Abdominal Pain Mystery

[flipper21]

Dr. Steve:

First off, love your insight and the help you are providing the denizens of this board. Here's my tale of woe.

Back in August I started getting kind of bloated in the mid to lower abdominal region. At first I chalked it up to falling off the good eating wagon and my old body (just turned 45) not being able to adjust. Then I started to get cramping and sharp pain in the center and right side just below the ribcage about 20-30 minutes after eating. It didn't matter what I ate, I always wound up doubled over. The area was also tender to the touch.

So I went to my PCP and he did a full blood work-up (including checking for H. pylori bacteria), which showed nothing out of the ordinary. He then ordered an ultrasound to check for gallstones. Negative. Next was a CT with oral and injected contrast. This supposedly showed a hiatal hernia, fatty liver and some diverticulosis. He prescribed some Nexium and suggested I see a gastroenterologist.

The gastro poked and prodded and sent me for a HIDA scan with CCK. Gallbladder is functioning normally. Next he perfomed an esophagogastroduodenoscopy (which is much more fun to say or write than EGD). He said everything looked normal, including no sign of said hiatal hernia. Finally he performed the Dreaded Colonoscopy this past Tuesday. The prep was much worse than the procedure. The roofies they gave me knocked me the eff out! He said I'm all healthy and pink inside. Oh joy.

So, today I had the follow-up, still in pain, still tender, and he feels there is nothing more he can do. He is sending me to a surgeon to see what he thinks. There was some mention of it being a neuropathic issue, possibly connected to lower back pain and bulging discs that have been bothering me for some time, but I'm not totally buying this.

So in the meantime, any thoughts? I'm off to find a surgeon that's in the network. Thanks in advance.

[Dr Steve]

Flip:

I decided to try to answer this question AS I read it, just to see if it helps to reveal even a little bit how doctors think about medical problems. I don't even know if your question would be appropriate for this, I swear I haven't read it yet...we'll see!


Dr. Steve:

First off, love your insight and the help you are providing the denizens of this board.

ok, this guy is starting off great, complimenting the doctor, ha. I need to pay close attention to his problem!

Here's my tale of woe.

Back in August I started getting kind of bloated in the mid to lower abdominal region.

Ok, bloating in the mid to lower abdominal region...I'm already thinking irritable bowel, gluten sensitivity, ulcers, colitis, a host of crap. Let me hear more...


At first I chalked it up to falling off the good eating wagon and my old body (just turned 45) not being able to adjust. Then I started to get cramping and sharp pain in the center and right side just below the ribcage about 20-30 minutes after eating. It didn't matter what I ate, I always wound up doubled over. The area was also tender to the touch.

Ok, so far...45 years old, bloating, sharp pain in the right upper abdomen after eating, tenderness...sure sounds like gallbladder so far. Though an ulcer or even irritable bowel could be in there as well, gallbladder's going to be the thing I have to rule out

So I went to my PCP and he did a full blood work-up (including checking for H. pylori bacteria), which showed nothing out of the ordinary.

althought your PCP didn't rule out an ulcer, he/she at least made one caused by H. Pylori (a bacteria that is associated with ulcer formation and reflux symptoms) a lot less likely. I'm still thinking gallbladder...

He then ordered an ultrasound to check for gallstones. Negative.

CRAP! Oh well, my theory is knocked back, but not OUT. A poorly functioning gallbladder with no stones in it will look normal under ultrasound...it takes a HIDA SCAN to dope that out!

Next was a CT with oral and injected contrast. This supposedly showed a hiatal hernia, fatty liver and some diverticulosis. .

Fatty liver, eh? It's a side issue (fatty liver doesn't cause pain), but why do you have that? Do you drink alcohol a lot? Is your serum triglyceride high? Do you have glucose intolerance or diabetes? It bears looking into as a separate issue.

Certainly diverticulosis can cause abdominal pain and bloating; it's usually constant, though. Now, there's a certain kind of diverticulum called "Meckel's Diverticulum" which is a defect of the intestine that is hard to see on standard imaging and can cause severe mid to upper abdominal pain.

He prescribed some Nexium and suggested I see a gastroenterologist
Nexium will help reflux symptoms and ulcers...if the pain goes away, you've made the diagnosis! If it doesn't, it doesn't mean as much. I like the gastroenterologist idea. Sounds like the PCP has taken the problem about as far as he/she could. I'm still jonesing for a HIDA scan.

The gastro poked and prodded and sent me for a HIDA scan with CCK. Gallbladder is functioning normally.

CRAP!!!! Well, actually that's good, but it messes up my theory...I was pretty much fixated on the whole "it must be gallbladder" thing that now I'm concerned I've missed some detail. For the most part, this plus the ultrasound rules out the gallbladder as a cause.

Next he perfomed an esophagogastroduodenoscopy (which is much more fun to say or write than EGD).

Just to get everyone on the same page...this is the good ol' fiberoptic scope down the gullet. This will rule out a lot of things, including ulcers.

He said everything looked normal, including no sign of said hiatal hernia. Finally he performed the Dreaded Colonoscopy this past Tuesday.

yeah, what I would have done too.

The prep was much worse than the procedure. The roofies they gave me knocked me the eff out! He said I'm all healthy and pink inside. Oh joy.

actually, all of this is very encouraging...you don't really want to find anything too scary! "Normal" is always good. One thing I don't understand...they said you had diverticulosis on the imaging study, but not on the colonoscopy??? Something doesn't jibe here. I'd want to reexamine the original imaging study to see what exactly it was that they saw.

So, today I had the follow-up, still in pain, still tender, and he feels there is nothing more he can do. He is sending me to a surgeon to see what he thinks.

honestly, a move of desperation, but not necessarily a bad move. However, I'd like to see them at least consider Irritable Bowel and give you some treatment for this just to see if it gives you any relief...


There was some mention of it being a neuropathic issue, possibly connected to lower back pain and bulging discs that have been bothering me for some time, but I'm not totally buying this.

Well, a last ditch theory since they're not coming up with anything concrete to explain your symptoms. A pinched nerve in the midback can cause pain that radiates forward into the stomach region, but it's usually on the OUTSIDE surface of the abdomen and doesn't cause tenderness in the abdomen itself. If this feels deep inside, I kind of agree with you on this one.

So in the meantime, any thoughts? I'm off to find a surgeon that's in the network. Thanks in advance.

I'm going to get slammed for recommending Citrucel again, but if it's irritable bowel syndrome OR diverticulosis, it'll likely help. Increasing the fiber in your diet is always a good thing, and Citrucel is a cheap and easy way to do that without causing bloating or gas. Your PCP could, if he/she wanted to, also prescribe some sort of antispasmodic that will relax the bowel and keep it from cramping up; if your pain goes away, the diagnosis is made.

If you've had surgery before, you could have scar tissue in the small bowel that no one would ever see by colonoscopy (doesn't go up far enough) or EGD (doesn't go down far enough). Only a surgeon would be able to dope that out.


I hope this helps! It was an interesting experiment for me to walk through it with you. You're a good "historian" and it made it easier.

keep us in the loop on this. I'd be very interested in what the surgeon says.


your pal,



steve

[flipper21]

Thanks immensely for the detailed analysis. I got through the first part of the "eating season" with a lot less pain than I thought I'd encounter. Things have subsided a bit but I still intend on following up with another doc. I'll post an update when I figure this out.

[Reynolds]

I have ulcerative colitis, and I used to get stomach cramps that would be unbearable. I was on asacol for a few years but haven't taken it in a while, but haven't had any real problems. Every once in a while when it flares up the doc puts me on a steroid, and it goes away. When I have a giant shit building, my back still hurts pretty bad.

[SonnyJim]

This was great to see how a doctor's deductive mind works.

[flipper21]

Hey Doctor Steve:

Long overdue update here. After the myriad of tests described in my original post, I went to a surgeon as suggested by my gastro. He quizzed me a bit, poked & prodded me and came away with no ideas. He said he could just yank out the gallbladder but didn't want to unless we could find some evidence of it's failure. He recommended that my gastro do another endoscopy but this time with CCK and collect some bile to test for crystals. Although he said it was not a conclusive test for GB problems it would be enough in my case to potentially warrant it's removal, since we exhausted all other avenues. Of course, this was negative as well!

While I was at it I went for an upper GI series to rule out Crohn's, as well as another full blood work-up since it had been 6 months since the last. Both were negative. So I was back to square one. Gastro sends me back to surgeon who says despite all the negative tests for gallbladder failure, the area of pain, tenderness and when it occurs (20-30 min after fatty foods) might be enough to consider it's removal. He explains the potential issues of life without a gallbladder and I decide to get rid of it. They're giving me a 50/50 chance that this will do it. After this many months of pain I'll take those odds. I guess we'll see. Surgery is scheduled for next Thursday the 12th.

Thanks again for the earlier response and listening (well, reading) my long winded saga.

[Dr Steve]

Hey Doctor Steve:

Long overdue update here. After the myriad of tests described in my original post, I went to a surgeon as suggested by my gastro. He quizzed me a bit, poked & prodded me and came away with no ideas. He said he could just yank out the gallbladder but didn't want to unless we could find some evidence of it's failure. He recommended that my gastro do another endoscopy but this time with CCK and collect some bile to test for crystals. Although he said it was not a conclusive test for GB problems it would be enough in my case to potentially warrant it's removal, since we exhausted all other avenues. Of course, this was negative as well!

While I was at it I went for an upper GI series to rule out Crohn's, as well as another full blood work-up since it had been 6 months since the last. Both were negative. So I was back to square one. Gastro sends me back to surgeon who says despite all the negative tests for gallbladder failure, the area of pain, tenderness and when it occurs (20-30 min after fatty foods) might be enough to consider it's removal. He explains the potential issues of life without a gallbladder and I decide to get rid of it. They're giving me a 50/50 chance that this will do it. After this many months of pain I'll take those odds. I guess we'll see. Surgery is scheduled for next Thursday the 12th.

Thanks again for the earlier response and listening (well, reading) my long winded saga.

Well, if it works, you were simply one of those people with "acalculus" gallbladder pain. ("a" = no and "calculus"=stone). It's a mystery, but a significant portion of people with typical gallbladder pain and normal HIDA scans get relief when their gallbladder is removed. Another chunk doesn't get any relief. So far we can't predict which group someone will fall into. I'm hoping you fall into the former.

Good luck and keep us in the loop!


we'll be thinking of ya on the 12th!


your pal,


steve

[flipper21]

So far, so good! The gallbladder is a goner! Came out without a problem on Thursday. Liquid diet soon after, cereal and milk the next day and a regular diet on Saturday have not caused any problems. I am still battling with the CO2 bloating and pain killer-induced constipation, but I'm confident that this was a good move. I'm going to continue on the low fat regimen I was on pre-op for a while just to make sure.

Thanks again, Dr. Steve, for listening during this long drawn out process.

[Dr Steve]

So far, so good! The gallbladder is a goner! Came out without a problem on Thursday. Liquid diet soon after, cereal and milk the next day and a regular diet on Saturday have not caused any problems. I am still battling with the CO2 bloating and pain killer-induced constipation, but I'm confident that this was a good move. I'm going to continue on the low fat regimen I was on pre-op for a while just to make sure.

Thanks again, Dr. Steve, for listening during this long drawn out process.

I really hope this does the trick!

Yeah, Narco-dumping is a difficult business. I like Miralax in this situation...it's not habit forming and it has no taste or consistency AND you can buy it over the counter.

Give us an update in a month or so...if you're still pain free, you win. :-)

your pal,

steve