RUQ Pain - IBS or Gallbladder?

[alexandria]

I am a 36 year old female with a history of severe,constipation predominant IBS, chronic constipation, reflux/gastritis, high BP and asthma. Due to a female surgury that created bowel adhesions a year ago, I have chronic constipation that requires a daily dose of Citrucil (1/2 cap), Milk of Mag (1 Tbls) and Miralax (1 cap). I've struggled with severe IBS which is constipation predominant and pain predominant (usually resulting in severe, intermittant bloating and colon spasms). In addition to the above meds, I am also on Prevacid, Benecar, Advair Diskus, Allegra, Florastor, oral BP pills continuous and Slow FE (for mild iron deficiency). Over the past year, I've had a lot of tests (due to the abdominal problems) including blood tests, CBC, liver and pancreatic enzymes, chest and abdominal xrays, abdominal CT scan, upper GI, lower GI, small bowel follow through, colonoscopy, colon transit study, endoscopy for celiac disease, etc. All tests were normal and only showed mild reflux and a redundant sigmoid colon. Since January, I have been seeing an IBS specialist in New York. Have been put on a mild, low fat diet. However, after recently going off my diet on two occassions - once for 6 Krispy Kreme donughts and a second time for 6 slices of cheese pizza (I learned my lesson), I developed cramping, spasm like pain in the right upper quadrant under my rib. It begins about an inch under my rib cage (toward the center)and goes to the right middle of rib. Pain is like a dull ache and sometimes feels like a dull pressure under the rib cage. However, it also extends about 1 /12" below the rib cage. Not sure if this if pain from the colon, duodenum, or gallbladder. The area under my rib is always sore and tender to touch and the cramping and fullness begins when I eat anything. Pain only subsides by morning but still feels tender and inflammed. It doesn't hurt when I eat, but about 20 minutes to 1/2 hour after. Eating temporarily subsides the moderate pain, but the cramping begins soon after. It's worse after lunch or dinner. About a year ago, I had a number of ultrasounds for gallbladder which were normal. Also had HIDA scan with CCK which was normal but mildly slow. Doctor told me since I was on BC pills, the test was normal. The only thing that seems to help subside the pain and pressure is Librax. However, when I take I need to increase my laxative dose as Librax is constipating. I've had pain similar to this 2-3 times over the past 3 years, but milder and it went away on its own (sometimes after 2-3 months). Endoscopies showed nothing. Do these symptoms seem indicative of gallbladder or an exacerbation of IBS, or perhaps duodenitis? Reflux has been worse over the past 3 weeks. Is there anything else I should consider and how should I treat? Does the fact that Librax helps the pain indicative of anything?

[Kevin Pho, MD]

You clearly have had a comprehensive workup for IBS including the studies listed above.  

If these tests are negative, then IBS may be a reasonable consideration.  There are some small studies suggesting improvement with the administration of Librax.  

You may want to consider Zelnorm - which has been shown to help in some cases of constipation-predominant constipation.  It can decrease constipation, abdominal discomfort, and bloating in some women with constipation-predominant irritable bowel syndrome. There is no evidence that it offers any advantage over standard treatment (eg, fiber supplementation or antispasmodics) since direct comparison trials have not been performed. The main adverse effect was diarrhea, which was typically transient.

Other options include tricyclic antidepressants - which have shown some benefit in small studies.  

Also showing some benefit in small studies are antibiotic treatment (specifically with Metronidazole).

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.

[alexandria]

Just wanted to add one more thing. I also notice that the area begins cramping when I bend over. Not sure if this tells you anything. Again, usually worse after eating.