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Gastroenterology (Expert Forum)
Gi Problems and Muscle psasms
Answered by
Kevin Pho, MD - Internal Medicine
KevinMD.com
This forum is for questions regarding Gastroenterology issues such as Acid Reflux (GERD), Barretts Esophagus, Colitis, Colon/Bowel Disorders, Crohn's Disease, Diverticulitis/Diverticulosis, Digestive Disorders, IBS, Stomach Pain.
Gi Problems and Muscle psasms
by macleodj, Dec 10, 2005 12:00AM
Thank you for taking your time to read this, not am I only experiencing GI problems, but Neurological problems as well. I am asking if you would pass this on to Neurology, as I have tried numerous times to post, and have not been successful. I apologize for the lengthy letter, I have been suffering with these Sx for 8 mo, and I am desperate for answers! In late April 2005, one evening I started to have pain and tightness in my left trapezius muscle. I have never been a migraine person, or someone who has suffered from muscle spasms. Before all of this started, I was a healthy person who lives a healthy lifestyle. The night that the spasm started, it got progressively worse, by the next morning, I was unable to turn my head, and pain was shooting down my left arm into my pinky finger. That same morning I made an appointment with my primary physician who agreed that this was an extreme muscle spasm, and sent me home with pain medicine, a muscle relaxer, and a Rx for physical therapy. The following day I was in excruciating pain and saw a physical therapist. I was sitting in the waiting room to be seen, and when the physical therapist came to call me back, he told me that he could see my trapezius muscle sticking up through my shirt- the spasm was the worst that he had seen in all of his years of practice. That day the physical therapist could not treat me, and sent me home with directions for bed rest, as he could not do anything with me in the state that I was in. He told me that I should have been in a "ten care pile-up" due to the fact that the muscles were so severely spasmed up, and I had sustained no injury that could explain my condition. He was very concerned. I spent the next three days down, and I was in so much pain that my MD wrote for even stronger pain meds. Three days later, I awoke one morning in such a severe state, that I had pain shooting up the left side of my face and into my head. I went to the ER per my MD, as she felt that an X-ray and pain control was needed. The X-ray came back normal, and I was sent home after receiving Morphine and Valium. Over the next couple of weeks, I continued to see PT, and the spasms were improving, but I was still suffering spasms off and on. I lost my appetite, became nauseated all of the time, and started experiencing explosive diarrhea daily. Over the next 4-6 weeks I had to be seen in the ER twice for dehydration due to the diarrhea, it is still an occasional problem, also involving horrible gas. Finally, in June, I awoke one morning with the most excruciating headache I have ever had in my life. I began vomiting from the pain and could not stop. That morning my husband took me in to see my primary care physician, who gave me Phenergan and Demerol. I went home, fell asleep, and when I awoke, the headache was back in full-force. I was sent to the ER by my physician, and I was admitted for 8 days. During the eight days, I had a spinal tap, blood work, a CT of my head and abdomen, and an endoscopy. All of my tests were essentially normal, although I did develop Pneumonia secondary to what I believe was a fluid overload. I have no memory of the first three days in the hospital due to the severe pain that I was experiencing. On day four of the hospitalization, I was evaluated by a Neurologist, who diagnosed me with headaches secondary to subocippital paraspinal myositis with greater occipital neuralgia. Not only were the traps spasmed, but the occipital muscles were spasmed up as well, and were causing pressure on my cranial nerve. The Neurologist had an Anesthesiologist there within a half an hour. The Anesthesiologist did a nerve block that helped the headache. Upon discharge, I was referred to the Anesthesiologist for a series of Cortisone injections and another nerve block. I have had the Cortisone injections in both traps and in the suboccipital muscles, as well as another nerve block, and have failed these treatments. I have failed physical therapy, as it aggravates the muscles and causes even more pain. At my next appointment we will be doing Botox injections and a Ten's unit. I have seen an infectious disease doctor in our area, and she threw her hands up, and told me that if it were a virus, it would be nearly impossible to isolate it and treat me with an anti-viral drug. The Neurologist that I currently see has referred me to Stanford. When I got sick, three other nurses and one housekeeper (who all work night shift) experienced the exact same symptoms as me. Shortly before us all got sick, the hospital where we work started a huge renovation project very close to our dept. Are dept. also has intake/output vents, that on a few occasions were known to not be working. For the past eight months, we have all continued to have the same problems- intermittent spasms of the trapezius muscles, headaches, and even involvement of the muscles of the arms and legs. Recently, all of us have been out of work on different occasions due to “flare-ups.” I continually have severe trapezius spasms, and my upper back, legs, and arms, are involved. 6 weeks ago, I started seeing a different physical therapist/chiropractor/MD who works very closely with the anesthesiologist/pain specialist that I see. The first time I saw him, he said that even under the most stressful conditions my muscles should not be in this shape. He told me that this was very abnormal. He ordered a stat MRI, as he did not feel comfortable adjusting me or working with me until he saw the results of the MRI. The MRI was essentially normal; it did show a lack of curvature due to muscle spasms. I have also failed his treatment; my muscles are just too sensitive to manipulation. I am only 29, have three children, and I am currently enrolled in a nursing program. The daily pain that I suffer is almost too much to bear, and I am feeling like at this point I am ready to "loose it". I am too young to be relying on pain medicines and muscle relaxers, and the days that I am in school or working, I have to rely on Advil and spend my day suffering. I hope that you may be able to help us, or at least make a suggestion as to what testing needs to be done prior to our eval. At Stanford. We have used all of the resources here, with no luck. I feel like I have been put on the back-burner to suffer, and it is very wearing. At no point, has any physician been concerned that these symptoms have involved 5 employees. Next week, I have an appointment for a muscle Biopsy, EMG study, and a nerve conduction test. I recently had a heavy metal panel done (blood) which showed: Arsenic: 6.2 (0.0-62.0), Lead: 1.1 (0.0-24.9), and Murcury: 1 (0-10) In the reading I have done, the blood tests only reveal a recent exposure, and that a 24 hour urine or hair testing may be more accurate in determining a past exposure? I appreciate any help or advice that you can give me, if you think that this may be the best place to be evaluated, I am more than willing to make the trip. Thank you.
Doctor's Answer
by Kevin Pho, MD, Dec 12, 2005 12:00AM
, Dec 12, 2005 12:00AM
I am not a neurologist, and will defer the neurology components of your question to the neurologist.
Regarding your GI symptoms of nausea, gas pains and diarrhea, you can consider further evaluation. The upper endoscopy would make diseases like ulcers, inflammation of the upper digestive tract or anatomical obstruction less likely.
You can consider imaging studies (like an ultrasound) to evaluate the gallbladder. More specialized testing like a gastric emptying scan as well as esophageal motility studies can be considered to evaluate for gastroparesis and motility disorders respectively.
These options can be discussed with your personal physician. I will ask the administration to forward your question to the neurologist.
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.
kevinmd_b
Regarding your GI symptoms of nausea, gas pains and diarrhea, you can consider further evaluation. The upper endoscopy would make diseases like ulcers, inflammation of the upper digestive tract or anatomical obstruction less likely.
You can consider imaging studies (like an ultrasound) to evaluate the gallbladder. More specialized testing like a gastric emptying scan as well as esophageal motility studies can be considered to evaluate for gastroparesis and motility disorders respectively.
These options can be discussed with your personal physician. I will ask the administration to forward your question to the neurologist.
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.
kevinmd_b
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Pain - The pain of FMS has no boundaries. People describe the pain as deep muscular aching, throbbing, shooting, and stabbing. Intense burning may also be present. Quite often, the pain and stiffness are worse in the morning and you may hurt more in muscle groups that are used repetitively.
Fatigue - This symptom can be mild in some patients and yet incapacitating in others. The fatigue has been described as "brain fatigue" in which patients feel totally drained of energy. Many patients depict this situation by saying that they feel as though their arms and legs are tied to concrete blocks, and they have difficulty concentrating, e.g., brain fog.
Sleep disorder - Most FMS patients have an associated sleep disorder called the alpha-EEG anomaly. This condition was uncovered in a sleep lab with the aid of a machine which recorded the brain waves of patients during sleep. Researchers found that most FMS patients could fall asleep without much trouble, but their deep level (or stage 4) sleep was constantly interrupted by bursts of awake-like brain activity. Patients appeared to spend the night with one foot in sleep and the other one out of it.
Sleep lab tests may not be necessary to determine if you have disturbed sleep. If you wake up feeling as though you've just been run over by a Mack truck – what doctors refer to as unrefreshing sleep – it is reasonable for your physician to assume that you have a sleep disorder. Many FMS patients have been found to have other sleep disorders in addition to the alpha-EEG, such as sleep apnea, sleep myoclonus (nighttime jerking of the arms and legs), and restless legs syndrome. A newly discovered sleep disorder, upper-airway resistance syndrome, is also being evaluated for its association with FMS.
Irritable Bowel Syndrome - Constipation, diarrhea, frequent abdominal pain, abdominal gas, and nausea represent symptoms frequently found in roughly 40 to 70% of FMS patients.
Chronic headaches - Recurrent migraine or tension-type headaches are seen in about 70% of FMS patients and can pose a major problem in coping for this patient group.
Temporomandibular Joint Dysfunction Syndrome - This syndrome, sometimes referred to as TMJ or TMD, causes tremendous jaw-related face and head pain in one quarter of FMS patients. However, a 1997 published report indicated that close to 75% of FMS patients have a varying degree of jaw discomfort. Typically, the problems are related to the muscles and ligaments surrounding the jaw joint and not necessarily the joint itself.
Other common symptoms - Premenstrual syndrome and painful periods, chest pain, morning stiffness, cognitive or memory impairment, numbness and tingling sensations, muscle twitching, irritable bladder, the feeling of swollen extremities, skin sensitivities, dry eyes and mouth, dizziness, and impaired coordination can occur. Patients are often sensitive to odors, loud noises, bright lights, and sometimes even the medications that they are prescribed.
Aggravating factors - Changes in weather, cold or drafty environments, infections, allergies, hormonal fluctuations (premenstrual and menopausal states), stress, depression, anxiety and over-exertion may all contribute to symptom flare-ups.
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POSSIBLE CAUSES
The cause of FMS remains elusive, but there are many triggering events thought to precipitate its onset. A few examples would be an infection (viral or bacterial), an automobile accident or the development of another disorder, such as rheumatoid arthritis, lupus, or hypothyroidism. These triggering events probably don't cause FMS, but rather, they may awaken an underlying physiological abnormality that is already present.
What could this abnormality be? Theories pertaining to alterations in pain-related chemical transmitters (particularly substance P, nerve growth factor, serotonin, and norepinephrine), immune system function (e.g. abnormally elevated levels of cytokines that form the communications link between your immunologic and neurologic systems), sleep physiology, and hormonal irregularities are under investigation. In addition, modern brain imaging techniques are being used to explore various aspects of brain function. The body's response to exercise, stress, and alterations in the operation of your autonomic nervous system (the one that operates in your peripheral tissues) are also being evaluated. Substance P and nerve growth factor are increased threefold and fourfold (respectively) in the spinal fluid of people with FMS, but researchers are working to figure out why these elevations exist. With regards to genetics, its role in FMS is also the focus of many investigations.