Cause of pain in the Abdominal area through to lower back?

[Wayne-Long]

  Doctors have thus far been unable to diagnose severe and constant lower
  internal abdominal pain a friend of mine is having (in her early fifties).
  It continues at only a slightly abated level after recent gallbladder surgery.
  She has been hospitalized twice two weeks after surgery for extreme pain and
  subsequent analysis with no sure diagnosis in sight.  This email goes out to
  all that might have experienced or have an idea of what the root problem(s)
  could be. Please help if you can:
  
     History of the Abdominal Pain:  (first occurrence to now)
     ------------------------------
     1. A similar form of the pain (located in the lower right quadrant)
        started intermittently back in Nov. 97, approximately one year prior
        to first diagnosis of a large gallstone and subsequent removal.  Prior
        to surgery, the pain came on intermittently, very intensely, usually
        at night, and faded over 2-8 hours; with no accompanying jaundice,
        nausea, vomiting, or fever; just extreme sharp pain. Pain occurred
        without any external causes.
     2. Subsequent X-rays in Sept. of this year ('98) were negative (for problems).
        However ultrasound showed a large gallstone, so she subsequently had
        gallstone surgery one month ago (Cholecystectomy/laparascopically:
        4-incision method: typical recovery time should be in the days to one
        week period, no longer).
     3. After surgery, pain remains intermittently as before surgery, so there
        is a question as to whether the gallstone was every the root cause.  It
        may just have been coincidental.  However, after surgery the pain,
        although identical in location and similar in intensity, is now induced
        by certain body motions which effect the site of pain (which is now the
        same site as the incisions.  (see Inducers of the pain below).
  
     Sites of Pain:
     --------------
     1. Front and 4" to the right of her navel (lower right quadrant).
        Very sharp and intense pain.  Travels through the inner torso
        and connects to site #2.  (VERY similar to the pain prior to surgery,
        occuring at same locations, but slightly less intense.)
     2. Lower right back - very sharp intense pain - but does not go
        up the rear of the back. (VERY similar to the pain prior to surgery)
        Summary of #1 and #2 above:
        ---------------------------
        "Its like when you're running and you get a bad stitch in the side,
         but much more intense and painful."
     3. Intermittent shoulder pain - originates at the lower right abdomen
        (site #1) and travels up to the front shoulder (new pain after
        surgery, only occurred twice thus far - most probably referred pain).
        Touching any of these sites (#1,#2,#3) with the hands does NOT cause
        pain (as you might expect it would).  This baffling.
  
     Instigators/Inducers of the pain (post-operative):
     --------------------------------------------------
     1. Hurts terribly at sites #1 and #2 (lower right quadrant) when
        she leans backwards.
     2. Hurts terribly when there is any right-side movement.
    3a. Rolling over to the right when reclined seems to pull and make
        the pain worse.  (Has become slightly more manageable after recently
        taking Motrin and Muscle relaxant - exception is in the morning.)
    3b. Rolling over to the left when reclined causes pain but can bear it
        enough to get up.
     4. For three weeks after surgery: Deep breath induced extreme sharp
        pain at both sites.  (This cause has since subsided.)
     5. Continual trouble using the abdominal muscles to get out of bed or
        off the couch, worst in the mornings upon awakening.  (again, it
        causes pain at the two sites.)
        Can sleep only on back due to #2,#3, and #5 above.  Does not move
        much at night so muscles no doubt are sore in morning.  Used to
        only sleep on stomach prior to surgery.
  
     (A)symptomatic for:                             Symptomatic for:
     -------------------                             ----------------
     1. No nausea, vomiting or fever.                1. Bloating (now gone).
     2. Bowel movement OK.                           2. Gas (post-operative).
     3. She's "Hungry as a horse."
     4. Emergency room/hospital tests show:
        - Blood work shows normal.
        - Urinalysis shows normal.
        - No cardiac problems, EKG looks normal,
          as is pulse and blood pressure.
        - Recent CT scan show no other stones in bile duct, but does
          show lower right abdominal inflammation (at site of incisions)
          (however anti-inflammatories and muscle relaxants are
           having only a minor effect in reducing the pain at this time.)
        - Sonogram shows negative.  X-rays show staples, nothing else abnormal.
        - No damaged organs (no pancreatitis, liver damage, ulcer, appendix)
  
     Suspected by surgeon but so far, treatment has had minimal effect:
     ------------------------------------------------------------------
     1. Muscle spasm (initial muscle relaxant didn't help, new one might?)
     2. Abdominal inflammation (anti-anflammitories have had some effect.)
     3. Depression (the surgeon seemed to be "reaching" on this one - patient
        is far from depressed; however, expectantly, quite "unhappy" in the
        mist of a pain attack - intense pain understandably does bring tears.
  
     Ruled out by surgeon but still questionable:
     --------------------------------------------
     1. Staples came loose?
     2. Staples touching/pinching nerve, causing referred pain?
     3. Staples causing electrochemical stimulation of nerve,
        causing referred pain?
     4. Pinched nerve due to other causes?
     5. Surgically cut nerves in the muscles are very sensitive?
     6. Left something inside? (x-rays, sonograms, CT-scan doesn't show it)
     _. Please submit your ideas.
  
     Medication History:
     -------------------
     1. Medication prescribed before surgery:
          Hormone supplement for non-related condition.
     2. Medication prescribed 2nd day after surgery:
          Cephalexin - 500 mg - 1 every 12 hours
          Promethazin - 25 mg - 1 every 4 hours
          Propox-N/APAP 100/650 mg  1-2/4hrs
     3. Medication prescribed after emergency hospitalization (2-wks later):
          Vicodine -5/500
     4. Medication prescribed the next day by surgeon:
          Flexeril - 10 mg - 3/day
     5. Medication prescribed 3 days afterward:
          Valium - absurd - prescription never filled.
     6. Medication prescribed after second hospitalization:
          Motrin - 800 mg - 2-3/day
          Zoloft - 50 mg  - one-half tablet in morning
          Ambien - 500 mg - 1/night
  Please submit any similar experiences, solutions, or ideas you may have.
    
  --
  Wayne Long      ***@****
_____
Dear wayne
It is evident from your detailed letter that this is a complicated problem.  You are correct in your supposition that the gallstone was probably an incidental finding.  There are many postings in our archives documenting a similar story.
Your friend needs to discuss with her surgeon the possibility of other diagnoses e.g. inflammatory bowel disease [Crohn's Disease], gastroparesis.  The appropriate tests can be performed quite easily and help in determining the cause for her symptoms.
This information is presented for educational purposes only.  Ask specific questions to your personal physician.
HFHSM.D.-rgf
*keywords: abdominal pain
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