) and give it an hour or two to work. If you’re not feeling better, get to the E.R. for a detailed examination and discussion of further treatment options.
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Quick Consult
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Pain Pills
Pain medications are frequently used to treat back pain. Increasingly, however, doctors and the general public are learning that these drugs have many side effects, particularly when taken for months or years at a time. In addition, the strongest pain relievers have the greatest risk of abuse and dependence.
To minimize side effects and the risk of dependence, doctors treat all nonsevere pain using a pain ladder that was originally developed for cancer-related pain. On the ladder, you start with the gentlest drugs that have the fewest side effects, then work up to the big guns only if absolutely essential.
Most of the nonprescription drugs in the first rung fall into a group known as nonsteroidal anti-inflammatory drugs, or NSAIDs. The most popular are ibuprofen/Advil/Motrin (400 to 600 milligrams every eight hours) and naproxen/Aleve/Naprosyn (220 to 500 milligrams twice per day). NSAIDs are great for back pain but can cause problems in people with kidney disease or heart disease. They can also irritate the stomach and even cause ulcers.
If you can’t take NSAIDs for some reason you can instead try acetaminophen/Tylenol. This medication is very safe if taken at recommended doses (500 to 1000 milligrams every six to eight hours). If you take more than 4000 milligrams over twenty-four hours, however, you will be at risk for life-threatening acute liver failure. If you already have liver disease, you should ask your doctor about safe doses of acetaminophen.
The first rung also contains prescription drugs that may help relieve pain, like antidepressants (duloxetine/Cymbalta, amitriptyline/Elavil), muscle relaxants (cyclobenzaprine/Flexeril), and medications for nerve pain (gabapentin/Neurontin, pregabalin/Lyrica).
The second rung on the ladder contains weak opioids, like codeine, while the third rung contains stronger opioids, like hydrocodone (found in Vicodin), oxycodone (found in Percocet and Oxycontin), and methadone. All require prescriptions. Because these drugs can be addictive, they should be used only for very short courses (a few days) or when all other long-term options have failed. The current opioid epidemic is related, in part, to the overuse of these medications for pain that could be treated using other medication classes combined with physical therapy, massage, and other non-medicinal interventions.
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You also have fever or chills. Your symptoms may indicate an infection in or around the spine. The most worrisome location is adjacent to the spinal cord itself, where an infection can press against the cord and cause permanent nerve damage. A doctor will order some blood tests and may perform an MRI of your spine. The treatment of a spine infection is usually several weeks of antibiotics. If the infection is near your spinal cord, it may need to be surgically drained. One alternative explanation for these symptoms (which still warrants an E.R. visit) is a kidney infection, which causes fever and lower back pain. This type of infection is even likelier if you also feel the frequent need to pee. The treatment is antibiotics.
You are having occasional spasms of severe lower back and pelvic pain. You may be passing a kidney stone. These stones form in the kidneys, often in response to dehydration, and then get pushed into the very narrow tubes that drain to the bladder. The stones don’t really fit through those tubes, so they get stuck and form painful blockages. The tubes periodically try to push the stones through, causing severe pain. You may also notice some blood in your urine. The diagnosis is confirmed with a CT scan or ultrasound. The treatment is intravenous fluids (to increase production of urine, which will push the stone along), pain medication, and medication to enlarge the tube where the stone has gotten stuck. If the stone is too large to pass on its own, doctors may perform a procedure (using ultrasound or a laser) to break the stone into smaller fragments that can pass more easily.
You were in a car accident or had some other major physical trauma. Hopefully you know better than to try to skip the E.R. after a major injury. You could have fractured one or more vertebrae and may also have damage to your internal organs, like your kidneys, liver, or spleen. Get checked out before it’s too late.
Part 3
Belly
Belly Pain
Tell us if the following scenario sounds familiar. You’re sitting on the toilet in agonizing pain, holding your head in your hands. You’re thinking back on all the meals you’ve eaten in the past two days, cursing your poor judgment (clearance oysters?!) and swearing off food for the rest of your life.
All of us know and dread the feeling of having our guts twisted up in knots. Indeed, pain in the abdomen (the soft area between your ribs and your hips) is one of the most common complaints in the emergency room, accounting for about one in ten visits. Unfortunately, there are about a gazillion different causes of abdominal pain, and though most are nothing to worry about, some are life-threatening if not promptly treated.
So how long should you wait before getting help? Is this just a bad case of food poisoning that needs a few more hours to work itself out? Or are you and your appendix enjoying your final evening together?
&nbs
p; Take a Chill Pill
You have had one or two days of intermittent, nonsevere pain with nausea, vomiting, and/or diarrhea. You probably have gastroenteritis (irritation of the stomach and intestines). The major tip-off is crampy, non-severe pain associated with vomiting, diarrhea, or both. The most common causes are contamination of food by bacteria, like Staph, or infection with a virus. To stay hydrated, you need both water and sodium (salt). The best options are simple broths, solutions like Pedialyte, and sports drinks like Gatorade or Powerade. (Of note, we do not recommend regularly consuming sports drinks, unless you’re trying to gain weight.) You can also take Pepto-Bismol to relieve the pain. If your symptoms continue for more than five days, speak with your doctor. Also, patients with heart failure or high blood pressure should ask a doctor before guzzling salty broths.
You have mild upper belly pain after eating that gets worse when you lie down, gets better after drinking water, and may be associated with a bitter taste in your mouth. You likely have acid reflux, which occurs when stomach acid ventures up to the esophagus (the tube connecting the stomach to the mouth). The esophagus is not accustomed to being bathed in acid, so it becomes inflamed and painful. When you lie down, the esophagus becomes level with the stomach, making it even easier for acid to creep in. A tall glass of water can flush the acid back down and relieve the pain. If the reflux reaches all the way up to your throat, you’ll also note a bitter taste.
Some simple lifestyle changes can defeat reflux. First, cut back on chocolate, fatty foods, spicy foods, and carbonated drinks; unfortunately, if you’re like us, these may constitute a major portion of your diet. Second, avoid lying down soon after eating. Third, stick some books under the head of your bed (not this one of course, unless doing so will make you buy more copies). By raising the head of your bed, you’ll keep your esophagus above your stomach and reduce the risk of reflux. If those measures don’t work, try antacids like Tums or Rolaids to neutralize your stomach acid. The next step is daily over-the-counter medications, like ranitidine/Zantac or omeprazole/Prilosec, to reduce stomach acid production. Be sure to keep your doctor in the loop, not only to confirm the diagnosis but also because long-term reflux can lead to serious problems, like esophageal cancer.
You have occasional crampy pain, and you last pooped a week ago. Are the unread magazines starting to pile up in your bathroom? Constipation is a common cause of abdominal pain, and it’s defined as fewer than three bowel movements per week, lumpy/hard stool, great difficulty pushing out your stool, or the feeling you can’t fully unload. See the section on constipation for detailed information and recommended treatments. Of note, if you experience frequent abdominal pain and constipation, you could have irritable bowel syndrome (described here).
Your pain occurs after drinking milk or eating foods that contain milk. Lactose intolerance is extremely common, particularly among blacks, Asians, and Hispanics. The main symptoms are bloating and pain after consuming milk or milk-based products, like ice cream, yogurt, and cheese. Your body can’t handle lactose, the sugar in milk, so it delegates the job to your intestinal bacteria. Unfortunately, these punks produce loads of gas when they eat lactose, bloating your intestines and causing pain. The easiest solution is to avoid milk altogether—though, if you’re like us, you’d sooner endure the agony than give up ice cream and cheese. A better solution is to take lactase supplements to help your body process lactose.
Make an Appointment
You have had several weeks of a frequent, burning sensation in your upper abdomen, which may get better or worse after eating. You may have ulcers in your stomach or intestine. Ulcers are small craters in the lining of your guts, which don’t take well to being drenched in stomach acid. Typical symptoms are upper belly pain, bloating, belching, and feeling full or uncomfortable after just a few bites of food. In rare cases, ulcers can cause major bleeding events or even punch a hole right through the gut wall (rapidly leading to severe infection and possibly even death). Bottom line: you do not want ulcers.
The diagnosis is usually established with an endoscopy, a procedure in which a camera is steered down the throat to the stomach and intestines. In the past, ulcers were thought to result from stress, excessive booze, and cigarettes. Although medicine continues to have a negative view of all three, we now know that most ulcers result from infection with the bacteria Helicobacter pylori, or H. pylori. As a result, ulcers are usually treated with antibiotics alongside acid-suppressing medications.
You get pain in the right upper part of your abdomen after eating. You likely have stones in your gallbladder, a little pouch tucked under the liver. The liver produces bile, a greenish fluid that helps your intestines process fat, and stores it in the gallbladder. When you eat a plate of bacon-covered cheese fries (yum), your gallbladder injects a dose of bile into your intestines. If you have gallbladder stones, however, they can temporarily block up the tube leading to the intestines and cause crampy pain. This unpleasant sequence of events is known as biliary colic. In some cases, stones permanently block drainage of the gallbladder, causing it to swell and even become infected. This condition, known as cholecystitis, causes continuous, intense pain and requires more urgent attention (see here).
All medical students learn that the biggest risk factors for gallstones are the four Fs: fat (obesity), female, fertile (one or more children), and forty (or older). So that’s about a hundred million Americans right there, give or take a few.
Fortunately, most people with gallstones don’t have biliary colic, or any other symptoms, and don’t require an intervention. They lead happy, satisfying lives, totally unaware of the small sack of rocks under their liver. Those that do have symptoms from their gallstones, however, have few options other than having their gallbladder whacked out with a scalpel. Fortunately, the surgery (cholecystectomy) is almost always done using minimally invasive techniques, resulting in just three or four very small scars.
You have had several days of diarrhea, and you are taking (or recently took) antibiotics. Antibiotics frequently cause diarrhea—which is just one more reason to take them only when absolutely essential. If you started antibiotics a day or two ago, the diarrhea is probably a direct side effect. If you’ve already been on antibiotics for three or more days, or you took them in the last few weeks, you may have Clostridium difficile infection. C. diff (as the cool kids call it) is a type of bacteria normally kept in check by your colon’s other, good bacteria. Antibiotics, however, cause something like the apocalypse for those good bacteria, and C. diff is like the roaches that survive—tough, nasty, and very hard to eliminate. Less often, C. diff can also take over the colon even without the help of antibiotics. Treatment consists of special antibiotics (ironically) that specifically target C. diff.
You have had worsening pain and diarrhea for more than three days. You may have something more severe than the run-of-the-mill infections that usually cause gastroenteritis. The catalog of horrors includes Clostridium difficile infection, as just described, or other nasty bacteria, like Shigella, Salmonella, or E. coli. Alternatively, you could have an autoimmune condition like inflammatory bowel disease or celiac disease, in which your immune system declares a misguided war on the lining of your intestine.
You have frequent pain that improves after defecation, along with months of intermittent diarrhea and/or constipation. In irritable bowel syndrome, or IBS, the lining of the colon becomes very sensitive and generates pain when loaded with stool. People with IBS get frequent bouts of abdominal discomfort that usually improves after a satisfying number two. IBS also causes diarrhea or constipation, sometimes in an alternating pattern. Depending on your symptoms, your doctor may prescribe dietary changes and/or medications to bulk up or thin out your stools. Some patients also get pain relief with antidepressants and/or medications that decrease intestinal spasms.
You have pelvic pain that gets significantly worse with your period. Most women experience bloating and mild abdominal pain when Aunt Flo comes to town. An unlu
cky subset, however, experience disabling pain that interferes with school and work. Two of the more common causes are endometriosis and fibroids.
In endometriosis, an abnormal collection of cells that look and behave just like the cells in the wall of the uterus gets inexplicably stuck somewhere they don’t belong—on the ovaries, the lining of the pelvis, or the intestines. Like the tissue in the wall of the uterus, the extra tissue swells and bleeds during the menstrual cycle, leading to pain. Some women also get pain during intercourse or defecation, depending on where the extra tissue is located.
Fibroids, meanwhile, are uterine growths that either stick into the uterus or protrude from its outer surface. The growths are not cancerous but can cause profuse menstrual bleeding and chronic pain. In some cases, they can also compress the bladder (causing the frequent urge to urinate) or even lead to infertility (if the uterus becomes so misshapen that it can’t accommodate a fetus).
Both endometriosis and fibroids are diagnosed with a physical exam and ultrasound of the pelvis. (Technically, endometriosis needs to be confirmed with a biopsy, though this step is often skipped.) The treatments include pain relievers, hormone therapies, and surgical removal.
Get to the E.R.
You have blood in your feces. The combination of abdominal pain and bloody stool is always a bad omen. The potential explanations include colon cancer, autoimmune conditions like inflammatory bowel disease, severe colon infection, and interruptions in the blood supply to the colon. If there’s more than just a streak of blood in your stool, get to the emergency room for an urgent assessment.
Am I Dying Page 9