Every now and then, I feel sick to my stomach but I’m not sure how sick is enough to go to the ER. What should I do?
Many patients call their physician’s offices overnight to get a gut check on a worrisome symptom, and they leave with the same answer: When in doubt, just go to the emergency room.
It’s rarely the answer someone wants. If they’re calling instead of already driving over, it’s often because they’re hoping to hear reassurance that they don’t need to go to the hospital at 2 a.m. Believe me, as a physician and as a patient, I’ve been on both sides of that conversation.
The problem is it can be impossible to tell someone definitively that “they’re fine” without actually checking their vitals, performing a physical exam and potentially running some tests. Most people recognize that when their pain is a 10 out 10 — or when they see their toilet bowl filling up with bright red blood — they need help.
But over years of taking patient calls overnight, I’ve heard many symptoms that immediately raise red flags — even when they don’t seem alarming to someone without medical training.
While not meant as individualized medical advice, here are a few warning signs — some surprising — that your abdominal pain may need urgent attention.
Pain that’s worse when you cough
If your belly pain feels worse when you cough, jump — or if you’re in a car and you roll over a bump — then that may signal an emergency condition called peritonitis.
Peritonitis refers to inflammation of the lining of your abdominal cavity — the space beneath your chest cavity where abdominal organs hang out together. That space becomes inflamed if something bursts open — a perforated bowel, appendix or cyst.
To help make the diagnosis, a physician may order imaging studies or check for “rebound tenderness” — pain that’s worse, not when they press down on your abdomen, but when they release pressure. If a doctor confirms you have peritonitis, it could mean you’ll need a surgery. So don’t wait to get evaluated if this sounds like you.
You stopped farting
This is no laughing matter. If you’re experiencing abdominal pain and haven’t been having bowel movements or passing flatus, it could be a sign of a bowel obstruction. That’s an emergency.
Depending on the obstruction’s location, you may also experience severe vomiting and feel like you can’t keep any food or liquid down — which alone is an important reason to go to the ER. In some cases of bowel obstruction, people may find their vomit is a darker-green color. This suggests bile — which normally empties into the small bowel — is actually working its way backward and upward.
Fever and yellowing of the skin or eyes
Abdominal pain, especially on the right side of your body, accompanied by fever is already a problem — it could be a sign of appendicitis or other intestinal infection. But you should also watch out for this symptom: yellowing of the skin, which medical professionals call jaundice, or yellowing of the whites of the eyes. These could mean you have an infection of the bile ducts.
Bile duct infections, sometimes caused by a blockage, are emergencies we must act on fast. These infections have a high risk of developing into full-blown sepsis, where the bacteria enter the blood stream. You may need a special procedure to clear and drain the bile ducts as well as intravenous antibiotics.
Stool that’s black and shiny like your smartphone
When we think of blood, we picture shiny and red — but that’s not always the case. Black stool can also be a sign of blood.
When blood mixes with our stomach acid, it can turn black and tarry. And no, really, really dark brown stool isn’t it. I usually ask my patients if it was black like the color of their smartphone screens (and if you’re throwing up, that mixture of acid and blood can look like coffee grounds). If that describes what you’re seeing, you may need an emergency procedure called an esophagogastroduodenoscopy, or EGD, to find and treat the source of the bleeding.
However, odd-colored poop in the absence of other symptoms isn’t always a medical emergency. Taking iron pills or medications like Pepto-Bismolcan cause black stools, and artificial dyes and foods like beets can also cause unusual colors that are nothing to be concerned about.
Dizziness or feeling like you’ll faint
Any time you have abdominal pain and dizziness, it’s an emergency until proved otherwise. That’s because it could be a sign of internal bleeding leading to low blood pressure.
Sometimes, the cause is painful, such as a peptic ulcer. Sometimes it isn’t. For instance, diverticular bleeding famously produces painless bright red blood — and a lot of it — into the toilet bowel. This happens when a vessel in a small pocket of the colon, called a diverticula, bursts.
One dangerous exception that won’t show up in the toilet is a ruptured abdominal aortic aneurysm. This is a life-threatening emergency where the main artery of your body’s blood supply bursts inside the abdominal cavity. People often feel sudden severe pain in their belly, backs and even legs that can quickly lead to shock if enough blood is lost.
What I want my patients to know
The average person survives a ruptured abdominal aortic aneurysm less than 50 percent of the time, even with immediate surgery. (They are uncommon in young people but the risk rises with age; about 1.4 percent of people ages 50 to 84 have one.)
What most of my patients don’t know is that we’re supposed to screen for abdominal aortic aneurysms in all men ages 65 to 75 who have ever smoked cigarettes (at least 100 over the course of their lifetime). While some people who have them may notice a pulsating mass in their abdomen, these aneurysms are often totally asymptomatic for years — until they burst. That’s why anyone who suddenly feels dizzy and feels pain in their belly — even without seeing blood in the toilet — should get help, fast.
Screening involves a one-time quick outpatient ultrasound to see if you have an aneurysm, and depending on its size and growth, we may offer surgery to fix it before it ever becomes an emergency. We typically screen just once in a person’s lifetime, but if an aneurysm is detected, your physician may follow up with repeat surveillance ultrasounds in future.
The problem is that we’re doing an abysmal job with screening: Only 4 percent (four!) of eligible men in the United States have been screened, despite the strong recommendation by the U.S. Preventative Services Task Force.
That means many deaths could be prevented if more people knew about it. So if this is news to you — or to a father, brother or husband who should be screened — have this conversation and get the ultrasound done.
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