Tuesday, January 10, 2012

Focal Abdominal Pain in a Post- Menopausal Woman


50 female, menopause and all it's glory.  Had lots of issues over the years.  I've had belly tenderness and pain for 3 weeks now.  Right side below the rib cage and it moves around my back.  I feel like there's a football in there taking up space.  On occasion, a very sharp/knifelike pain in my back on the right.  Over the years I've had off an on issues with my belly on the right.  They tell me it 'must be IBS' and when you can't 'go' or you are passing/puking blood, then is the time to call the doc.  Well, my 'gut instinct' is telling me this isn't a good thing happening.  Should I wait until one of the 3 options happens?  I know that describing belly pain is a nightmare since it could be something totally not 'belly' related.

Gender: Female
How tall are you (feet and inches)?: 5'4"
What is your weight in pounds?: 153
How old are you?: 50

How long has this been going on?: A week or two
Check all symptoms you are currently experiencing:
Abdominal Pain

Describe associated symptoms not listed above: Belly is tender to the touch just below my right rib cage.  From the belly button on a diagnoal about 2" up. Constant 'discomfort and pressure' which escalates to sharp shooting pain that circles around my right side to my back.  When I breathe in deep, it feels like there is a football stuffed in my belly on the right.  I have a buging disc at C3-4, C5 is crumbling/pinching nerves and there is pressure on my spinal cord at C4-5.  I have been seeing a pain management specialist for 6 years now.  Injections as needed into the C3-4-5 area.

What have you done so far to remedy this condition? Please include tests and relevant studies here.

Increased water and fiber, lower caffeine and alcohol.  Haven't complained to my GP yet.  Trying to walk more.

Please list any chronic medical problems and also list any prior surgery (lacerations don't count!):

I have a 5.5 cm hiatal hernia/reflux/Barrett's esophagus  ongoing for 15 years.  I've had a salpingo oopherectomy/hysterectomy thanks to stage IV endometriosis, gallbaldder removed, tonsils are gone and they took the appendix with the removal of the first offspring.  DCIS diagnosis 9/11 (no big deal).  
Check all conditions present in your immediate family... :
Asthma / Lung Problems

Please list any medication allergies that you have : :   Recent bad reaction to sulpha drug for UTI.  Turned beet red and felt as if I was on fire.  Stopped the drug immediately.  Old fashioned penecillin doubles me over with intestinal pain/cramping/diharrhea.

Please list any medications you are currently taking (and dosage if known) ::

Nambumetone  ??mg  2Xday), gambapentin (100 mg 2Xday), albuterol(as needed/not to exceed 2 inhalations 3Xday), advair 100/50  2Xday), citrical-D, vit C, magnesium, skelaxin(as needed ??mg).

When was your last menstrual cycle?: I no longer have a menstrual cycle
Are you currently using or do you have a history of tobacco use?: Yes
Are you currently using or do you have a history of illegal drug use?: No
Please describe your alcohol consumption :: Weekly

I don't want to be labelled a cry baby/whiner/hypocondriac which is what happens as soon as you walk in and you don't obviously have a knife sticking out of your body.  On the other hand, I'm really close to being in a miserable state and realize this is not an ER issue.  If you can at least tell me the best language to use with an MD to describe my pain that would help.  I'll be seeing my oncologist on Friday and he's bound to go poking on my guts.
May we send you a satisfaction survey after your question is answered? It takes a minut to fill out.: Yes


MDSTAT_DOC_7 said...

Well, actually, it may BE an ER issue!

With what you described, if I were seeing you in the ER, I would order an ultrasound of your gallbladder - sounds like classic choleycystitis!

Sometime your gallbladder can hurt WITHOUT it being infected or inflammed - if you only have GALLSTONES then the pain will come and go (over years, with different amounts of pain-free intervals), and will worsen with certain foods (usually dairy, fried or greasy foods) because these things make your gallbladder contract. When the gallbladder contracts on a collection of stones, it hurts! IF the only problem is stones, then you can set up an appointment with the surgeon of your choice to take out your gallbladder when it is convenient for you - if the symptoms are such that you want to take on the risk and expense of surgery.

HOWEVER, if there is active inflammation or infection in the gallbladder, not just stones, the removal of the organ needs to happen on a more emergent basis - like today or tomorrow. This is usually determined with a combination of certain lab tests (blood work tells us so much!) and the ultrasound I mentioned above.

Now, if you get your gallbladder checked out and it all seems normal, there are a few other culprits. Your pancreas (which is adjacent to and related to your gallbladder) is one. Problems in the bottom of your right lung - pneumonia, blood clot... could cause similar symptoms. You mentioned you have IBS - you know very well that your gut could be the bad guy... but that would require an endoscope (EGD) done by a surgeon or gastroenterologist to determine (for example, if you have a big ulcer in your duodenum - the small intestine just past your stomach).

I suggest you go get this checked out - today!

MDSTAT_DOC_7 said...

Ah - I missed the part in your history where you said the gallbladder has already been removed.

BUT, with right upper quadrant pain and an absent gallbladder, sometimes we still consider a stone in the pancreatic duct. A CT scan of the abdomen can reveal this, or a surgeon will sometimes request a HIDA scan to look more into the ductwork of your pancreas.

The hiatal hernia you mentioned sounds pretty significant. Going back to the idea that this may be an ulceration in the duodenum, an EGD sounds appropriate.

If your pain is not bad enough that you feel you should go to the ED, you should at least go see a GI specialist that can schedule an EGD or other study to ensure that your Barrett's esophagus has not degenerated into something more sinister (this condition is well known to be a precursor to cancer)or that you have developed a duodenal ulcer.

space doc said...

Several possibilities for the right upper abdominal pain.
Doc 7 has already pointed out that even after removing the galll bladder stones can still occur--and can definitely cause a back up of pancrearic secretions leading to pain and sometimes jaundice.

Other possibilities are: cysts; fatty accumulation in the liver; liver infections; also cyts in the pancreas.

The feeling of a 'football' in the right abdomen when you take a deep breath again suggsts something under the diaphragm ( liver, possible abcess etc.)

Certainly you can start off with your G.P. but as Doc 7 suggests a visit to a gastroenterologist for possibe edoscopy ( or a similar procedure called an ERCP if there is a sone at the pancreatic duct.)

Often an ultrasound to screen for stones, liver problems , cysts etc. is done first along with blood test to check liver function, infections; maybe a chestx-ray to check on the diaphragm and the right lower lobe of the lung.

This is definitely nothing in the "wimpy" catergory--you've got some real important things to be looked into

Your oncologist may have some other suggestions, or he may want to get started with some of the routine tests.

Looks like you've been battling through quite a lot!
I hope you continue on battling--a wimp you are not.

Best of luck!! Space Doc.

space doc said...

I think the decription you have given to us of your symptoms would certainly be fine to present to any of your doctors (Just an after thought).

Space Doc

Anonymous said...

Thanks much for the input. I called the GP to see if they could send me to my GI guy they said start with the GP. Okay, when I ask? The 18th. Well, okay then. She asked why I needed to come in and I told her. She put me on hold and said to see him tomorrow so I guess I'm glad. I sure had hoped this would 'pass'. No jaundice thankfully and I watched for that. My dad died of pancreatic cancer and the first I knew of it was that his 'gut had been bugging him' then a call that he had turned yellow. So, while not paranoid I do pay attention to those things! Here's to hoping it's just an infection of sorts! Thanks again.

space doc said...

Dear Anonymous:

Sounds like you are on your way to getting things solved.

Again, good luck! Would love to hear how things turn out.

Space Doc.

Anonymous said...

Chest and full belly X-rays are complete as is a blood panel and UA. Hoping it's something obvious and easy to fix. They took shots to include the bladder. Can the ovary be seen on that view? I've always had a theory in my head that because the endometriosis was so extensive, that it's still there and causing issues even on my bowel. Surgeon said at the time of the hysterectomy it was on my bowel, bladder, had twisted and enveloped completely the right ovary and tube, was on the left one but not as much. Since it can't be fully irradicated and can thrive off of stored estrogen, and what little estrogen was produced from the remaining ovary, can it twist your guts too as high up as your ribs? Thanks again and I'll be glad to provide closure if and when I get some!

MDSTAT_ER_DOC_1 said...

Can you tell us the imaging methods used? Ultrasound? CT scans?

Anonymous said...

To start with today it was just a full belly from bladder to chest X-ray series. He told me his next move would most likely be ultrasound depending on what/if anything could be seen in today's views. I am expecting to have someone tell me that my guts have finally squeezed up through that monster hernia, haha. Sure could explain how I feel. I informed the Xray techs of the hernia and my lack of gallbladder and that the clips may show up also. Have looked on line to see if there is info on the ovary showing up during this type of series but didn't find much.

MDSTAT_ER_DOC_1 said...

Plain X rays will likely show your hiatal hernia but not much more. They will definitely not show the ovaries. Please keep us posted.

space doc said...

Hope the visit yo your oncologist went well.

Any more findings? Sometimes the ultrasound of the abdomen and a vaginal ultrasound for the pelvic area may not give enough clarity. These can be followed by a C-T scan if necessary. I'm sure your physicians will fill you in on all the possibilities'

Would love to hear how you are doing!

All our best!
Space Doc.

Anonymous said...

Well, got the blood work back and the only thing that fell out of the normal column was amylase (115). Not screamingly high but (to me) would warrant a further look at my guts. The X-rays were 'normal' although I haven't seen a radiologist's report. I've found that reading those are a much better indication of what is happening but you have to go and get them/pay for them. So, I have a call in to his office to see what if anything is next. The pain is at a level of annoying and I can deal with it but I don't want to live the rest of my life this way. Any thoughts?

MDSTAT_ER_DOC_1 said...

well, honestly, not much there. amylase is a non specific lab test. it could be elevated if your pancreas was a bit angry, and elevated if your parotid gland in your cheek were a bit angry....

if not done so already we are getting near the stage at which a gastroenterologist might be very helpful.

you really haven't had any definitive studies done as of yet. as i mentioned above a plain film in your situation was unlikely to be helpful.

if you had gone to the ER, which I am not suggesting that you do, you would have had a CT scan about three times by now and that's just the way the ER works, but we ARE getting to a point at which a more specific and detailed imaging study such as a CT scan, or even an upper and lower endoscopy performed by the Gastroenterologist would provide much more valuable information that what we have now.


space doc said...

Dear Anonymous:

An elevated amylase certainly sounds like something is going on in the pancreas.

Pancreatitis (inflammatioin) by itself can raise the amylase.

Any blockage at the juncture of the common bile duct
where it joins the pancreatic duct (gall stone, cyst etc.) i can definitely cause the amylase to rise. (remember gall stones can still form even after the gall bladder has been removed)

Certainly ask your primary care M.D. aabout the possibility of seeing a gastro-enterologist (If there happens to be a stone in the gall bladder duct / pancreatic duct, the G.I. doc would be doing the ERCP.
endocopic procedure to take care of the stone)

Also I hope you have been able to keep an eye on your Barrett's esophagagitis--sometimes those esophageal cells can change into a pre-cancerous condition.

Tumors, cysts, cancers have to be considered in the pancreas. (especially with your dad's history)

I don't know whether your hiatal hernia could be causing any pressure on the pancreas.

An ultrasound might not be quite as definitive as a C-T scan (with contrast material for the best definition) to clarify what's happening.

Let us know how everything turns out. I'd love to hear a success story. (I'm still leaning toward a stone as the underlying cause)
All our best! Space Doc.

Anonymous said...

Quick update to you good folks. CT with contrast (both IV and some ymmy berry flavored 'redi-cat') were completed. I got a note from my primary doc with the rediculous statement of:'Changes noted are not of significant finding". Uh, pardon me but, WT??? What changes? What's the definition of significant? Gut still hurts and football is now a softball (I'm happy!) unless I eat. then, the softball gets angry and inflates etc. So, yeah..it's my guts and I need to find a way to the GI guy.

Last time I took someone's word for it, I found out they had been noting 'small yet insignificant changes' during my mammograms each year until I was told I had DCIS. I do kind of like to have more info than what he's offering me at this time.

Thanks all!