Mysterious acute attacks of epigastric pain

[Michele__0__0]

  Having received the negative results of yet another test, I searched
  and came across this Forum.  I am hoping for direction that my
  gastroenterologist and I can pursue for other tests that may help
  identify my problem.
  I am a 36 year old female, 5'3", 125 lbs, non-smoker, drink only
  1 glass of wine every evening or so.  The only meds I am currently
  taking are tri-phasic BCPs.
  For the past 18 months, I have been plagued with attacks of severe
  epigastric pain - located centerline about half-way between the
  bottom of the breastbone and navel.  I have no warning of these
  attacks coming, I have not been able to identify them with any
  particular food or cooking, and they usually occur late morning to
  mid afternoon.  The severe pain lasts well into the night (keeps
  me awake), and is followed by a couple of days of general soreness
  in the area, feeling like a muscle soreness from overexertion.  
  No OTC meds for acid control or indigestion help.  The pain does
  not radiate towards any other area.  It is a relatively constant
  pain which varies slightly in degree while the attack is happening.
  Other symptoms during the attack are alternating hot flashes and
  cold chills, occasionally a very mild nausea (mostly because the
  pain is so bad).  Warmth and pressure on the painful region seem
  to offer some relief.  There is no accompanying change in bowel
  movements.
  There have been roughly a dozen attacks in during the past year
  and a half.
  I have been through an abdominal ultrasound, which showed only a
  very slightly high-normal diameter of a bile duct from the liver.
  I have had an upper G.I. series, which showed only a possible very
  tiny hiatal hernia, and did not show any abnormalities with that
  bile duct.
  During my last attack, which occurred 6 months after the one before
  it and happened mid AM on a nearly empty stomach, I went to the
  hospital and had abdominal Xrays (neg), urinalysis (neg), and
  bloodwork: amylase, bilirubin D&ID, basic metabolic panel, CBC,
  and liver function panel.  All normal except an elevated white
  count.  I was given an injection of Bentyl and one of Toradol and
  the pain gradually subsided over 45 minutes.  This was by far the
  worst attack I've had.
  2 weeks after this attack, I went into the hospital for a HIDA
  scan (normal ejection fraction) and an EGD (all normal except
  confirmation of the very tiny hiatal hernia).  Biopsies were done
  during the EGD and came back normal.  The only thing I noted is
  that the injection of Kinevac (synthetic CCK, I believe) to start
  the gall bladder caused pain identical to my attacks, including
  the sweating and chills, but the pain subsided in a few minutes.
  (It was followed by a latent muscle soreness, again not as long as
  with "real" attacks).
  This past Monday, I went in for an abdomical CT scan.  We received
  the results yesterday - again nothing was found.
  In general, I feel best when I don't eat or drink a lot.  Often,
  I will feel intestinal bloating after eating too much.  There is
  no excessive thirst or hunger or urination.  There has been no
  weight loss associated with this; in fact I have gained 7-10 lbs
  and feel like I'm eating less now than a year ago.  I have
  noticed an increased "acid stomach" when eating things like
  tomatoes (I take Pepcid AC for this).
  I realize, and my doctor says so too, that the next course of
  tests would be while I'm actually having an attack.  I'm just
  wondering what sorts of tests we might try so that I can better
  educate myself.
  Thanks,
  Michelle
______________
Dear Michelle,
I can appreciate how frustrating it is to feel sick and for the doctor to be unable to identify the cause.  
Your symptoms of bloating, decreased appetite and abdominal pain could be due to gastroparesis,
afailure of the stomach to empty at the normal rate.  Usually, the pain of gastroparesis
is a chronic ache but I have seen patients with sharper pains, similar to those that you describe,
A gastric emptying study ( a test in which you eat a meal containing a radioactive tracer and then have pictures taken
of your stomach to measure the rate at whuch the marker leaves the stomach) should determine if delayed gastric emptying
is the cause for your problem.
To complete the workup you should probably also have a colon evaluation.  Finally, you and your physician should discuss the possibility that
irritable bowel syndrome could be the cause of your symptoms, assuming that the completed wokup does not reveal a cause for your symptoms.
This information is presented for educational purposes.  Always discuss specific medical issues with your personal physician.
HFHSM.D.-rf
*keywords: abdominal pain, gastroparesis
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