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Family Medicine (Expert Forum)
Left abdominal pain/weight loss
Answered by
Kevin Pho, MD - Internal Medicine
Kevin Pho, MD
Boston - MA
Questions in the Family Medicine forum are answered by Dr. J.M. Keyes. Topics covered include general health issues, adolescence, babies, child health, eating disorders, fitness, immunizations and vaccines, infectious diseases, medical tests and procedures, and senior health.
Left abdominal pain/weight loss
by Newzealander, Apr 29, 2004 12:00AM
I am a 42 year old male, non-smoker, athletic, generally healthy with no history of serious disease, injury or surgery. I am 6’2” tall and, until recently, a very stable 197 lbs.
3 months ago I began experiencing episodes of acute adrenaline rushes. Symptoms were heart palpitations (pulse around 100 bpm), cold hands and feet, sudden fatigue, light headedness, shortness of breath, very dry mouth. These episodes last anywhere from 30 minutes to 3 hours and occur 1-2 times per week. During a recent occurrence, in addition to the other symptoms, my left arm from the elbow to the hand went numb (as though I had slept on it badly and cut off the blood flow). I cannot consistently correlate the on-set of an episode with any specific activity, though they seem more likely to occur after eating or exercise.
About a week after these episodes started I began noticing changes in my bowel habits. Loose stools with mucus (not diarrhea exactly, just much looser than normal), and the need for a bowel movement 2-4 times per day, sometimes quite urgent (normal for me is once at nearly the same time each morning). These changes were accompanied by persistent pain in my left abdomen in two locations: 1) on level with and about 3”-4” distal from my navel, and 2) just under the curve of my left rib cage about 5” distal from my sternum. This pain is localized to these areas, constant (i.e. not affected by eating) and moderate intensity (4 out of 10)
I also noticed that I had started to loose weight. About 4 pounds by that point and a further 6 since then, though it seems to have now tapered off and I have been fairly stable at 185 for the past 2 weeks. Additional symptoms have included extreme tiredness, swollen lymph nodes just under my jaw, particularly on the left side (sometimes these reduce in size to near normal, but in a few hrs. swell again), intermittent headaches and an occasional (minor) nosebleed.
My internist and a gastroenterologist have not yet found a diagnosis,. Tests so far: blood work (repeated x3) including white and red blood count, platelets, enzymes , creatinine, glucose level, sedimentation rate (2mm after 1 hour, 5mm at 2 hours), free T4 and TSH all within normal ranges. Also test for Epstein Barr = negative. VMA 24 hour urine test in normal range. Stool test for parasites = negative. Abdominal and urinary tract ultrasound scans normal. Lumbar spine MRI normal except for degenerative L4-L5 disk. Abdominal/pelvic CT Scan with iodine contrast normal except for a small “simple” liver cyst. Stress ECG normal. Colonoscopy normal except for removal of 2 small polyps. Biopsy report on the polyps showed no pathology.
Family history includes: heart disease (father), melanoma and colon cancer (mother), diabetes and melanoma (sister).
I would appreciate your advice on any additional investigations to exclude truly serious conditions before I adopt the “sit back and let my body fix itself" approach. Thanks for any advice!
3 months ago I began experiencing episodes of acute adrenaline rushes. Symptoms were heart palpitations (pulse around 100 bpm), cold hands and feet, sudden fatigue, light headedness, shortness of breath, very dry mouth. These episodes last anywhere from 30 minutes to 3 hours and occur 1-2 times per week. During a recent occurrence, in addition to the other symptoms, my left arm from the elbow to the hand went numb (as though I had slept on it badly and cut off the blood flow). I cannot consistently correlate the on-set of an episode with any specific activity, though they seem more likely to occur after eating or exercise.
About a week after these episodes started I began noticing changes in my bowel habits. Loose stools with mucus (not diarrhea exactly, just much looser than normal), and the need for a bowel movement 2-4 times per day, sometimes quite urgent (normal for me is once at nearly the same time each morning). These changes were accompanied by persistent pain in my left abdomen in two locations: 1) on level with and about 3”-4” distal from my navel, and 2) just under the curve of my left rib cage about 5” distal from my sternum. This pain is localized to these areas, constant (i.e. not affected by eating) and moderate intensity (4 out of 10)
I also noticed that I had started to loose weight. About 4 pounds by that point and a further 6 since then, though it seems to have now tapered off and I have been fairly stable at 185 for the past 2 weeks. Additional symptoms have included extreme tiredness, swollen lymph nodes just under my jaw, particularly on the left side (sometimes these reduce in size to near normal, but in a few hrs. swell again), intermittent headaches and an occasional (minor) nosebleed.
My internist and a gastroenterologist have not yet found a diagnosis,. Tests so far: blood work (repeated x3) including white and red blood count, platelets, enzymes , creatinine, glucose level, sedimentation rate (2mm after 1 hour, 5mm at 2 hours), free T4 and TSH all within normal ranges. Also test for Epstein Barr = negative. VMA 24 hour urine test in normal range. Stool test for parasites = negative. Abdominal and urinary tract ultrasound scans normal. Lumbar spine MRI normal except for degenerative L4-L5 disk. Abdominal/pelvic CT Scan with iodine contrast normal except for a small “simple” liver cyst. Stress ECG normal. Colonoscopy normal except for removal of 2 small polyps. Biopsy report on the polyps showed no pathology.
Family history includes: heart disease (father), melanoma and colon cancer (mother), diabetes and melanoma (sister).
I would appreciate your advice on any additional investigations to exclude truly serious conditions before I adopt the “sit back and let my body fix itself" approach. Thanks for any advice!
Doctor's Answer
by Kevin Pho, MD, May 01, 2004 12:00AM
, May 01, 2004 12:00AM
One consideration may be carcinoid syndrome. This is a disorder that is characterized by the release of hormonal factors. Episodic flushing is the clinical hallmark of the carcinoid syndrome, and occurs in 85 percent of patients. It primarily involves the face, neck and upper chest, which become red to violaceous or purple, and is associated with a mild burning sensation. Severe flushes are accompanied by a fall in blood pressure and rise in pulse rate.
Secretory diarrhea occurs in 80 percent of patients and is often the most debilitating component of the syndrome. Stools may vary from few to more than 30 per day, are typically watery and nonbloody, and can be explosive and accompanied by abdominal cramping.
The most useful initial diagnostic test for the carcinoid syndrome is to measure 24-hour urinary excretion of 5-hydroxyindoleacetic acid (HIAA), which is the end product of serotonin metabolism.
In addition to the tests you have already received, you may want to discuss this with your personal physician.
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.
Bibliography:
Sitaraman et al. Diagnosis of the carcinoid syndrome. UptoDate, 2004.
Sitaraman et al. The carcinoid syndrome. UptoDate, 2004.
Secretory diarrhea occurs in 80 percent of patients and is often the most debilitating component of the syndrome. Stools may vary from few to more than 30 per day, are typically watery and nonbloody, and can be explosive and accompanied by abdominal cramping.
The most useful initial diagnostic test for the carcinoid syndrome is to measure 24-hour urinary excretion of 5-hydroxyindoleacetic acid (HIAA), which is the end product of serotonin metabolism.
In addition to the tests you have already received, you may want to discuss this with your personal physician.
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.
Bibliography:
Sitaraman et al. Diagnosis of the carcinoid syndrome. UptoDate, 2004.
Sitaraman et al. The carcinoid syndrome. UptoDate, 2004.
Member Comments (2)
by ozark, Apr 30, 2004 12:00AM
have you had a cardiac workup to check for arrythmias or other abnormalities? or a neurological exam?
by 6inVA, Aug 18, 2004 12:00AM
Did they also check for C. Difficile (stool check)?
