I have a history of NSAIDS induced gastric ulcers (2 small ulcers) last December. These were discovered accidentally while undergoing an upper GI (barium swallow) to check for GERD due to chronic cough. The ulcers were confirmed by endoscopy, and were treated with sucralate and Prilosec and temporarily discontinued NSAID therapy. I never had any pain or symptoms. Following 12 weeks of treatment the doctor said the ulcers should be healed, and allowed NSAID therapy to resume, with a different NSAID. Original NSAID was Naprosyn....new NSAID was Relafin plus take Cytotec to prevent reoccurence. I am also on low dose daily prednisone therapy for the last eight months, also Fosamex, and plaquenil, plus an assortment of asthma medications. These are for treatment of undifferentiated connective tissue disease, and probable Sjogrens syndrome, although lupus and other autoimmune illnesses are still a possibility. I also take Synthroid for hypothyroidism. Anyway, about a month ago I started exeriencing daily
abdomen pain, generally centered around bellybutton and slightly above, sometimes the pain seems to spread a bit more. It is particularly worse when I am hungry....usually eating helps but occasionally makes it worse. Sometimes TUMS helps and sometimes not. Most of the time the pain is mild but aggravating, occasionally the pain feels moderate to even severe. I also have a history of irritable bowel syndrome, diagnosed by a description of symptoms....and treated with Levsin SL with only slight improvement. I have diarrhea almost daily, sometimes as many as 6 or more times a day. Usually it comes either during meals, or immediately after....but sometimes hits me without respect to meals. I am embarrassed because of two things...when the pain hits me it is intense....I get pale and sometimes even sweaty as I struggle to fight the pain and make it to the bathroom. Sometimes I don't make it and some leaks into my underwear....making it necessary for me to carry either a change of clothes or wear a large
sanitory napkin whenever I am out. Sometimes the pain and urgency hits me in the middle of the night while I am sleeping, and the pain is so great it is difficult to get to the bathroom. Sometimes, the urgency last as many as three or four trips to the bathroom before passing. The stools are liquid, and usually yellow, and very foul smelling. I have had stool tests done which were negative for blood or parasites. I do occasionally have days without this happening, but I never have days without pain anymore.
In addition, about a month ago I noticed blood on my underwear and with toilet paper ascertained that it was coming from my rectum. Although not profuse, it was enough for me to put a liner on my panties. It stopped within a few hours. I mentioned it to my internist at my next appointment....he used his finger to collect a sample and said there was no blood so the bleeding could not have been rectal and must have been vaginal. I knew where the blood came from, and also that it happened in the absence of a bowel movement, but didn't want to argue with him. However, on several more occasions, usually after a bowel movement but not always, I noticed varying amounts of blood on the toilet paper after cleaning myself. There is no doubt that it came from my rectum. The stools never look bloody, only yellow liquid. During this period of pain, I have quit the Relafin and Fosamex....temporarily as the rheumatologist is concerned about the possibility of ulcer, and told me to start Prilosec again. He did not
recommend going back to gastroenterologist, but I think I should.
Here are my questions....first, I am assuming that the rectal bleeding is probably nothing to worry about, as the amount of bleeding is relatively small, and is bright red, and is not appearing in the stool. My assumption is that there is irritation in the rectum, or possibly a fissure, or perhaps even a hemmoroid....all minor nuisances that probably do not need medical attention. Do you agree with this assumption?
Second, does it sound like I have IBS....the only tests I had were an upper GI, endoscopy, and stool sample. The number of episodes, the extreme pain, the yellow liquid stool, the fact that I am having accidents (I am 40....too young for this incontenince), and the fact that this sometimes occurs without food and during sleep concerns me. I try not to worry about it, but this chronic problem does affect the quality of my life. Are there other tests that should be done, or does my description sound like IBS. If it does sound like IBS, are there other treatment options that work better than the Levsin....I am already having to double the dose to get any relief at all. Plus after this new pain started I had ultrasound of liver, gallbladder, spleen, pancreas, and kidneys....all normal.
Last, how likely does it sound like there is a possibility of ulcer disease recurring. Since stopping the Relafin, the abdomen pain is somewhat better, but not gone. Yet without the Relafin, I hurt badly in my joints, and I am stiff and not nearly as mobile. I am a single mother and full time teacher of 25 preschool aged children, and needless to say it is difficult to fulfill my responsibilities under these circumstances. Is just taking the prilosec, and restarting the NSAIDS and other meds as soon as the abdomen pain resolves, an appropriate reproach as the rheumie suggests. Or should an effort be made to discover whether or not new ulcers have actually occured be conducted.
One more thing....during the time the pain in the belly started, I was running a fever of unknown origen for three to four weeks, ranging from 100 degrees to 102 degrees (confirmed 3 times in 3 weeks at the doctor's office). SED rate was normal, so rheumie does not think this was a flareup of CTD....the fever went away following dental pretreatment with antibiotics....total of 4500 mg Amoxil in 7 hours (I have heart valve regurgitation as well). Rheumie said maybe there was an undiagnosed infection like diverticulitis, and that large antibiotic dosage knocked it out, internist says no way would one day of antibiotics cure an infection regardless of the dosage. All I know is the high fever has now been replaced by my usual low grade fever, which I am used to. What, if anything, does this add to the equation? Was that kind of infection a possibility?
I have not traveled, my diet has not changed. I am sorry this is long, but I am hoping the detailed background will help you answer my questions.
Although NSAID induced gastrointestinal injury occurs most often in the stomach and duodenum all parts of the gastrointestinal tract can be affected. Some of the symptoms that you are experiencing are not consistent with a diagnosis of irritable bowel syndrome. Rectal bleeding, nocturnal diarrhea, fever need to be further evaluated. If weight loss has occurred this too should prompt further evaluation. You mentioned a history of peptic ulcer disease. In addition to NSAIDs causing ulcers, Helicobacter pylori infection is a cause. You may need to be tested and for this organism if present. A simple blood test can diagnose previous Helicobacter pylori infection. Cytotec (misoprostol) can also be the cause for your diarrhea. If discontinuing the Cytotec does not improve your symptoms I would recommend that you have further gastroenterological evaluation. I hope you find this information helpful.
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