1. Gas Pain and Constipation
Presentation
Excruciating, bloating, sharp, crampy, migratory abdominal pain may double the patient
over, but last only a few seconds and is relieved by bowel movement and passing
flatus. It may be related to loud bowel sounds (borborygmi) but not to position, eating,
or other causes, and is not accompanied by other symptoms, such as nausea, vomiting,
diarrhea, urinary urgency, et cetera. Rarely are patients awakened with nocturnal
symptoms. The physical examination is also benign, with no tenderness, masses,
organomegaly, or other abnormalities, and the patient does not appear ill between the
episodes of abdominl pain. Bowel sounds may become loud during each episode of
cramps.
What to do:
• Take a thorough history and try to determine the time of onset of symptoms and
whether their severity is increasing or decreasing. Ask if there was a similar
episode in the past. Perform a complete physical examination, including rectal
and/or pelvic examination, and a repeat abdominal examination after an interval.
• If the presentation is not clear, consider using diagnostic tests like urinalysis (to
help rule out renal colic or urinary tract infection); differential white blood cell
count (a clue to infection or inflammation); abdominal x rays (to show free
peritoneal air or bowel obstruction); ultrasonography (pyloric stenosis,
malrotation and intussusception in children, appendicitis and gallbladder
disorders).
• If constipation is part of the problem, disimpact the rectum, if necessary, and try
one enema in the ED.
• Instruct the patient to try relieving symptoms with ambulation, and local heat,
and to return to the ED or see his personal physician if symptoms do not resolve
over the next 12-24 hours. Suggest bulk in the form of bran or Metamucil for
prophylaxis.
• If the problem is chronic or recurrent, or associated with alter nating constipation
and diarrhea, suspect irritable colon inflammatory bowel disease or diverticulitis.
What not to do:
• Do not discharge the patient without one or two hours of observation, and two
abdominal examinations. Many abdominal catastrophes may appear improved for
short periods, only to worsen in an hour or two.
Discussion
While a patient may swallow excessive air in response to anxiety, an increased rate of
"empty" swallowing may also accompany a number of gastrointestinal abnormalities
including hiatal hernia and chronic cholecystitis. Heartburn increases salivation and
therefore the frequency of swallowing. In addition to air swallowing. intraluminal gas-

2. producing bacteria provide the other major mechanism for causing excess intestinal
gas. Some patients may be helped by advising them to reduce or eliminate their intake
of foods that contain non-absorbable carbohydrates such as beans, broccoli, cauliflower
and cabbage. Alternatively, they can be instructed to take Beano food enzyme tablets
with these healthful foods.
Colic attacks usually start when an infant is 7 to 10 days old and increase in frequency
for the next one to two months. they do not just happen suddenly one night when the
infant is six or eight weeks old. In that situation, look for some other acute problem
such as corneal abrasion, incarcerated hernia or digital hair tourniquet in an infant who
is irritable or feeding poorly with no previous problems. Constipation is one of the most
common causes of pediatric abdominal pain. After a digital rectal examination, a
glycerin suppository in infants or a single cleansing enema in children may provide rapid
symptomatic relief.