RLQ Pain. Could use surgeon input.

[NorthernBelle]

I'm a 36yr old healthy female who usually only sees a dr when I've broken a bone.  However, I've been having pain that came on suddenly and won't go away.

In late December I went to the ER with extreme pain in my RLQ that I thought sure was my appendix.  Pain was sharp and located about 3 inches in toward my navel from the middle of my hipbone. (After 10 years of marriage, it was the first time my husband had seen me cry)  ER did CBC-Normal (except elevated bilirubin), Xrays-Normal, Urine-Normal, Trans-vag US did not show any fluid in my abdomen (one small cyst on right ovary).  Sent home with pain meds and recommended I see GYN asap.

GYN was confident it was not a ruptured cyst and said the pain was "too high to be female".  Thought it was probably a ureter stone but sent me to Primary.

Primary ran CT scan - small cysts on ovaries and slightly prominent uterus.  He thought pain was urinary or colon, sent me to urologist first.

Urologist ran IVP-Normal, and Cystoscopy with retrograde-Normal. (gave me 500 Cipro after cystoscopy as preventative) Sent me to gastro.

Gastroenterologist did colonoscopy-Normal, appendix looked good too. (he said I had a lot of tenderness "in there", and that I squirmed as he rounded the corner so he had to give me additional anesthesia) He ran CBC which came back with elevated WBC and elevated bilirubin. Sent me for a HIDA scan but he said he expects that to be normal since my pain location is not typical of gallbladder.  On a second round of bloodwork, WBC and bilirubin are normal (result of the cipro?).

The pain has not been near what it was that day at the ER, however it is constant, sharp and in the same location (If I put my hand on my hip, the tip of my middle finger touches the tender spot)  The pain intensifies several days a week.  When this happens, I have to lay still, then it seems to die back down.  I have not been able to connect the "waves of pain" to eating, movement or my menstrual cycle (I does hurt worse when I'm sitting in a straight chair).  No fever, nausea or reduced appetite.  The only other symptom I have is chills.

I'm glad so many things have been ruled out, but what's left?

[hmgt]

I have had a very similar experience.  I am a 25-year old healthy female.  About a month ago I went to the ER with suspected appendicitis (sent by my GP.)  I was vomiting but no fever.  A CAT scan/ultrasound showed negative for appendicitis so I was admitted for 2 days and given Gravol and Demarol.  I was told it was suspected Crohn's or a virus.

I was sent home but pain persisted so I followed up with my GP who sent me for a barium swallow.  The barium swallow showed negative for Crohn's but showed positive for possible ulcers so I was sent for an endoscopy - where they put a camera down my throat.  That showed negative for ulcers so they told me I had IBS.  I don't feel that this is the right diagnosis since I have had no change in bowel movements, constipation/diarrhea etc.

I was sent for another ultrasound earlier this week and for a HIDA scan which my dr. said he suspected would be negative.  Today I had the HIDA scan.  My gallbladder did show up but I overheard them afterwards pointing at the screen and saying that they would expect to see more diffusion and saying "could be small bowel."  I won't have the official results for another week though so I am wondering what this means.

Over the past four weeks the pain had remained constant in my RLQ at about my navel level or slightly below.  I am managing the pain with Percoced but obviously this is not a sustainable solution so I am hoping that there is another diagnosis.  I have also been prescribed Motilium and Buscopan but neither seem to help. Finally I was told to continue on the ulcer meds despite the fact that there are no ulcers... I am wondering why?

Also if it is IBS what does that mean?  I just live like this in pain forever?  The MD told me I could go to the ER and get pain relief when it got really bad but that seems like an unrealistic solution given wait times - besides last time I checked they don't just hand out Demarol to people with unspecific pain.  Also I have lost about 5-7 lbs since this began and cannot really afford to lose the weight.

I am also trying a new diet over the past few days and avoiding wheat, tea, coffee, refined sugar etc.  It has helped  nausea somewhat but I can't say I notice a major difference in the pain.

Please keep me updated on what happens to you both!

[NorthernBelle]

Wow - our symptoms do sound similar!  Since I posted, I had repeat blood work (which came out normal this time) and a repeat CT Scan (normal).  The latest scan showed the same small cyst (1.7cm) on my right ovary which had not decreased in size.  The gastro guy is stumped and said that according to my exam he'd say I have appendicitis... but the CT scan shows it as normal.  So he sent me to a surgeon for another opinion.  The surgeon said he wasn't sure either, but perhaps I had some endometriosis or a small hernia.  He wanted me to see my gyn again to rule out other female stuff, if nothing there, he wants to do a laproscope to look inside. I have an appointment tomorrow with my gyn.  I'm sure you have been researching your symptoms as well as I have... female stuff doesn't exactly fit the pain and nerve impingement could possibly be it.  The pain is really deep in there though.  Hernia would make sense since the pain is worse for me at night, and feels a little better by laying down flat.  Oh yeah, gastro guy said he might want to run a small bowel xray. Please post again with an update on your findings.  Perhaps we can help each other get to the bottom of this.

[Wonderer]

I am a 33 yr old white female who has had chronic rlq pain for eight weeks now.  I had first went to the hospital and they thought I had a cyst on my ovary.  Been through a papsmear, ultrasound, MRI, CT pelvic scan, hip x-ray, bone scan, and colonoscopy.  Everything has turned out normal and now going for small bowel xrays tomorrow.  The gastroinologist is trying to detect where the pain is coming from.  I had just read over the other ladies complaints and boy did it sound like mine and I hope you are right that the bowel test should be next and if nothing shows up then I am more prepared as to what would come next.  Please post what the other lady finds to be wrong with her and I will definitely do the same.

[surgeon]

the thoughts I have, while you're waiting for Dr. Pho's answer, are it's possible to do the CT scan with contrast geared toward assessing the small intestine, or to do what's called a "small bowel follow-through" xray, to get a more detailed view -- crohn's disease, for example, is a possibility. Laparoscopy would also afford a direct view. Finally, one might consider musculoskeltal issues, such as a nerve impingement in the spine.

[Kevin Pho, MD]

Other causes that haven't been looked at include inflammatory bowel disease or irritable bowel syndrome.  An upper GI series with small bowel follow through can look for Crohn's disease.  

I would also consider referred musculoskeletal pain.  Hip films or an MRI of the joint can be considered to evaluate any problems with the joint.  Pain from an inguinal hernia can radiate into the RLQ.

You have already been through a comprehensive evaluation.  If everything is negative, irritable bowel syndrome may be considered - although this is normally accompanied by a change in bowel habits.  Increasing the amount of fiber and possible antispasmodic therapy can be considered.  

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.

[NorthernBelle]

500mg of Cipro (correction)

[NorthernBelle]

I also wanted to add that the pain goes straight through to my lower right back.  And, it hurts worse when I shift my weight to my right leg.