Upper right side pain

[tonker]

I’m 32, 5’8” and a little over weight. I’m an active individual who enjoys a wide spectrum of sports.

At the beginning of the year, after playing hockey, I had severe diarrhoea (last two days), nausea (last a week) and pain (hasn’t left). Whilst the Diarrhoea lasted, I had two forms of pain cramps and pain in the mid to upper right side (under my ribs). The pain was dull with periods of sharp pains that lasted between 5 and 20 minutes. I was also being woken several times at night with a pain just below my sternum and on the right side that prevented me from breathing properly. The only way to slightly relieve it was to pass urine but I would wake a few hours later with the same pain.  Once the diarrhoea and nausea subsided I was left with the pain in my right side this spread into my groan and round the top of my pelvis and up my back to my ribs, this area became very sensitive to touch (hand and clothing). Whilst exercising I was getting pain under my right rib when my foot struck the ground + heavy breathing and after I had finished. In addition to this I would get pains in my right shoulder and breast at the same time I had the abdomen pain.  No pain was present on the left side. The pain did peak and trough.

I went to see my GP who sent me for an ultrasound of my gallbladder and Kidney’s. Kidney’s were clear and the gallbladder was retracted ??!! I was asked if I had fasted as requested, which I had, but on reply I felt I was being accused of eating!  I was advised to see my GP who would decided if it was worth seeing a consultant. My GP sent me to a consultant, I explained the above and also explained I was now getting pain whilst passing urine and stools (mid flow and motion). The consultant listened to me and then had a feel of my abdomen. I felt a little discomfort whilst he was palpating me but afterward the pain increased. When we sat down to discuss his thoughts he keep concentrating on the cramps. Three time I repeated the cramps only last two days and that the pain had been present for months! He couldn’t explain the exercise pain or the night pain as it was nowhere near my bladder thus happily dismissed them. He said he believed it to be IBS but did do some bloods all clear (don’t know what they were) and tested for celiac diseases (clear). Which is good. He suggested Peppermint oil capsules. I wasn’t happy but decided to give the capsules a go and see if they made a difference.

I took the peppermint capsules for a month, didn’t stop or help the pain. So I decided to keep a pain and food diary. I also recorded my period as I noticed the pain increased each time I menstruated. I have never had regular period and can have dreadful period pains but I also have periods with no pain. They really have no pattern.  As I was keeping the diary I was being to struggle. The pain was becoming more prevalent but I was battling with the thought it was all in my head as the previous tests had all been clear!

I kept the diary for 3 months and got to the point I couldn’t bare it any more so asked my mum to come to the GP to help. My GP wasn’t overly receptive to start with and was happy to leave it as I had been ‘extensively tested’,Mentioned above. However my mother mentioned something that changed her attitude (Neither of us I know what triggered the change but I helped my case). She began to question me about menstrual cycle in relation to my pain and thought it possible I had endometriosis.  She referred me to another consultant and requested a lower abdominal ultra sound (clear).

I went to the consultant who agreed her conclusion and suggested an transvaginal ultra sound (Clear) followed by a possible laparoscopy. After another clear ultra sound and long deliberation I had the laparoscopy where they found a congenital cyst hanging off  my right ovary (it was cut out) and a small amount of minimal endometriosis (Lasered).  

A week after the operation I had one of the worst periods I have experienced. The consultant was surprised that this had happened and despite his findings he is dubious that the cyst or endometriosis is causing all my pain. I asked him how extensively he investigated my abdomen and if he had search the upper right side as I wondered if I had endo elsewhere? He wasn’t forth coming with his explanation of his search but did assure me I couldn’t have endometriosis elsewhere. He recommend I take loestrin 20 for 5 months then come back.

It is now 2.5 months after the op,  and I have had another period despite starting the pill which was painful and long. It’s 3 weeks since my period started and I still have blood mixed in the fluid from my vagina. I am pleased to say the pain in my lower right side has more or less gone however the pain in my upper right side is persisting. It sometimes feels like a stinging pain inside, it hurts when I breath and I am always aware of something under my right rib. It doesn’t respond well to exercise but I have put weight on with the pill and would rather the pain than put more weight on which I don’t imagine is helping. I have had unexplained diarrhoea, nausea and heartburn. The pain has returned at night and passing water can hurt. At time my stools have black speckles through it (when I was constipated after the op but when movement became regular again my stools were speckled with the same black specks). I tend to get the black speckles after a period of pain but they are not always speckled with black.

I’m tired of the pain and torn between the thought it is in my head and that something else maybe wrong. I’m reluctant to go back to the GP but know I will have to at sometime as it is just not getting better.

I would be grateful of any advice or suggestion on how to tackle my next GP visit.

[LivingInHope]

Yes, I think you definitely should get that HIDA scan done with ejection fraction (as long as you don't have kidneys that are failing because dye is involved).

There is a hard to reach area that a gyn surgeon with less experience might miss called the cul-de-sac where endometriosis can go.  The bowel needs to be properly prepped as well in case they found any endometriosis on (and possibly growing into) the bowels.  

Because even with my second laporotomy, where they excised rather than burned as much as possible and also removed my reproductive organs, the surgeon said there might still be microscopic implants... because of that and dangerous side effects I'd heard about with hormone replacement therapy (HRT), I've chosen not to take any HRT, because it could affect what was missed & the synthetic, even in a ting mg patch amount where I called of estrogen I believe it was, they said it was possible an implant could still change into cancer, a potential side effect of the patch!

[tonker]

Thank you for your comments you've given me some food for thought and investigation. You've also helped me decided to bite the bullet and go back to see my GP. I definitely think they may have been to quick to dismiss my gall bladder. I'm apprehensive as I saw a GI consultant about my gall Bladder before and he dismissed it but something needs to be done as this isn't normal.

Your comments on endo were interesting and oddly reassuring (I don't feel so nuts!), the consultant insisted he had removed all there was to remove but your point on microscopic is a valid one and I had read before the op that a laparoscopy was not full proof and very dependant on the surgeon. I'll bring it up with him at the next appointment.

[LivingInHope]

Some ideas- I think they dropped the ball about your gall bladder too soon- I would ask for a HIDA scan with ejection fraction, as a surgeon told me sometimes ultrasounds miss something with the gallbladder.  Another source of pain in the upper right rib cage area can be what it turned out I had- a painful musculoskeletal problem called costochondritis- try looking that up!   The peppermint was likely to try to relieve gas, if that was an issue for you.  It's not something you want to take when having heartburn though, because peppermint can aggravate that.

Now about endometriosis, sometimes minimal endometriosis can cause a great deal of pain.  And it can sometimes go to less common places.  One of those places is it can be flung onto your bowels.  When that happens, it can start to grow into the bowels and cause problems with them (though black speckles might be caused by a different problem, like gastric bleeding or even by certain foods, like red meat or taking iron, etc.).  Endometriosis can also be flung onto the bladder (happened to me) and start growing there.  This can cause painful bladder symptoms that can make you think you've got an infection.  

When they do surgery, they can't guarantee that they got all the endometriosis, because there can be microscopic implants they didn't see.  With your body producing estrogen, these left over microscopic implants can continue to grow and sluff like the lining in your uterus does.  Endometriosis typically is not seen by ultrasound or even MRI.


Ask for occult blood test you can do at home, which can find hidden blood in the stool.  If that comes back positive, they may want to do a colonoscopy and take a look at the insides of your intestines.

Ask for a referral to a gastrointestinal (GI) specialist.

Ask for HIDA scan with ejection fraction to take another look at your gallbladder and ducts- looking for problems.

Ask for an upper endoscopy to see if they can spot evidence of GERD (gastroesophageal reflux disease) or ulcer(s) since you are having heartburn and nausea.  Also, the burning can be worse at night when you are lying flat, particularly if you at within two hours of going to bed.

Look up costochondritis, which can be very painful, usually can be pinpointed as a painful place you push on and can hurt to breath deeply.

Consider endometriosis being flung &/or growing since your surgery and adhesions (scarring sticking things together) from your laser burning (I have read excision of endometriosis is better than burning, because the body views the burned material as foreign to it and thus produces more scarring than excising) as possible sources of pain.  It would be extremely rare to end up at the distal location of your upper right abdomen as far as that pain goes though.