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Abdominal pain under right rib area.
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Abdominal pain under right rib area.

Gastroenterology is my best guess for where to post this question.

I'm a 44 year old male who has suffered from this pain intermittently for around 18 months.  It's about 2 or 3 inches below my rib cage, on the right side.  If you draw a clock face with my belly button facing forward to 12 o'clock, the pain would be about 2 o'clock position, but sometimes it could move a little more central or else more around to the right side 3 o'clock position.  It's a discomfort/dull ache which is made worse by sitting down/leaning forward.  It comes and goes and I can't easily relate it to any food/drink/habit, other than perhaps that feeling full in my abdomen (e.g. after food) seems to increase the discomfort.

Initial examination from my doctor failed to reproduce the pain or find any sensitive area, he also doubted it could be a hernia, and instead said I should try drinking lots of water, in case it was some kind of intestinal blockage, but this didn't help.  Returning some time later, he ran blood tests in case of some organ problem, but these (and later repeats) have shown no problem.

An ultrasound scan of my abdomen could find nothing wrong, whilst a detailed X-ray of my Kidneys found no problem either.

The fact that the pain occurred in a diffuse arc, but lacked any specific pain point and could not be reproduced when pressed/probed, made my doctor next suspect a back/nerve related 'phantom' pain.  I've been getting monthly osteopathic treatment for years now, and they did think there is sensitivity in the lowest back/rib joint which could explain the pain.  But they say it's hard to manipulate, and countless attempts to shift the pain have had little lasting benefit, leaving me doubting if this is really the cause.  I will say that when rolling on my back (for exercises) there is some sensitivity somewhere below my right/lower back area, but this is not conclusive.

On holiday, I felt this pain much less, raising the theoretical chance that it could be related to stress or else something else a change of habit affects.  Googling similar posts has yielded several possible explanations, but nothing fits very well.

A Gall Bladder problem ought to be badly affected by fat, but I felt it far less discomfort on a holiday consuming more fat than normal, nor have I found other high fat foods particulary effect it.

A Hiatus Hernia should be associated with acid reflux/indigestion, but I don't have these.

The quite serious sounding symptoms of Pancreatitis don't seem to match either.

Irritable Bowel symptom would give toilet habit variations which I don't recognise.

It's possible it could be muscular I suppose, but it has lasted too long it seems.   Could this be a gut problem?

I'm genuinely confused as to whether this is a 'phantom' back pain or else some more conventional internal organ type problem.  I  would appreciate any pointers on conditions or symptoms I may have overlooked or dismissed too readily.
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611999_tn?1298761891
I would ask for a hida scan to determine if you have a normal gallbladder ejection fraction.  Gallbladder pain is not the same for everyone.  I did not have trouble with fats all the time either.  Mostly just pain.  
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Avatar_m_tn
Thanks for your reply.  There are certain aspects of my condition which I always felt could be Gall Bladder related (the sense of something deep inside, around the correct area, which did not like the physical pressure of sitting/bending), but the absence of adverse reaction to fat made me think this could not be to blame.  Now you've set me thinking again.

Is the HIDA scan a form of MRI, or something else/more specialised?  I ask as it can be hard to get MRI scans in the UK without private medical insurance (unless very strongly indicated) and so I'd be interested in knowing how rare/costly HIDA is?

Does my description of discomfort/pain/bloatedness in that area sound possible to you?  Is there any food/suppliment etc which has any beneficial effect on Gall Bladder pain, if only to help circumstantially give evidence that it is to blame?
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611999_tn?1298761891
I think it would be worth it to check it out.  A hida scan is a test where they first inject you with a radiactive tracer.  You lay perfectly still on a table with a camera over you for about 45 min - 1 hour.  When they see the gallbladder and small bowel on the screen then they inject you with CCK.  This is a type of enzyme that mimicks a fatty meal.  Then you lie still about 15 min and it determines how well your gallbladder contracts.  This test can also determine if you stones or other problems with that area.   The CCk injection will usually mimick the pain in most people with gallbladder isssues. If the pain is reproduced with the injection and the ejection fraction is below 35% then most doctors will remove it.   I had my pain last year and the hida scan showed a fraction of 88%.  It went away but came back this year.  I had another hida scan at 22% and decided to get mine removed.  My pain this year was probably less that last year so that makes no sense to me.    When the surgeon took mine out a few weeks ago he told me it had adhesions and had formed a fatty layer attaching it to the liver so he had to scrape it off.  He said those things were from it being inflammed at some point.    It has been almost 2 weeks and I still have a little pain in the same spot so hopefully it will go away.   My pain was in the same area as yours.  It felt like a soreness in that area.  Sometimes I could push and feel the pain and other times I could not.  It did look a little bloated also.  My husband could not tell but I could.  

  In the mean time you could try a very lowfat diet everyday to see if that helps the pain.  The gallbladder flushes etc that are advertised are not a good choice.  If you find out you truly have gallbladder problems then you will probably have to get it out eventually.  
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611999_tn?1298761891
Oh I also had trouble with bending at times .  It felt like a stitch or pull deep in the area when I would bend.
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Avatar_m_tn
Many thanks for the detailed info.  I have to say, I am forming more and more the opinion that my symptoms are just like yours.

When I first saw my doctor, he quickly scanned through options (e.g. hernia, appendicitis etc.) and the gall bladder was dismissed once I said I had no particular fatty food reaction.  But what you are saying, is that this really isn't enough to rule out this organ.

I've felt unusually bloated lately, especially after food, and whilst most of us struggle with our weight and so at times feel like this, I've just had the feeling that my abdomen felt 'bigger' than it should do after even a light meal.  Reading my post, my partner has just agreed that I do sometimes appear abnormally bloated to her too.

Generally, pushing/probing the area has been not successfull in reproducing the pain (hence the phantom/nerve pain idea) but feeling full after food and sitting/bending do fairly reliably cause the symptoms.  It's like there's something (say, fist sized) been left inside that area which doesn't fit in.  Does the gall bladder actually get larger when problematic, or does sensitivity just make it feel that way?

I know that the gall bladder releases bile to help fat digestion, but if it does get removed as seems very common, what effect does this have on digestion/lifestyle etc?  Are there any alternatives (e.g. drug therapies) to surgery?


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611999_tn?1298761891
I was always bloated before my surgery a few weeks ago. I never connected it to the gallbladder.   It almost looked like I was pregnant.  I have noticed after surgery my stomach is not as bloated so I have had to buy some smaller pants.  

The gallbladder does actually swell when inflammed so maybe that is what causes pain along with adhesions formed after it is inflammed.  In some cases gallbladders are so inflammed and large they have to do the oldfashioned operation with the big cut in your abdomen to get it out.  This is rare though.  Usually they can manage with the 4 small incsions.  


When you have your gallbladder removed then the bile is free flowing all the time since there is no where for it to be stored anymore.  This can cause diarrheah in some people for the rest of their life.  My surgeon told me that in most people the bile duct will eventually enlarge or swell to take the place of the gallbladder.  It will hold the bile.  He said it may take a while in some for the body to realize there is not a gallbladder and begin compensating.  Then there are the few whose bile duct never does this and they are placed on welchol or questran to bind the stool and help with diarreah (diarrhea).  This is a cholesterol drug so it also helps lower your cholesterol.  Calcium carbonate has also helped to bind stool in some.  Caltrate 600 is what some use.  From what I have heard most people are limited to a low fat diet for a while after removal and eventually can tolerate some fat and spices but not a lot  .  You just have to figure out what your body can tolerate after surgery. I have been on bland diet of chicken , soup, potato,  cereal after surgery.  I tried some chips today but it made my stomach hurt a bit and had to go to the bathroom.  I had  upset stomach before the surgery because of bacteria so it may still be some of that.  I still need to get that cheked.  


Another problem that sometimes occurs after gallbaldder removal is spincter of oddi dysfunction.  This is rare and it usually was there from the beginning and was the true source of the pain instead of the gallbladder,  but this problem is never investigated until after gallbladder removal because the test to diagnose it has risks of pancreaitis  Basically spincter of oddi  is a tightening or a narrowing of the bile ducts which can cause nausea and pain similar to gallbladder pain.  if they cut the duct and widen the passageway this usually relieves symptoms but some patients have had to have it done multiple times.  


Some people try to prolong removal as long as possible until they cannot live with the pain anymore or they wait until an emergency and get surgery ( stone in duct, serious infection)  This is sort of risky since surgery should be carried out when you are not seriously ill.    The hida scan is expensive so maybe that is why they do not test for it right away.  I was living in italy when my pain started last year and they would not even check for it.  I had to come to the states and see  a doc here.  Maybe you could say you did have pain after one meal just so he would do the test :/   There are no drugs to help with gallbladder problems.  The only thing is try to eat low fat as possible to ease the burden on the gallbladder.
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Avatar_m_tn
Thanks again for another enlightening post.  The bloating remarks really ring true for me.  I'm not all that big or fat, but have long felt my stomach was often bloated (almost drum tight) beyond what I could reasonably blame on a large meal etc.  Would I be right in assuming this is excess gas, somehow caused by Gall Bladder/bile problems?

I was rather perturbed by your comments about life without a Gall Bladder, I really would not want some of these possible side effects.  As a vegetarian, I've long enjoyed a good/fast digestive tract, and the thought of being plunged into diarrhoea or treatments for this would be very unwelcome.  Given my diet, spices are a vital part of making food interesting, so again avoidance of these would be a problem.  I understand the fat content aspect of the condition, but what do spices do, and are we taking about hot spices (like chillies) or else most of them?

If the HIDA scan is expensive, then I really doubt I will get this on our free (but therefore rationed) medical system.  Does anything else, like MRI, shed any light?  The absence of a clear fat-reaction (I think I've just a general food-reaction) is going to leave me trying to convince my doctor (who I see again Monday) that this is a Gall Bladder problem at all.  Some online posts have suggested Gall Bladders are often removed on a 'lets give this a try' basis, frequently failing to cure the problem.  I want this problem investigated, but certainly not a rush to surgery given your comments.
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Avatar_m_tn
I just wanted to add the following online quote regarding chronic gall bladder pain:

'Most people feel a sharp pain when a doctor presses on the upper right part of the abdomen.'

Did you ever have this?  I've never been able to cause pain there by pressing and prodding, neither has my Doctor, which seems odd if I've got an inflamed organ in there?
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Avatar_f_tn
After years of severe intermittent upper right quadrant pain, I was diagnosed with SOD Type III.   I have just had a HIDA scan (private scheme with work) NHS won't pay.  The results were back today and show normal gall bladder function.  My Doctor suggested the scan before having my gall bladder out, now he's suggesting ERCP again.  I am not sure if its worth it, given I was only symptom free for three months last time and the stent they placed caused a bout of acute pancreatitis  The pain returned and like everyone else who has posted, nothing obvious sets it off and sitting and bending down certainly does not help.  Once the pain starts it goes on for hours and little helps to ease it.  I am really begining to think that not eating would be the best thing, apart from the fact after a few hours of not eating, the pain under my ribs near my gall bladder is very uncomfortable, I just can't win!!
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Avatar_f_tn
hello. I would like to share a few thoughts. I am a Gastric Bypass patient with intestinal problems that really anyone can have and I am thinking you may as well. I get the same pains as you have described about every 3 months. I had an EGD and it showed I had Gastroparesis ( http://www.healthline.com/adamcontent/gastroparesis?utm_medium=ask&utm_source=smart&utm_campaign=article_toc&utm_term=Gastroparesis+test#signsandtests&ask_return=Gastroparesissignsandtests ). It is where your food moves slowly through the intestines. Also I had an Endoscopy (or scope for short)and found that I suffered from strictures that required me to have to have them stretched while under during the scope ( http://www.healthline.com/adamcontent/esophageal-stricture-benign) . This was the main thing that made the sharp pains go away (IMMEDIATELY)...and that I think your symptoms are so much like. It really makes me feel so much better immediately. Have you been scoped yet? Its very simple and it helped with my bloating too that comes with the Gastroparesis and strictures... Oh and just a heads up they did find a small hernia with mine as well during the scope (way cool to find all this with the scope and the other test....) and I drank Carafate medication and it healed it up very quickly. To avoid the hernia returning I have been told to take Prilosec daily. and because of my bypass I have to be scoped every 3 months and restretch the strictures. To avoid syptoms (symptoms) of the gastroparesis I have to make sure I dont get constipated. All of these together caused my abdominal distress and pains and felt like what you described and I am thinking it couldnt hurt for you to have the 2 simple tests to rule them out and am really surprised your Dr didnt do the scope already since your pain is in your abdominal area. Anyone can suffer from these symptoms you dont have to be a gastric bypass patient. So I would suggest to have the EGD, but most importantly the Endoscope will reveal if you suffer from any abdominal distess as I do and I think a must have test for you to do.... I wish you well and to find out what is wrong and be healed from your pain as I do..every 3 months!! Ps You wont have the same as me... mine returns every 3 months due to my surgury. You should be healed if you have it with the scope. ok bye~!
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Avatar_f_tn
I forgot to mention the Gastroparesis causes bloating pain.The EGD showed this disease. I did include a link with each of the symptoms mentioned though for you to look at Also I was unable to tell I had the hernia because I also did not show with acid reflux/indigestion. The scope showed it. But it contributed to the strictures so I take the Prilosec daily now. If you do have any of these(Gastroparesis, Strictures,Ulcer) at least you know you have options to recover and be healed(either with scoping (Dilation (stretching) of the esophagus is the preferred treatment. Repeated dilation may be necessary to prevent the stricture from returning.),(acid-blocking medicines) can keep a peptic stricture from returning, also the Carafate was for a Ulcer not a hernia sorry I made a mistake and confused the two. So I was referring to an Ulcer in the previous post not a hernia, so that would make better sense Im sure. Anyways hope Ive helped you!!
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Avatar_m_tn
Thanks for your thoughts.  You know, I'm really not sure if Gastroparesis is what I've got.  I do recognise the bloating references, but my digestive tract is not at all slow.  When my doctor first suggested I drink loads of water, I didn't believe his implication of a blockage, and if transit time is anything to go by, I'm as good as I could be.

That's not to say I don't have a digestive problem.  I guess I must have something wrong.  In the UK, you first see a General Practitioner, effectively they diagnose the rough problem area and refer you to a specialist if it's not something they can treat with drugs etc.  This is why there's been no endoscopy yet, that would be for a specialist at a later stage.  My problem is that it's not at all certain where my pain stems from, and he could disagree with my assumptions.

I'd be pleased with a Gastrointestinal referral, but my GP could regard this as a back/nerve problem (which they tend to do very little about), or a muscular problem (leading to physiotherapy maybe) or who knows what else.  You kind of have to make a nuisance of yourself to get taken seriously enough to see a specialist, major problems being treated fairly quickly/well, but lower level annoyances being much harder to get taken seriously.

Anyway, I'll post again with what he says Monday.
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Avatar_f_tn
Im so sorry to hear how difficult it is for you to get to the right Dr to get treatment. I am lucky here in the US that I can just call my Surgeon on my cell and tell him that i need to be scoped again when i feel my symptoms coming on. In a way they dont really mind me because Im kinda a cash cow that way LOL.  Thank goodness for my husbands military insurance!! They do treat me very well though since they are aware of my Gastric Bypass situation and know that it has created the reoccurring problems. Saddly I may have to do these procedures my entire life. But other than those problems Im happy with my weight loss. I was 240 pounds when I first did it and lost down to 89 pounds (so not happy then), and gained up to 135 or so as it really fluctuates. (depending on how well i eat and excercise) So Im happy to have lost over the 100 pounds. Any how back to you. Please do keep in touch as we surely care enough to want you to get better!! and I will look for an update post from you! Till then peace! ;)
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Avatar_m_tn
Well I saw my Doctor briefly this morning.  He didn't sound very convinced when I suggested Gall Bladder problems, as the ultrasound scan had found nothing, but he did agree to refer me on to a  Gastrointestinal consultant, whose remit appears to cover the Gall Bladder and the most other abdominal areas too.  This referral will take several weeks typically.

Quite by chance, I also spoke with another (older) Doctor this morning.  He hasn't met me before, but did offer his opinion on my story.  He too doubted the Gall Bladder idea, but said that the pain could be irritation of the duodenum by stomach acid, as it follows meals by some time.  He said that the duodenum 'runs the same course' as the gall bladder so could give pain in a similar area.  He suggested that I take Omeprazole (20mg once/twice daily for a month) and see if that helped.  If it did, he suggested that this might be just a 'minor tendency' in that area and nothing necessarily worse in terms of digestion.

This got me thinking, it was slightly strange that any digestive problem had not been at least considered before.  Googling the drug Omeprazole, it does seem to get a generally good press for acid related gastric problems.  It also set me thinking as to whether I could actually have something more like a duodenal ulcer, rather than just the 'sensitivity' he suggested.  It would seem that such ulcers, usually caused by H.pylori, are very common.

At least this keeps me in the right forum for this post!  I'd be curious to know if this makes any sense to others with related problems?
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