210 SECTION 3 • MEDICAL PROBLEMS IN THE ATHLETE
period is a frequent exacerbating factor. Side stitches
usually stop immediately on ceasing exercise. As an
individual gains aerobic fitness, the frequency and
severity of attacks tend to subside.- While their true etiology remains elusive, they are
most likely caused by hypoxia-induced diaphragmatic
muscle spasm (Pate, 1988). Other potential etiologies
include pleural irritation, hepatic capsule irritation,
symptomatic abdominal adhesions, and right colonic
gas pain (Lauder and Moses, 1995). - The management involves using the history to rule out
not only the other GI diseases discussed in this chapter,
but also other exertional pain syndromes, especially
angina. Fortunately, other serious causes of abdominal
pain with exercise such as mesenteric ischemia,
bowel infarction, omental infarction, and hepatic vein
thrombosisare rare; however, in the setting of unremit-
ting pain, especially with signs of systemic illness or
shock, these conditions need to be considered in the
differential and patients referred for potential surgical
evaluation. - Athletes with the typical features of a side stitch
should be reassured that this is a benign process and
will get better as their conditioning improves. They
should be advised against exercise immediately after
eating. If an episode of pain does occur, temporarily
stopping exercise, stretching the right arm over their
head and exhaling through pursed lips can help abort
it quickly (Stamford, 1985).
ELEVATED LIVER ENZYMES•Liver enzyme elevations observed in otherwise asymp-
tomatic long distance runners and other athletes are
usually incidental findings. The suspected etiology is
an ischemic insult secondary to reduced splanchnic
blood flow and oxygen tension during vigorous exer-
cise (Lijnen et al, 1988). Observed increases in alanine
aminotransferase (ALT), aspartate aminotransferase
(AST), alkaline phosphatase, creatinine phosphatase,
and lactate dehydrogenase are confounded by the fact
that these enzymes can be elevated in response to mus-
culoskeletal injury. Hepatocellularinjury can be con-
firmed by measuring glutamate dehydrogenase and
gamma-glutamyl-transferase (GGT), enzymes more
specific to the liver. (www.mamc.amedd.army.mil/
referral/guidelines, 1999).- Since these asymptomatic enzyme abnormalities are
often discovered in the convalescent setting, the his-
tory and physical should focus on recent training
sessions and environmental exposure, evaluating for
evidence of a missed heat injury or episode of
exertional rhabdomyolysis. The athlete should be
questioned regarding any history of chronic liver dis-
ease or alcohol dependence and their medication list
reviewed for any potentially hepatotoxic agents. With
the nearly ubiquitous use of nutritional supplements,
it is crucial to investigate this often-overlooked area.- The majority of athletes can be reassured that this is a
benign process and the enzyme abnormalities usually
revert to normal within just 1 week after abstaining
from exercise. The first step in the laboratory evalua-
tion is to obtain a repeat liver enzyme panel after
abstaining from NSAIDs, alcohol, and exercise for
1 week. If the liver enzymes are elevated at that time,
they can be rechecked in 1 month. If the liver enzyme
abnormalities persist on serial examinations, further
evaluation should start with an iron panel, TIBC, and
hepatitis serologies. Second tier tests include ANA
titer, antismooth muscle antibody, ceruloplasmin,
alpha-1-antitrypsin and serum protein electrophoresis.
A right upper quadrant ultrasound is useful to evaluate
for fatty liver, cholelithiasis or other obstruction. GI
referral should occur for abnormal lab testing, mildly
elevated liver enzymes for over 6 months despite a neg-
ative evaluation, significantly elevated (AST or ALT
- without improvement for 2 months,or signs of
evolving hepatic insufficiency (www.mamc.amedd.
army.mil/referral/ guidelines, 1999).
- without improvement for 2 months,or signs of
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