Epigastric/RUQ pain for two years

[huck_finn]

I am an active 31 y/o male and I have suffered from RUQ/epigastric pain for the last two years.  Location of the pain is beneath the ribs just a bit down and right of the sternum.  I occasionally feel the pain in my right shoulder area and sometimes in my back, though not usually.  

The character of the pain varies a bit, but is generally a dull ache of varying intensity with ocassional sharp twinges.  The pain is alost always there, but is usually fairly mild (1 or 2 out of 10).  When it is bad, I would rate it a 5 out of 10 at worst, which is to say it is uncomfortable, but not debilitating.  the bad stretches last from days to weeks and I cannot figure out the trigger(s).  There is no obvious correlation between food and/or drink and the nature or duration of pain.  Also, I haven't had any other symptoms in conjunction with pain (GI upset, jaundice, etc.)

I have had many diagnostic tests.  All blood tests have been normal/neagtive over the last two years, including liver function, h. pylori antibodies, and amalayse/lipase levels.  I have had two abdominal sonograms -- the first about 1.5 years ago showed "mild fatty liver infiltration," but nothing else. The second, about a month ago, was negative all around.  An upper GI series about 9 months ago was normal.  With respect to the gallbladder, two HIDA scans (~7 and 4 months ago) revealed a 21% and 15% ejection fraction, respectively.  Last week, I had an abdominal CT during a bout of rather bad pain and it came back entirely normal.  

With respect to my general health, I am fairly active (run and/or gym 2-3 times per week) and have no other present or past health problems.  I eat a reasonably well, I am not overweight, don't smoke (never have), and drink moderately (I fairly regularly have one to three drinks, usually beer or wine).  I do drink a fair amount of coffee -- 2-3 mugs day.  

My primary physician thinks this is all gallbladder-related (acalculous cholecystitis) and has recommended that I have the gallbladder out.  I have consulted with a gastroenterologist and surgeon, and both are quite skeptical.  I am obviously concerned that something is being overlooked (stomach, liver or pancreas).  I guess I have two main questions: (1) What do you think of the gallbladder hypothesis, and (2) what do you think would be a good "next step"?  I am afraid I am going to start glowing in the dark if I have any more radiological exams!

Thanks in advance for your insight into this frustrating situation.

[Kevin Pho, MD]

Hello - thanks for asking your question.

Acalculous biliary pain is certainly a possibility.  In people with normal gallbladders, the ejection fraction ranges between 35-75 percent. Patients who suffer from bouts of biliary pain and have lower ejection fraction readings are assumed to have ABP. Studies have shown that surgical removal of the gallbladder (cholecystectomy) helps ABP patients more than 90 percent of the time.

You may also want to consider an upper endoscopy since dyspepsia can also cause RUQ pain.  This test can evaluate for ulcers and inflammation of the stomach or esophagus.  

To answer your questions:
1) The gall bladder hypothesis is certainly feasible.  You do have documented low gallbladder ejection fraction.  Surgery provides relief in excess of 90 percent of the time.  

2) I would consider an upper endoscopy to make sure there is no other disease present.  If negative, I would consider surgery.  

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.

[tessa0825]

Hello, Im no Dr.....I have however had gallbladder disease and your symptoms (and tests results) indicate it...21% and 15% ejection factor indicates that your GB is not functioing like it should..Usually if it is below 35% they advise having it removed...If it is your GB causing your symptoms they are likely to increase and become more painful over time.....I hope you consider having it removed.....Good luck......Tessa

[surgeon]

in addition to the low ejection fraction, it's useful information if, during the hida scan, the hormone CCK was injected and if doing so reproduced your symptoms. In that case, relief by removing the gallbladder is pretty likely.

[schaeff]

For what it's worth, about 15 years ago, I had symptoms precisely as you describe for several years as well. After a physical exam, some routine blood work and an upper GI series, all normal, but no abdominal ultrasound, my long-time internist put me on a drug called combid, (I think a time-released combination of compazine and something else) which I understand no longer exists. My symptoms went away in a few weeks.  Of course, identical symptoms can arise from completely different causes (my doctor said "the abdomen has a finite number of ways of expressing itself")so the course of action suggested by your physician and those here should be your guide.

Hope you feel better soon.

[5fan]

The first paragraph of your post sound almost exactly like the pain I have been describing now for more than a year.  The only major difference is I'm a 31-year-old female.

I began having episodes/attacks in March 2002 and really didn't think that much about them because they were not frequent in the beginning and after I vomited they would subside.  I could usually tell that an attack was somewhere in the near future because I would get a pain in the middle of my back (like a pressure/gas pain) and then the attack ususally hit full scale around 2 or 3 a.m.

I couldn't find a trigger for the attacks. It seemed like it different make any difference what I ate or didn't eat they would still come.  Now, in retrospect, I do see where alcohol did trigger some of the worst attacks, but I do not drink very often (maybe one or two drinks every 3 months or so) so this wasn't a consistent enough event for me to focus on.

Finally in mid-July 2002 I had the worst attack.  It was so bad it caused trouble with my breathing.  I ended up at the ER and a diagnosis of acute pancreatitis and was told that my gallbladder would have to come out as it was enlarged and the wall was thickened.  I spent five days in the hospital as they tried to control the pancreatitis and finally on the sixth day had surgery and was discharged on the seventh.  Three and one-half days without any oral intake at all - IV fluids only.  One and on-half days of clear liquid (broth, jello, etc.)  Finally my enzymes were under control enough for the gallbladder to come out.  I DID NOT HAVE ANY GALLSTONES.  I underwent abdominal x-rays, ultrasound, CT of the abdomen and a HIDA scan and the doctors weren't able to find anything.  They still told me that there was the chance that once they started the surgery they may have to convert to a traditional surgery if they found a stone once they "got in there".  My gastroenterologist didn't want to do an ERCP unless he had absolutely no other choice because of the risks of causing pancreatitis.  

I was lucky in some respects and not so lucky in others.  The last trocar to be taken out of my abdomen nicked an artery so I ended up with a 5cm incision so they could repair the artery (I fell lucky because I know it could have been much worse).  I had a lot of pain after the sugery due to the complication, but my liver and pancreatic levels returned to within the normal range (although still at the high end of the range)and stayed there.

Unfortunately, the pain did not go away.  Since surgery not quite 10 months ago I have been admitted to the hospital once for a six day stay and undergone:

Repeat abdominal ultrasound
Repeat abdominal CT
2 gastric emptying studies
Small bowel follow through
MRCP
Countless series of blood tests (including two Trypsin tests)
Endoscopy
2 sets of abdominal x-rays; and
A secretin test

Although the tests done the second time I was in the hospital came back with normal results, I was lucky that my gastro believed me and when he was unable to come up with a diagnosis he referred me to a hospital here that is connected to the state university.  He thought it was possible I had Sphincter of Oddi Dysfunction and needed and ERCP with manometry done.  

I went to the specialiast on December (after a three month wait) and basically started all over again.  This time however, some of the tests showed abnormalities.  My Trypsin level was just out of the normal range but not far enough to automatically kick me into a diagnosis chronic pancreatitis.  My gastric empyting study showed that my stomach did not empty within the normal range so I was given a diagnosis of gastroparesis.  After three months of treatment with erythromycin and not much releif the doctor decided to perform a secreatin test for my pancreas.  He explained that he developed the test and explained what it entailed.  I underwent the test in March and it was discovered that the amount of enzymes my pancreas produces is below normal therefore I do fall into a chronic pancreatitis diagnosis.  

I have been taking Viokase 16 (pancreatic enzymes) for almost four weeks now with only one attack.  I still have pain but not anywhere near what it was.  I follow-up with the specialist in mid-June and he will decide then whether or not he wants to go through with doing a bowel motitility test.

As he explained to me the last time.  He feels (as does my gastro) that my gallbladder was not necessarily the "problem", but that the underlying "problem" caused the issues with my gallbladder and that I seems to have symptoms of various diseases/disorders and it's like a puzzle.  They have to get all the pieces together before they can put it all together.  

I do have to say that I feel relieved now that I at least seem to be getting somewhere.  They may have found multiple health problems (IBS, Gastroparesis and Chronic Pancreatitis), but at least I'm headed in a direction where there are answers.  It took a while, but I was lucky that my doctors listened to me when I said I didn't feel well and when they couldn't give me answers they sent me to the place they felt I could get them.  I know many people haven't been that lucky.  The specialist has been a God send for me.  I knew I was in pain and something wasn't right, but after having multiple tests come back that tell you everything is normal you start to second guess yourself even though you know it not in your head.

I know this is a long post, but just wanted to share my experience and diagnosis.

Take care and best of luck!

[cars]

Can I ask where your specialists is? I ahve similar problems and NO answers,at least your getting somewhere?Thanks