Functional Bowel Syndrome
Intermittent cramping abdominal pain, associated with episodes of constipation or diarrhea, with or without mucous stools.
Patients with this problem give a history of periodically recurring symptoms, often provoked by stress. X-ray evaluation of the abdomen will show no abnormality and all lab studies will be normal. The pain will move from place to place in the abdomen.
Treatment is generally supportive with reduction of stress when that is possible. Avoiding (or treating) constipation or diarrhea is helpful. Non-narcotic analgesics can be given if the pain is quite significant. Antispasmodics are sometimes helpful. Psychoactive drugs are inadvisable unless a specific psychological disorder is present which would be expected to respond to the psychoactive drug.
Gastroenteritis
Acute inflammation of the stomach and intestines, resulting in cramping abdominal pain, distention, nausea, vomiting, diarrhea, fever, and chills. This may be due to bacterial infection, viral infection, or ingestion of a toxic substance (food poisoning).
Patients usually complain of diffuse, cramping abdominal pain with marked GI symptoms. The pain migrates from place to place. Treatment is mostly supportive (rest and observation in mild cases, IV fluids in severe cases) with specific antibiotic therapy when the causative organism is known and sensitive to this approach.
Diverticular Disease
Diverticular disease represents a spectrum of abnormalities ranging from asymptomatic “diverticula” (small outpouchings of the colon) to “diverticulitis” with peritonitis, abscess formation and sometimes perforation of the colon.
Diverticular disease is usually focused in the sigmoid colon in the left lower quadrant, although diverticula can be found in small numbers anywhere along the course of the large and small intestines.
Cramping lower abdominal pain with diarrhea alternating with constipation are symptoms common to those with diverticular disease (and also functional bowel syndrome). If accompanied by fever and elevated white blood count with a mass in the left lower abdomen, “diverticulitis” is likely to be present.
Mild symptoms require only supportive treatment. Diverticulitis often requires IV fluids and antibiotics.
Appendicitis
This condition is characterized by progressive right lower quadrant pain. Nausea and anorexia occur early. Vague pain begins in the periumbilical area and migrates over several hours to McBurney’s Point in the right lower quadrant. The patient lies supine with the right hip flexed.
On examination, marked tenderness at McBurney’s Point, voluntary guarding, rigidity and rebound tenderness are found. Fever is not common unless appendix is ruptured. Bowel sounds are quiet and no bowel movement will have occurred since the onset of the pain. Motion of the uterus or right adnexa causes marked pain.
X-ray of the abdomen may show an oval, calcified fecalith up to 1-2 cm in diameter in the right lower quadrant of the abdomen. A sentinel loop of gas-filled small bowel next to the appendix may be seen. Ultrasound may show a fluid-filled appendiceal lumen. CT scan can show appendicitis.
Historically, treatment of acute appendicitis has been surgical with removal of the appendix. However, in military settings, timely emergency surgical intervention may not be possible. Extensive experience with antibiotic treatment of simple (non-perforated) appendicitis has shown generally good short term results. 90% of these patients can avoid initial surgery, although 30% will still require surgery within a year. Over the course of many years, surgery will ultimately be needed in about 40% of these patients.
Table 1
Antimicrobial regimens recommended by the World Society of Emergency Surgery recommendations for treating extra-biliary community-acquired intra-abdominal infections. From World J Gastroenterol. 2012 Mar 7; 18(9): 865–871.
| Antimicrobial agents | Dosage | |
| In stable, non-critical patients | ||
| With no ESBL-associated risk factors | Amoxicillin/clavulanate | 2.2 g every 6 h (2-h infusion time) |
| Ciprofloxacin | 400 mg every 8 h (30-min infusion time) | |
| + | ||
| Metronidazole | 500 mg every 6 h (1-h infusion time) | |
| With ESBL-associated risk factors | Ertapenem | 1 g every 24 h (2-h infusion time) |
| Tigecycline | 100 mg LD then 50 mg every 12 h (2-h infusion time) | |
| In critically ill patients presenting | ||
| With no ESBL-associated risk factors | Piperacillin/tazobactam | 9 g LD then 18 g per day via continuous infusion or 4.5 g every 6 h (4-h infusion time) |
| With ESBL-associated risk factors | Meropenem | 500 mg every 6 h (6-h infusion time) |
| or | ||
| Imipenem | 500 mg every 4 h (3-h infusion time) | |
| + | ||
| Fluconazole | 600 mg LD then 400 mg every 24 h (2-h infusion time) |
Bowel Obstruction
A condition in which a portion of the large or small intestine becomes obstructed.
Patients with bowel obstruction complain of pain, which may be cramping or constant. Abdominal dissension is prominent and patients are constipated. Nausea and vomiting usually accompany this problem. Plain x-rays of the abdomen show a distended, gas-filled loop of intestine proximal to the obstruction. If the problem is not resolved, gangrene and peritonitis develop.
Initial treatment consists of decompression from above with NG suction and support with IV fluids. Partial obstructions are usually relieved with these simple measures. Complete bowel obstruction requires surgery and bowel resection. Without surgery, a complete bowel obstruction would be expected to be fatal.