Why is this pain so hard to diagnos?

[gsue]

I recently had another ERCP done July 1 where they found that my duct to my pancreas had closed up again for the second time in just a few months.  This time the doctor assured me that he made a cut wide enough it shouldn't close up again.  However, soon afterwards I developed pancreatitis and was in the hospital for 8 days.  Thought I was better still not eating well but was told it would get better in a few weeks.  Now it is not better only worse.  Pain is more severe and blood tests show that mY Liver GOT is elevated to 85(0-47normal), Alk. PHOS 158 (50-136normal),GPT 111 (0-65normal), Lipase is high 281(0-200normal) but it was much higher 495 when they did the ERCP don't know what the others were but I'm told they weren't high or as high.amylase is  83 (25-115 normal).  Pain is in upper right quadrant and rotates towards back but sometimes is extreme towards center of abdoman.  Hurts more when I eat and is sometimes so severe that I throw up everything I eat or try to eat durring a day.  When it first started getting severe it hurt more in my lower left back and I thought I had a kidney stone again but when I went into the ER they said no that my pancreas was inflamed and that it was just a bad case of pancreatitis.  My GI doctor did a CT scan, which only showed gas or air in the left ducts, and feels that another ERCP is not needed that it has to be something else but so far he is just not sure and now he wants to send me out of town for more tests.  What more can there be? Please tell me what else could be causing this so far I'm having to take morphin in order to endor the pain enough to eat and stay out of the hospital.  What other types of tests can still be done?  I keep thinking that there are more ducts and maybe he missed something is that possible? There has to be something causing this much pain and so far I've gotten no where with my local doctor so I know he is right I need outside help but I'd still like to have some kind of clue or know in advance if someone else has any ideas as to what could be causing this.  Please give me some ideas. Oh I almost forgot I was diagnosed with a fatty liver about 2 years ago and then had my gallbladder removed, also the elevated liver enzymes and stomach trouble started then but it was after I was taking Zocor.  When I came off the Zocor the enzymes came down some and some of the stomach trouble stopped until the gallbladder was removed and since then nothing but trouble. I hope this helps you give me some advice on what could be causing this.  Thank you in advance.
gd

[Kevin Pho, MD]

Hello - thanks for asking your question.

Without examining you or your studies, it would be difficult to say exactly what is going on.  From your description, it seems that you underwent a sphincterotomy via ERCP.  Studies show that this is an effective method to reduce pain scores - approximately 80-90 percent of patients report relief.  Unfortunately, pancreatitis is a known complication - you may inquire about the possibility of a pancreatic stent which can reduce this complication.

However, there is always the possibility that the sphincterotomy did not alleviate the obstruction.  Other options would be surgical approaches which has the benefit of reduced scarring compared to the endoscopic approach.  Perhaps our surgical colleague on the board can comment on this.

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.

FYI - I will be away from August 1-9th.  I will look forward to answering your questions when I return.

[paty91356]

I have had a long-standing diagnosis of Sphincter of Oddi dysfunction...chronic, but not severe.
In February of this year, I had a total hip replacement.  The hip replacement was relqatively easy, but the reaction I had to the pain relieving drugs was a killer!  I know I had a bad reaction to Dilaudid and Vicodan, and really don't know what others they gave me...however...it flared up the pancreatic problem, and I developed a pancreatitis.  My SGPT went up to 424, Lipase 104, and Alkaline Phosphatase 205.  My GI doc said that some narcotics have been shown to cause spasms in sphincters (like the pancreatic sphincter). I was just thinking that perhaps whatever drug you're taking for the abdominal pain may be aggravating the problem.....just a non-scientific thought.

[gsue]

Yes it was sphincterotomy via ERCP done twice due to closure.  As for the pain meds I didn't start them until the pain was already severe so it doesn't seem likely that it is causing the problem.  I did however wonder if the pancreas enzyme pills they put me 3 times a day were contributing to it.

[5fan]

I have not been diagnosed with SOD, but have been diagnosed with chronic small duct pancreatitis.  I have had a few "break through attacks" since started Viokase 16 (4 pills 4 times a day)(pancreatic enzymes).  The first attack I had after beginning the enzymes I asked my doctor if it was possible that the enzymes would cause an attack.  His response was no.

He indicated in my case (I have gastroparesis (slow stomach emptying) and take Erythromycin 4 times a day to help my stomach empty)the most likley cause of the break through attack was consumption of alcohol (which wasn't possible because I don't drink) or the fact that my stomach was not emptying properly.  I had to alter the way I took the enzymes and go to a strict clear fluid only diet for three days.  I was lucky and that helped.  If it hadn't it would have been a trip to the hospital for me.

[keri2400]

I have had my gallbladder removed and a sphincterotomy via ercp.  I still have pain when I eat.  My doctor prescribed cholestyramine.  This coats my stomach and allows me to eat non-acidic foods without pain.  Carafate is another drug that can do the same.