Don't know how to proceed

[nessi]

I am a 38 yr old woman in very good health. 5'6', 150 lbs. Medical history significant for a very large (benign) L ovarian tumor, removed in 06/2000. Complaints prior to removal of the tumor were LLQ abd pain, constipation, and persistant abd distention/bloating. Obviously the tumor was compressing my bowel and rectum. After removal of tumor, those complaints obviously resolved. Only thing remarkable after the surgery is that, pre-tumor and pre-surgery, I had normal bowel habits (approx. daily formed stool). Post-operatively, I now typically have liquid stools and rarely have formed ones. This is probably irrelevant to my current complaints, but I mention it anyway. CURRENT COMPLAINTS: (1) persistent, unrelenting abd distention/bloating with suddent onset. Began in mid-January and hasn't ceased in 11 weeks. At no other time in my life have I had a problem with bloating (except when I had the tumor). I look 6 mo pregnant. I have grown 2-3 clothes sizes in my waist only. Bust and hip sizes haven't changed, since I haven't gained any weight. NOT diet related. Gave up milk 7 yrs ago. Don't drink sodas or chew gum. I'm a registered nurse, so I know what foods cause gas. I have avoided such foods since the bloating started. Also, I underwent a 48 hr bowel prep for a procedure. 48 hrs of clear liquids and laxatives did not change the bloating at all. (2) abd pain x 9 weeks. Pain in LLQ, where I had my surgery. I understand the statistical probability that it's related to adhesions. However, the pain didn't appear until 2 weeks after the bloating started. Certain activities increase the pain (such as sitting for extended periods, bending over, squatting, overhead reaching. (3) change in bowel habits x 4 weeks. As I stated earlier, it is rare for me to have a formed stool. When I have had formed stools in the last month, they have been ribbon-like (which is the change). My primary tells me I have an internal hemorrhoid, and that could be the cause. TESTS UNDERGONE: negative pelvic ultrasound; abd CT scan with IV contrast negative for all except for the bowel distended with gas; negative double-contrast barium enema. Now where do I go from here? I can't accept the diet/stress diagnosis, because I think it's a complete cop-out. It doesn't make sense. However, I don't want to undergo more procedures that end up being negative (and my HMO doesn't want that either). So is this the end of the line for me, and I just have to accept the pain and the extremely uncomfortable (and disfiguring) abd distention? Should I ask my primary for a referral to a gastroenterologist? If I were your patient, what would you do with me? Do you have any thoughts as to what could be the cause of my symptoms (in light of the negative test results)? Please advise! Thank you!

[Kevin Pho, MD]

If you were my patient, I would refer you to a gastroenterologist.  You have undergone a pretty good evaluation, but with any change in bowel habits as well as change in stool shape, you need a colonoscopy.  A barium enema is not sensitive enough.  Things like a colorectal mass or inflammatory bowel disease are all possibilities that may lead to your symptoms - and endoscopy is the most comprehensive test we have to exclude these causes.  

If there is a silver lining with the negative test results, it is that it makes it less likely with each passing negative test that a major disease process is present.

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.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[surgeon]

An internal hemorrhoid would absolutely NOT be the cause of your symptoms. A GI consult, and maybe one with a surgeon, would be reasonable.