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Gastroenterology (Expert Forum)
Constant Abdominal Pain
Answered by
Kevin Pho, MD - Internal Medicine
Kevin, M.D.
Boston - MA
This forum is for questions regarding Gastroenterology issues such as Acid Reflux (GERD), Barretts Esophagus, Colitis, Colon/Bowel Disorders, Crohn's Disease, Diverticulitis/Diverticulosis, Digestive Disorders, IBS, Stomach Pain.
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Constant Abdominal Pain
by barryk805, Nov 14, 2003 12:00AM
I have had constant abdominal pain for five months. Although the pain varies in intensity it is always there. It started as a deep pain in the area of my navel. Sometimes, it stays in the navel area and sometimes it seems to stretch across the areas above the navel across my right side to the bottom of my gall bladder surgery (1993) scar. There is sensitivity if you press down on these areas. I have had numerous tests with no definitive reason for the pain. In March 2002 I had a colonoscopy done because I was in my 50s. The observations were diverticulosis and hemorrhoids. I have had infrequent occurrences of bleeding from these hemmorhoids for years.
Here are the tests I’ve had since this pain began:
CT Abdomen/Pelvis W Contrast
Finding: Mild fatty infiltration of the liver. Small accessory splenule. Small right inguinal hernia containing fat. Probable right hydrocele. Vert mild diverticulosis. Prominent external iliac veins of uncertain significance. Bilateral spondylolysis L5. Follow-up with surgeon on the inguinal hernia determined this to be symptomatic and not the cause of the pain.
Upper endoscopy
Finding: There was gastritis present with diffuse erythema and petechial marks seen in the antrum and fundus consistent with gastritis. Biopsises were taken. The decending duodenum appeared to be slightly erythematous. Biopsises were taken. The biopsises came back normal.
MRCP and MR of the pancreas
Finding: No evidence of choledocholithiasis or pancreatic divisum. There were four bright T2 lesions within the pancreas. Three smallest difficult to characterize on the post contrast images due to their size. The largest does not appear to enhance. These likely represent pancreatic cysts and may be epithelial cysts but will require imaging follow-up. In the differential of the largest cyst given its location would be a small fluid filled duodenal diverticulum. This cannot be confirmed as a contrast filled or air filled structure on the basis of the CT and a pancreatic cyst of the uncinate process is more likely. Follow-up recommended in three months to ensure stability. (scheduled for 11/18).
MRI & MRA Abdomen – 3 D Recon
Finding: Superior mesenteric artery is widely patent as is the celiac axis. There is flow within the inferior mesenteric artery. Given its small caliber, cannot asses for focal areas of stenosis. However, it is visualized down to the level of its branch vessels.
EGD-EUS-laser
Finding: Serial endosonographic images of the pancreas and surrounding structures were obtained. The pancreatic parenchyma appeared homogenous. There was one anechoic cystic lesion in the head of the pancreas measuring 14.5mm X 12.0mm. EUS evaluation of this lesion revealed neither septations nor a solid component. Another smaller anechoic structure in the body of the pancreas measuring 4.3mm. The pancreatic duct was not dilated and there was no communication between the duct and these lesions. No peri-pancreatic lymphadenopathy was noted. The celiac axis, porto-spenic confluence, SV and SA were all seen without adjacent lymphadenopathy. A spenic splenule was noted. Impression: simple cysts.
After all these tests I had a period of two weeks without sleep. At this point I was referred to a psychiatrist. While the psychiatrist did give me medication that does allow me to sleep, the pain goes on. I also just had an epidermal cyst I was born with become infected. I had it drained and will have it surgically removed in a week. I recently started seeing a new GI doctor. He had me see a surgeon to confirm that there was no involvement from the gall bladder surgery. I am going to see him in a few days. Do you have any idea what the cause of my constant pain is or can you provide me with home help on what to ask this new doctor?
Here are the tests I’ve had since this pain began:
CT Abdomen/Pelvis W Contrast
Finding: Mild fatty infiltration of the liver. Small accessory splenule. Small right inguinal hernia containing fat. Probable right hydrocele. Vert mild diverticulosis. Prominent external iliac veins of uncertain significance. Bilateral spondylolysis L5. Follow-up with surgeon on the inguinal hernia determined this to be symptomatic and not the cause of the pain.
Upper endoscopy
Finding: There was gastritis present with diffuse erythema and petechial marks seen in the antrum and fundus consistent with gastritis. Biopsises were taken. The decending duodenum appeared to be slightly erythematous. Biopsises were taken. The biopsises came back normal.
MRCP and MR of the pancreas
Finding: No evidence of choledocholithiasis or pancreatic divisum. There were four bright T2 lesions within the pancreas. Three smallest difficult to characterize on the post contrast images due to their size. The largest does not appear to enhance. These likely represent pancreatic cysts and may be epithelial cysts but will require imaging follow-up. In the differential of the largest cyst given its location would be a small fluid filled duodenal diverticulum. This cannot be confirmed as a contrast filled or air filled structure on the basis of the CT and a pancreatic cyst of the uncinate process is more likely. Follow-up recommended in three months to ensure stability. (scheduled for 11/18).
MRI & MRA Abdomen – 3 D Recon
Finding: Superior mesenteric artery is widely patent as is the celiac axis. There is flow within the inferior mesenteric artery. Given its small caliber, cannot asses for focal areas of stenosis. However, it is visualized down to the level of its branch vessels.
EGD-EUS-laser
Finding: Serial endosonographic images of the pancreas and surrounding structures were obtained. The pancreatic parenchyma appeared homogenous. There was one anechoic cystic lesion in the head of the pancreas measuring 14.5mm X 12.0mm. EUS evaluation of this lesion revealed neither septations nor a solid component. Another smaller anechoic structure in the body of the pancreas measuring 4.3mm. The pancreatic duct was not dilated and there was no communication between the duct and these lesions. No peri-pancreatic lymphadenopathy was noted. The celiac axis, porto-spenic confluence, SV and SA were all seen without adjacent lymphadenopathy. A spenic splenule was noted. Impression: simple cysts.
After all these tests I had a period of two weeks without sleep. At this point I was referred to a psychiatrist. While the psychiatrist did give me medication that does allow me to sleep, the pain goes on. I also just had an epidermal cyst I was born with become infected. I had it drained and will have it surgically removed in a week. I recently started seeing a new GI doctor. He had me see a surgeon to confirm that there was no involvement from the gall bladder surgery. I am going to see him in a few days. Do you have any idea what the cause of my constant pain is or can you provide me with home help on what to ask this new doctor?
Doctor's Answer
by Kevin Pho, MD, Nov 15, 2003 12:00AM
, Nov 15, 2003 12:00AM
You have had one of the most comprehensive workups I've seen, including CT, upper and lower endoscopy, endoscopic ultrasound, MRCP and an abdominal MRI. Essentially all was found were simple pancreatic cysts, gastritis and duodenitis, and diverticulosis.
Given that the pain is on the right side of the navel, it would be unlikely that the pain can be caused by the cysts. If the gastroenteroligst determined that the cysts were causing your symptoms, you may want to consider resection.
One possibility would be Sphincter of Oddi dysfunction, which is an uncommon cause of abdominal pain in those who have had cholecystectomies. A fatty meal ultrasound study or Sphincter of Oddi manometry would be the tests to consider if this was suspected.
Our surgical colleague on the board may have more ideas. If after all these tests, there is no revealing diagnosis, then you may want to inquire about non-GI sources of pain (i.e. neurology referral).
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
Given that the pain is on the right side of the navel, it would be unlikely that the pain can be caused by the cysts. If the gastroenteroligst determined that the cysts were causing your symptoms, you may want to consider resection.
One possibility would be Sphincter of Oddi dysfunction, which is an uncommon cause of abdominal pain in those who have had cholecystectomies. A fatty meal ultrasound study or Sphincter of Oddi manometry would be the tests to consider if this was suspected.
Our surgical colleague on the board may have more ideas. If after all these tests, there is no revealing diagnosis, then you may want to inquire about non-GI sources of pain (i.e. neurology referral).
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
