Abdominal pain can quickly end a climbing trip or mountaineering expedition no matter the cause. From traumatic injury to a host of bacteria, viruses, or amoebas that cause dysentery and diarrhea, this chapter will discuss the most common issues that climbers face, both within the United States and at common climbing locales worldwide. The issues discussed also include common genitourinary issues that originate in the abdominal region.
Gastrointestinal (GI) issues are frequent during climbing activities. A ten-year study conducted at Everest Base Camp (EBC) from 2003 to 2012 showed that GI diagnoses accounted for almost 16% of patient visits to the Everest ER (Nemethy 2015). Gastrointestinal issues were the second most common medical diagnosis (after pulmonary issues), with acid reflux, diarrhea, and gastroenteritis as the top three. Diarrhea is a common problem among mountaineers, and many medical studies—including one relating a gastroenteritis outbreak on Denali in 2002—have documented this problem (McLaughlin 2005).
While some GI and abdominal problems cannot be solved easily, a few simple points can help prevent a great majority of those most commonly experienced by climbers. These easy measures include:
1. Good hand hygiene
2. Proper food preparation
3. Proper water disinfection (see Appendix E)
This chapter is subdivided into distinct areas focusing in sequence on abdominal pain by location (upper and lower), other medical GI issues without specific location, pain associated with abdominal trauma, and infectious diseases that cause gastrointestinal distress.
The following conditions will cause pain in the upper abdominal region (both right and left upper quadrants) emanating above the umbilicus (belly button) (Figure 1-1). These are the most common medical ailments for climbers and mountaineers but they do not include every possible abdominal condition. Err on the side of caution and never risk your own or your partners’ health and safety by not seeking medical attention.
The gallbladder’s main function is to assist in digestion. It is located in the upper right quadrant just beneath the liver. While gallstone-related problems can range from mild to severe and include biliary colic, acute cholecystitis, ascending cholangitis, and obstructive jaundice, the most common is cholecystitis.
Acute cholecystitis causes right upper quadrant pain and tenderness that can radiate into the right shoulder. This pain increases with deep breathing and is accompanied by nausea and vomiting. Those predisposed to cholecystitis often have flatulent dyspepsia (upset stomach) with intolerance to fatty or fried foods.
It is important to note that symptoms associated with gallbladder problems, if severe, can also represent acute pancreatitis. While uncommon, this condition produces acute pain in the central and right side of the abdomen, sometimes radiating to the back, along with nausea and vomiting, low blood pressure, and high heart rate. Evacuation is necessary for this condition, and supportive measures during evacuation should include pain relief and intake of fluid by mouth or by intravenous (IV) route if available.
Treatment of acute cholecystitis includes pain relief, and if the symptoms continue, beginning a course of antibiotics such as ciprofloxacin. Because of the accompanying nausea and vomiting, rehydration is essential and fluids should be administered in small amounts. Fatty foods should be avoided.
Evacuation is necessary for cholecystitis as well as all of the major differential diagnoses for this condition (acute pancreatitis, ascending cholangitis, and obstructive jaundice).
Commonly known as GERD or acid reflux, this problem is caused by the reflux or movement of stomach (gastric) contents into the lower esophagus. The intrusion of gastric contents causes a host of symptoms, of which the most common is heartburn (the feeling of burning or cramping along the center of the chest below the sternum). Other common symptoms include regurgitating small portions of recently eaten food into the upper esophagus and mouth, a sense of fullness, belching, and sometimes difficulty swallowing. The onset of symptoms is usually soon after eating, and they usually ease as food is digested.
The best “treatment” is prevention, especially for a person who has experienced these problems in the past. Smaller meals are helpful as is avoiding fatty foods, caffeine, and chocolate. Avoiding food prior to sleeping and sleeping with the upper body slightly inclined can both decrease symptoms.
Antacids, H2 blockers, and a class of medications known as PPIs (proton pump inhibitors) can help. The most common examples of these drugs are: antacids (TUMS®, Rolaids®, and Maalox®); H2 blockers (Zantac®, Pepcid®); and PPIs (Prilosec®, Nexium®). Follow manufacturer recommendations for dosing.
This condition is rarely severe enough to limit climbing activities. Evacuation is not needed. However, substernal (midline) chest pain can also be caused by a host of other factors, including a heart attack, so a climber complaining of chest pain should be thoroughly assessed and monitored. If there is any question that the pain is heart-related rather than GERD, medical attention should be sought and evacuation considered.
A peptic ulcer is an area of stomach lining or intestine that is degraded due to the enzymes and acids of the stomach. It is identified by continual gnawing abdominal pain, usually in the center of the upper abdomen. Many peptic ulcers are caused by Helicobacter pylori infection. Risk factors for developing these ulcers include stress, smoking, long-term use of NSAIDs, steroids, and alcohol. Pain is the most common symptom and usually peaks one to four hours after eating.
Use of all NSAIDs (including aspirin) should be discontinued immediately due to risk of bleeding. Otherwise, treatment of peptic ulcers is much like that of GERD. Avoid risk factors and use antacids, H2 blockers, and PPIs to treat. Eating bland foods helps, as does drinking milk. If you are diagnosed with a peptic ulcer prior to a long climbing trip in a remote area or expedition, you should seek medical assistance to treat this condition prior to leaving.
Peptic ulcers do not usually require evacuation, though a climber experiencing symptoms should see a medical provider upon returning home. Severe cases that do not respond to field treatment should consider evacuation.
The medical conditions below are the most common for climbers, but they do not include every possible ailment that could occur in this region of the abdomen. The lower abdomen is considered to be any area below the umbilicus (belly button) and extends downward into the pelvis (Figure 1-1).
Appendicitis is a serious wilderness emergency. There is no widely accepted field remedy, and immediate evacuation is required. Initial symptoms will be general pain in the abdomen with nausea and vomiting. Diarrhea is usually not present. Within six to eight hours, this pain/tenderness will typically localize to the right lower quadrant but can occasionally be referred to the left side. Appendicitis can occur at any age, though it is more common for younger adults and children. Often people with pain associated with appendicitis bend forward or limp as they walk in an attempt to relieve the discomfort. Needless to say, climbers with a history of an appendectomy (appendix removal) are generally unlikely to have appendicitis. Even then, however, a rare condition known as “stump appendicitis” exists, when the stump of the removed appendix becomes infected, mimicking traditional appendicitis. While rare, its incidence is increasing, and surgical authorities feel it is both underreported and underestimated (Kumar 2013). Because of this, appendicitis cannot be completely ruled out even in climbers with a history of appendectomy.
Evacuation is needed for anyone believed to have appendicitis. Delay in evacuation could result in a ruptured appendix and the complications it entails (peritonitis). Food should not be given to the patient and drinks should be limited to very small amounts in preparation for surgical intervention. An antibiotic should be started for any patient suspected of having appendicitis. A recent publication (the Non-Operative Treatment for Acute Appendicitis, or NOTA, study) examined whether antibiotics alone could safely and effectively treat uncomplicated appendicitis without surgery. Patients in this study were given amoxicillin/clavulanate (Augmentin®). Results showed that 88% of patients had complete resolution of appendicitis with antibiotics alone. At a two-year re-evaluation, appendicitis had reappeared in 14% of patients, but of these, 64% enjoyed resolution of appendicitis again with another series of antibiotics (Di Saverio 2014). The implication of this study for climbers is that, for extremely remote trips or trips where evacuation may be prolonged, initiation of antibiotics rapidly may temporize or even treat the appendicitis. However, surgery is still the standard of care for appendicitis, and this study only looked at uncomplicated cases of appendicitis, so all cases of possible appendicitis should still prompt as rapid surgical attention as possible.
Climbers exhibiting symptoms of appendicitis should be evacuated as soon as possible.
Diverticulitis is an inflammation of a diverticulum (small outpouching) within the colon. It is more common in older climbers and is rarely seen in anyone under 40. It is most commonly located in the left lower quadrant, with symptoms that include nausea, vomiting, abdominal pain, and tenderness. Diarrhea may be present but not profuse as with gastroenteritis. In acute cases there may be a perforation of the intestinal wall, which can result in peritonitis. Signs of peritonitis include abdominal rigidity, high fever, and vomiting. These patients require evacuation. Additionally, blood in the stool is also a sign that the condition may be worsening and will require more immediate attention.
Rest, pain relief, and a fluid diet for 24 to 48 hours is recommended. An antibiotic should be given to these patients.
Evacuation is only necessary if the climber shows signs and symptoms of peritonitis, blood in the stool, or if the patient does not respond to treatment.
An ectopic pregnancy occurs when a fertilized egg is implanted in a fallopian tube. Any climbing expedition with women of child-bearing age should carry pregnancy tests, since severe abdominal pain with concern for ectopic pregnancies can easily be ruled out with a negative test. Sudden pain to one side of the lower abdomen is the most common symptom. Other symptoms may include breast tenderness, a menstrual period that is atypical or missing (amenorrhea), pain appearing in or radiating to the shoulder, and small amounts of vaginal bleeding, usually dark in color.
A female with a ruptured ectopic pregnancy will have the symptoms above as well as weakness, dizziness when standing, high pulse rate, and low blood pressure due to internal blood loss.
A ruptured ectopic pregnancy is a medical emergency and evacuation should not be delayed. Sexually active females of childbearing age experiencing any lower abdominal pain should be treated as an ectopic emergency until proven otherwise. IV fluids should be given if available and rescuers should be prepared to start resuscitative procedures en route to definitive medical care.
This is a medical emergency and evacuation should be expedited, using the fastest means available.
Obstruction of the intestines causes diffuse, cramping pain across the abdomen. Nausea and vomiting will occur, but may be delayed depending upon the location of the obstruction. Obstruction of the small intestine elicits nausea and vomiting earlier than in the large intestine. The abdomen will be swollen and tender. A complete obstruction will prevent any stool, liquid, or flatulence (gas) passing through the intestinal tract or out the anus. Patients will be dehydrated, have a high heart rate (tachycardia), and low blood pressure (hypotension).
There is no effective field treatment to remedy GI obstruction, whatever the cause, but there are many supportive treatments that should be undertaken while evacuation is completed. These include pain relief, rest, hydration by mouth (if vomiting permits), and, if possible, IV hydration.
Climbers experiencing an intestinal obstruction, whether total or partial, should be evacuated.
A hernia is defined as the protrusion of a portion of the intestine through a weak area within the abdominal wall. Hernias develop most commonly in the groin (inguinal) area of the lower abdomen and look like a slight abnormal bulge. They also are common at a site of previous abdominal surgery and near the umbilicus. Any climber who suspects a hernia should have it treated prior to leaving on a trip. Most hernias can be reduced (e.g., the intestine can be pushed back into the abdomen), but some become incarcerated (trapped). Symptoms of a hernia include swelling or protrusion at the site and general discomfort. Symptoms of an incarcerated hernia are severe pain, vomiting, no passage of stool or flatulence, and abdominal tenderness. The overlying skin is often red and hot to the touch.
If the climber is able to reduce the hernia by pushing the intestine back into the abdomen, they should avoid any type of work that might cause them to strain or put tension on their abdomen, such as heavy lifting or carrying a backpack. Analgesia should be given.
Any climber with an irreducible or incarcerated hernia should be evacuated immediately.
Also known as salpingitis, this genital tract infection can occur in all sexually active females, regardless of age. Roughly 50% of all cases of PID are due to chlamydia. Risk factors for PID include number of sexual partners and the use of an intrauterine contraceptive device (IUD).
Symptoms of an ascending infection include pelvic pain, fever, pain during intercourse, painful menstruation, and GI upset. Sometimes vaginal discharge is apparent and tenderness at the top of the pubic bone may be evident.
A combined course of antibiotics is the treatment for PID. The most commonly prescribed combinations include 1) amoxicillin-clavulanic acid or erythromycin and doxycycline, or 2) penicillin, metronidazole, and doxycycline. Analgesia should also be considered for the patient.
Evacuation is not necessary unless the patient is exhibiting sepsis signs and symptoms of systemic infection (discussed further in the sidebar above).
A urinary tract infection (UTI) is a common problem, especially for female climbers. The most common symptoms include frequent urination and a burning sensation when urinating.
The best treatment for a UTI is to increase fluid intake and begin a course of amoxicillin, ciprofloxacin, or trimethoprim-sulfamethoxazole (Bactrim®).
Evacuation is not needed for this problem unless signs of sepsis are present (see sidebar above).
Constipation is best described as difficult passage of stool. For climbers, this often occurs due to the change of routine, change in daily foods, lack of adequate water intake, and other dietary changes that occur on trips and expeditions. Constipation can also be a result of “holding” stool rather than defecating, as sometimes occurs on small ledges in roaring storms. Discomfort or feeling of a full or swollen abdomen are the most common symptoms of constipation.
The best treatment for constipation is probably to relax a little, increase fluid consumption, and eat fruits, bran-based cereals, and other foods that have high levels of fiber. Severe cases of constipation may lead to fecal impaction—hard stool that is wedged against the rectum. This may require breaking up the stool using a gloved and lubricated finger. No amount of water, laxative, or enema will soften this stool.
Evacuation is not necessary for constipation or fecal impaction unless the latter cannot be relieved in the field.
Bleeding from the gastrointestinal tract should be considered a serious problem and addressed immediately. Obvious signs include vomiting or defecating large amounts of red blood, vomit that resembles “coffee grounds,” stool that is black or tarry in color, weakness, and signs and symptoms of shock. Patients will exhibit signs and symptoms common to large-volume blood loss such as pale skin, high pulse (tachycardia), low blood pressure (hypotension), confusion, and low urine output. Small amounts of bleeding from the rectum may be related to hemorrhoids or anal fissure (tear of skin at the anus), and these are the only instances where bleeding in the GI tract is not a major concern.
The best treatment for GI bleeding is evacuation. Place the patient on their back (supine) with legs elevated, give IV fluids if available, stop any NSAIDs or aspirin, and give H2 blockers or PPI if available and tolerated.
Evacuate as soon as possible.
Hemorrhoids develop over time but can be exacerbated while on expedition due to the change in routine, food, and prolonged periods of sitting associated with travel. While some can be painful, especially if prolapsed (protruding) or thrombosed (clotted) outside the anus, generally hemorrhoids are simply an annoyance because of itching and general discomfort. Small amounts of red blood may be seen on toilet paper or outside of stool. If blood is a part of the stool and darker in color, intestinal bleeding may be present.
Itching and pain can increase due to hard stool. Staying hydrated by drinking plenty of water is the best treatment in the field and will soften stool. Hemorrhoid creams can help to lessen itching and irritation.
Evacuation is not needed.
Abdominal trauma comes in two forms: blunt and penetrating. While blunt abdominal injury is most commonly associated with motor vehicle accidents, 9% of all cases are from falls. While abdominal injuries in trauma patients are relatively rare (1%), they do occur, and climbers should understand the signs and symptoms associated with both blunt and penetrating injuries.
Although there are no known statistics of blunt abdominal trauma for climbers, statistics from the general population indicate that blunt trauma is more common than penetrating trauma. The major concern for climbers who have suffered abdominal trauma due to a fall is intra-abdominal hemorrhage (bleeding within the abdominal cavity). This bleeding is difficult to identify, as a physical exam is often unreliable. Patients with blunt abdominal trauma frequently have other serious and distracting injuries. A “distracting” injury refers to a head injury or other significant injury that can reduce a person’s ability to sense pain and tenderness, either directly (e.g., a head injury) or due to pain that is severe and overwhelms other sources of pain (e.g., an open leg fracture distracting the patient from their also-present abdominal pain).
Ninety percent of all blunt abdominal injuries occur to solid organs, namely the liver or spleen (Figure 1-1). There is also the possibility of an abdominal shearing injury related to severe deceleration during climbing injuries. This type of deceleration can cause thrombosis or tearing of the renal artery. Regardless of cause, intra-abdominal hemorrhage is a life-threatening injury.
The most common signs and symptoms of an intra-abdominal hemorrhage are decreased blood pressure, increased pulse, abdominal pain and tenderness, bruising, abrasions, and increasing abdominal size. There are some visible indicators that can assist in identifying the location of intra-abdominal bleeding. These are listed in Figure 7-1.
FIGURE 7-1. CLINICAL INDICATORS OF INTRAPERITONEAL BLEED
Kehr Sign |
Pain at left shoulder |
Suggestive of splenic rupture |
Cullen Sign |
Bruising at umbilicus |
Retroperitoneal bleed |
Turner Sign |
Bruising at flank |
Retroperitoneal bleed |
The only field treatment available for patients suffering blunt abdominal injury is to give fluids by IV, stabilize all other life-threatening injuries, and evacuate the patient to advanced medical care as soon as possible.
Evacuation should be immediate and the process started as soon as possible to prevent death.
There are no statistics related to high-energy penetrating abdominal trauma for climbers. However, there are certainly incidents of penetrating/puncture wounds, as is evidenced by the 54 reported incidents since 1984 in Accidents in North American Mountaineering (MacDonald 2015). Most penetrating abdominal trauma in the United States is due to gunshot wounds or stabbings, which are unlikely to occur in the climbing environment. But climbers do use items that can cause low-energy penetrating injuries. These items include ice axes, crampons, ice screws, carabiners, and various other forms of climbing protection.
Seventy percent of deaths from penetrating abdominal trauma occur within the first six hours. Most of the remainder occur within a period of 72 hours. Thus, it is essential to stabilize injured climbers and evacuate them as soon as possible. In addition to intra-abdominal hemorrhage, the other concern with puncture wounds to the abdomen is peritonitis from organ contents or blood spilled into the abdomen.
Stabilizing the patient, with a focus on life-threatening injuries, is the first step of treatment. Depending upon the embedded object, it may be best to secure it in place rather than removing it. Irrigation around the penetration site is helpful as long as it does not push organic material deeper into the wound. Control any external bleeding present at the wound site. If a lengthy evacuation is anticipated, consider antibiotic use if available. Patients must be evacuated to a medical center for a complete evaluation.
Evacuation should occur as soon as possible to prevent death or serious injury.
Gastrointestinal upset, diarrhea, and dysentery account for up to 33% of all medical problems on overseas climbing trips. Like constipation, diarrhea can occur due to changes brought on by travel, including changes in diet, the stress of travel, water consumption from a variety of sources, and of course, infection. Many of the diseases discussed in this section could be avoided through following these rules (mentioned at the beginning of this chapter but repeated here because they are so important):
1. Good hand hygiene
2. Proper food preparation
3. Proper water disinfection (see Appendix E)
FIGURE 7-2. ORGANISMS THAT CAUSE DIARRHEA
The following table divides the organisms discussed within this chapter into four categories based upon the presence (or lack thereof) of blood in stool and accompanying fever.
DIARRHEA— |
DIARRHEA— |
Travelers’ Diarrhea (E. Coli) Cryptosporidiosis Norovirus Giardiasis |
Salmonellosis Cholera |
DIARRHEA— |
DIARRHEA— |
Amebiasis |
Shigellosis Campylobacter Enteritis |
Sources: Hawker J, et al. Communicable Disease Control and Health Protection Handbook. 3rd ed. Chicester, UK. Wiley-Blackwell; 2012. |
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Diarrhea, though easy to prevent and fairly easy to treat, is as likely to stop an expedition in its tracks as an unstable serac above the only available line of advance. Some general rules for both prevention and treatment of gastrointestinal upset and disease will be discussed, followed by detailed information on the most common pathogens that cause diarrhea and dysentery.
Diarrhea is defined as four or more loose stools within a 24-hour period. Organisms causing diarrhea are described in Figure 7-2.
Dysentery is severe diarrhea that includes blood or mucus in the stool. Both can be debilitating, but dysentery is considered much more serious. By far the most dangerous element of these conditions is dehydration. Figure 7-3 describes how to identify moderate or severe dehydration.
FIGURE 7-3. SIGNS AND SYMPTOMS OF MODERATE AND SEVERE DEHYDRATION
MODERATE DEHYDRATION |
SEVERE DEHYDRATION |
Restlessness/irritability |
Lethargy/unconsciousness |
Dry mouth/tongue |
Very dry mouth/tongue |
Increased thirst |
Weak or absent pulse |
Skin returns to normal slowly after pinched |
Low blood pressue |
Decreased urine |
Skin returns to normal slowly (tenting) when pinched |
Sunken eyes |
Minimal or no urine |
Source: Centers for Disease Control and Prevention (CDC) “Rehydration Therapy” |
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Rehydration is the most important thing for diarrhea or dysentery. Oral rehydration solutions (ORS) should be included in all overseas medical kits for climbers. ORS may not be found in small villages or with other climbing parties. Most diarrhea and GI upsets will resolve within 48 hours and the use of antibiotics should only be considered if symptoms persist. Acetaminophen is recommended in general if there is accompanying fever or abdominal pain. Loperamide (Imodium®) is useful to limit diarrhea if needed (e.g., in a bivy during a storm or for a time-sensitive evacuation where stops should be reduced) but can also be associated with significant complications, so should only be used as directed and for as short a period as critically needed (Davis 2018). Generally, rehydration is more important than preventing fluid loss from diarrhea, and in this sense stopping vomiting may be much more important, as most rehydration is done orally. Ondansetron is a prescription medication with relatively minimal side effects that may help reduce vomiting and which can be administered as an oral dissolving tablet (not requiring swallowing and absorption, which can be difficult for a vomiting patient).
Seek medical attention if diarrhea continues and the patient has the following signs and symptoms: severe dehydration (Figure 7-3), fever greater than 40ºC (104ºF), high fever lasting more than 48 hours, diarrhea lasting more than four days, inability to drink and keep down fluids, and presence of dysentery.
Included in the following section are some of the more common organisms that affect climbers both in the United States and abroad. This list is not exhaustive, but it includes most of the usual suspects that cause diarrhea and dysentery.
Often caused by a strain of the bacteria Escherichia coli (E. coli) and referred to as “traveler’s diarrhea,” this is a common affliction of those traveling in Mexico, Southeast Asia, and South America. Most commonly acquired through contaminated food or water, traveler’s diarrhea can also be transmitted through contaminated eating utensils and dishware.
Watery, soft diarrhea is the main symptom. Climbers may also experience abdominal cramps/pain, nausea, vomiting, fatigue, and on occasion, fever. These symptoms usually last between two and five days.
Traveler’s diarrhea is often self-limiting and antibiotics are usually not needed, though a single dose of ciprofloxacin may help. An oral rehydration solution is recommended to prevent dehydration and keep electrolytes in balance.
There is usually no need for evacuation unless dehydration becomes severe (Figure 7-3).
Best known by the nickname “crypto,” this is a common enemy of the climber. Often caused by untreated or unfiltered water, the protozoa Cryptosporidium cause acute bouts of diarrhea. Cryptosporidiosis can also be acquired from infected individuals or contaminated food. It is especially harmful to climbers who are immunocompromised. Immunocompromise is sometimes a long-term condition if a climber has AIDS, takes routine steroid medications, or for other medical reasons, but climbers may also be temporarily immunocompromised at the end of a long expedition simply because food, drink, and rest have been limited.
Symptoms include watery diarrhea, abdominal pain, anorexia, nausea, weight loss, bloating, and in few cases, fever.
Crypto is self-limiting, and antibiotics are of no use. Maintaining hydration is key, as is rest and pain relief. It usually resolves within two weeks, but can reoccur for months to years afterwards.
There is no need to evacuate unless severe dehydration occurs (Figure 7-3).
The genus Norovirus, of which the only species is the Norwalk virus, is an increasing cause of travel-related diarrhea. Some estimate that it accounts for between 3% and 17% of diarrhea among returning travelers. Media attention has focused on recent outbreaks on cruise ships, but this viral illness often occurs in campsites and other areas where people live close together. Contaminated food and drink are frequently the source of this virus, though contaminated ice, shellfish, and prepared cold foods (sandwiches/salads) have been implicated in outbreaks.
Diarrhea and violent vomiting are the signature symptoms of Norovirus infection, along with abdominal cramps and, in some cases, a low-grade fever.
This illness is self-limiting. Focus should be on hydration status of the patient. Do not use antibiotics: They are not effective on viruses.
There is no need to evacuate unless severe dehydration occurs (Figure 7-3).
Giardia intestinalis is a scourge of climbers both within the United States and overseas. This protozoal parasite infects through fecal contamination of food and water or by contact with infected persons or objects (contaminated clothing or hard surfaces). Nicknamed “backpacker’s disease” and “beaver fever,” it is common among outdoor enthusiasts in the United States. Of importance for alpinists, Giardia is common in Nepal.
Most commonly, patients will have persistent pale, greasy diarrhea that has a particularly bad smell and may contain mucus (no blood or pus). Other symptoms include abdominal cramps and pain, bloating, flatulence that smells strongly of sulfur, nausea, fatigue, and anorexia.
Treatment is with antibiotics. A ten-day course of metronidazole (Flagyl®) is most effective. Maintain hydration and adequate rest.
Evacuation is rarely needed unless proper hydration is not maintained and signs or symptoms of dehydration appear (Figure 7-3).
This condition is caused by the bacterial genus Salmonella, and includes Salmonella typhi, discussed in detail later under “Typhoid.” The most common forms of Salmonella are acquired by eating undercooked poultry and from eggs. This infection occurs worldwide.
The most common signs and symptoms of non-typhoid salmonellosis are fever, abdominal cramps and pain, and severe diarrhea that may sometimes contains blood or mucus.
Staying hydrated is key. Antibiotics are not usually needed for salmonellosis, and symptoms should resolve in four to seven days. Salmonella has become resistant to many antibiotics, but ciprofloxacin and ampicillin are recommended for severe cases that spread beyond the intestines.
Patients need rest and hydration and will rarely require evacuation unless they are unable to maintain adequate hydration and signs or symptoms of dehydration appear (Figure 7-3).
Caused by the organism Vibrio cholerae, this disease causes massive amounts of watery diarrhea. It is transmitted through water and food contaminated with fecal material from persons with the active disease. A cholera vaccine is available and offers 60–80% immunity for a period of three months.
Patients will have prolific “rice water” diarrhea that is watery and has a “fishy” odor. This diarrhea, along with vomiting, can cause massive fluid and electrolyte loss. Tachycardia, hypotension, and thirst will be present. The large loss of fluid and electrolytes could cause a cascade of effects that include hypovolemia (low volume in blood vessels, such as from loss of fluid from bleeding or dehydration), shock, and death.
Rehydration is key, both by mouth and by IV solutions. It is important to ensure that the patient receives electrolytes during rehydration treatment. Antibiotics can help shorten the duration of the illness. Tetracycline is the most suitable choice, and doxycycline and ciprofloxacin can also be considered.
In remote areas, patients should be evacuated to medical care that will provide adequate rehydration and electrolyte replacement.
Amebiasis (amebic dysentery) can be an acute or chronic protozoal infection of the intestines caused by Entamoeba histolytica. While 90% of infected persons show no symptoms, the effects of the disease can be very widespread for some. Amebiasis can occur anywhere in the world but is more common in tropical regions. This infection is usually acquired by eating undercooked meats or drinking contaminated water.
Acute amebic dysentery can cause sudden high fever (40ºC [104ºF]), chills, abdominal cramping/pain/tenderness, diarrhea with blood and mucus, and excessive gas. Chronic amebic dysentery will cause irregular bouts of diarrhea that will recur multiple times within a year. Lesser forms of all the symptoms of acute amebic dysentery accompany it. There can be more advanced complications of amebiasis. Some of these rare complications include hepatic abscess, infection of the lungs, heart, and brain.
Examination of stool by a trained medical professional is needed for positive identification. Metronidazole (Flagyl®) is the antibiotic of choice for this infection.
As only ten percent of infected climbers will show symptoms, evacuation is not necessary; however, these ten percent may need advanced care depending upon the severity of the infection and resulting symptoms.
Shigellosis is also known as bacillary dysentery and causes severe diarrhea. There are four specific groups of shigellosis, all of which are treated in a similar fashion. The Shigella bacterium is transmitted by fecal and oral routes, and usually by direct contact with contaminated items or through eating or drinking from contaminated food or water.
Average incubation period from exposure to signs and symptoms is 72 hours. Common signs and symptoms include cramping and sometimes intense abdominal pain, headache, and fever. Diarrhea is often explosive and contains blood, mucus, and pus. Dehydration should be expected with a corresponding decrease in urine output.
Care to avoid disease transmission should be taken when treating these patients. Any soiled clothing or bedsheets should be isolated. Replacement of lost fluids is of the utmost importance and may require IV solutions. ORS should be used to counter dehydration. Antibiotic treatment may be useful; ciprofloxacin or trimethoprim-sulfamethoxazole (Bactrim®) are the most useful agents.
Climbers suffering from shigellosis will require intensive rehydration that may only be accomplished by IV solutions at a medical facility. Evacuation is necessary.
Campylobacter is the most common cause of bacterial diarrhea within the United States, and is common in the summer months. It is most often transmitted by contaminated food (particularly raw poultry), fresh produce, water, unpasteurized milk, and through contact with stool from an infected person or animal.
Beginning 48 to 96 hours after infection, patients will suffer from diarrhea with blood that can sometimes be severe. Abdominal pain and cramping with nausea, vomiting, and fever also may occur.
Unless severe, campylobacteriosis often resolves without treatment. For severe cases, ciprofloxacin or erythromycin should be used. Patients should rest and ensure that they remain hydrated.
There usually is no need to evacuate patients with campylobacteriosis.
Also known as enteric fever and caused by the bacterium Salmonella typhi, this disease affects more than 21 million people worldwide. The risk of typhoid is high in southern Asia (including Nepal and India) and also in Southeast Asia, Africa, the Caribbean, and Central and South America.
Typhoid is often acquired from contaminated food (especially shellfish) or from water contaminated by infected human feces. The best treatment is prevention, and a typhoid vaccine is recommended to prevent infection.
Signs and symptoms include fever, malaise, diffuse abdominal pain/tenderness, and constipation. This will usually begin seven to fourteen days after infection, with fever increasing in the evenings of the second week. Sweating, chills, continued weakness, delirium, increasing abdominal pain (with constipation or diarrhea), and a rose-colored abdominal rash will be present in the first two weeks. Symptoms will steadily worsen through the third and fourth weeks.
Antibiotics are the first line of treatment. Cefixime (Suprax®) or azithromycin (Zithromax®) are the drugs of choice. NSAIDs or acetaminophen should be used for fever and pain control. Rest and ORS are appropriate.
Patients suspected of having typhoid should seek medical attention as soon as possible.