Severe Abdominal Pain?

Question

Over the past four years I have been having infrequent attacks of severe abdominal pain. After some investigating, my doctors thought this was related to my gallbladder, but the ultrasound showed nothing. They ended up treating me for an ulcer. The attacks are still happening even after treatment. Ultimately, it was decided the problem was biliary cholic.
I get these attacks about four times a year. Each attack results in a trip to the emergency department, where I am given injections of gravol and a narcotic pain killer like Demerol or Dilaudid for the pain.

The pain is from my bellybutton to where my ribs meet - and sometimes wraps around my ribs migrating into my back. X-rays and ultrasounds always come back fine. My bloodwork shows an elevated white blood cell count. Liver, kidney, and pancreatic function are always normal. I'm being sent for a HIDA scan soon. Does anyone have any ideas of what this pain could be if it isn't my gallbladder?

Answer 1

RUQ pain is often due to biliary disease or hepatitis. Inflammation from an ascending appendix, MI, or renal disease should be excluded from the differential. In the condition that is sometimes inappropriately termed biliary colic, the pain is steady rather than paroxysmal. The pain of biliary colic is generally described as a constant gnawing that increases over a few hours postprandially and then subsides totally; it is due to increased pressure buildup in the gallbladder as an outlet obstruction causes it to contract. Acute cholecystitis occurs with prolonged blockage in the duct system; patients will present with steady, severe pain that may radiate to the subscapular region; nausea, bilious vomiting, and anorexia are common. If fever is present, the diagnosis is more likely to be cholecystitis than simple biliary colic. On physical examination, the most accurate diagnostic findings for acute cholecystitis are a positive Murphy’s sign,.


Other disease processes of the biliary system includ e acute cholangitis occurring when a stone lodges in the biliary or hepatic duct system, causing dilation and infection. The patient with acute cholangitis may present with jaundice, fever, and abdominal pain; laboratory studies may show a high WBC count, elevated bilirubin and pancreatic enzymes, and possible elevation in LFT results.


The pain of hepatitis is rarely acute at onset. The entire liver is tender to palpation, and pressure placed laterally over the intercostals will elicit pain; this characteristic helps to distinguish hepatitis from biliary tenderness, which is felt mainly over the right hypochondrium. Elevated bilirubin levels will cause the classic signs of jaundice as well as scleral icterus. Ascites may also be present due to underlying portal hypertension caused by chronic liver disease, and laboratory studies will show elevated LFT results early in the disease process. The pain from MI can be high in the epigastrium and thus may be difficult to differentiate from biliary pain. Biliary colic and acute cholecystitis are two of the most common noncardiac reasons patients are admitted to cardiac care units.


There are times when patients cannot pinpoint the location of their abdominal pain. As discussed previously, mesenteric ischemia and infarct are possible diagnoses. Other causes of diffuse abdominal pain include peritonitis and gastroenteritis.


Peritonitis may cause a patient to try to lie strictly immobile, often with knees bent. Pain from peritonitis becomes more diffuse as the infection spreads away from the originating organ. Patients will generally be febrile, tachycardic, and hypotensive, and abdominal examination will reveal a diffusely tender abdomen, even with gentle palpation.


Gastroenteritis can cause abdominal pain, especially cramping, along with diarrhea, nausea, and vomiting. Knowledge of recent exposure and illnesses within close contacts or the community can help lead to this diagnosis. Most cases are self-limiting, but special concern and treatment may be necessary for immunocompromised and elderly patients


Left upper quadrant (LUQ) pain may be attributable to pathology involving the spleen and the pancreas. Acute pancreatitis manifests as rapid onset, steady pain boring straight through to the back Gallstones are the most common cause of pancreatitis in the United States, causing pain and inflammation


Right lower quadrant (RLQ) pain is classically caused by appendicitis. Patients usually report having periumbilical pain, which then radiates to the RLQ


Left lower quadrant (LLQ) pain indicates diverticulitis in 70% of patients with this condition in the Western world.19 Patients with this pancolonic process present very similarly to those with appendicitis—with a few noteworthy exceptions, such as more pronounced changes in bowel habits. Fever and leukocytosis ar e more prominent in diverticulitis, while one often sees anorexia, vomiting, and nausea in appendicitis. Initial pain with diverticulitis is usually hypogastric rather than epigastric and radiates to the left iliac crest or suprapubic area. Patients suffering from an acute attack of diverticulitis probably have experienced this type of pain before; if elicited in the history, this information can thus give a good diagnostic clue.

Answer 2

I can't guess other than your gallbladder, but wanted to share my experience. I had one similar to yours, even to the point that the MD's at the ER thought I was making some of it up or having "panic attacks" It turns out it WAS my gallbladder. It just took an ER doc(suprise!) to go with his intuition and send me for the follow up HIDA scan and though I had no stones, my gallbladder was not functioning properly and probably never really was as it was later found in my mother and sister as well. My gb did not have a sufficient opening to output as it should have.
I'm sorry that you are going through this. I do hope they ultimately find out what is causing your problem and get it resolved. I will say that the day I had my gb out, and I was conscious enough w/out pain pills, I felt like a whole new person! I was never happier about a surgery!

Answer 3

First of all, six years is too damn long to suffer with any kind of pain. I think it is unconscionable for doctors to leave you hurting and not coming up with alternatives. You mention that you have had ultrasounds but have you have upper and lower GI's or MRI's? Have they run an endoscopy to see if you have GERD, ulceration, or any other problems? Sounds like you need a really good gastroenterologist to work with you. You could have adhesions from your previous surgery, Irritable bowel syndrome, Crone's disease or perhaps something as simple as an intolerance to lactose. If you have any teaching hospitals in the area, try to get a referral to the Gastro dept. They are usually tops in their fields and tend to charge much less. Do not allow them to just blow you off. Remember, the squeaky wheel gets greased. Best of luck, T

Answer 4

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Answer 5

I am just wondering if the problem could be a disc in your spine?