Tightness/pain beneath right rib radiating to mid and lower back

[revjr]

I'm a 37 year-old male. Approximately 6 weeks ago, I started feeling a tightness and pressure under my right rib. No fever or nausea accompanies it and it doesn't seem to worsen after meals. In the last few days, the tightness, which makes me visualize a golfball under my rib cage, seems combined with a pain in my mid and lower back. I also noticed that the area in my right rib is slightly tender to the touch now. It's most noticeable when I'm lying down. Really a ratcheting up or tightening sensation. My GP ordered a chest CT scan and RUQ ultrasound, both of which showed no "abnormalities." Now he wants to order a HIDA scan. I had a kidney stone in 2006 with radically different symptoms than those I'm experiencing now. My question - is it appropriate at this point for me to ask for a referral to an internist, gastroenterologist, or urologist? Each time my GP orders a test it takes about two weeks to get it performed, and I'm anxious about the length of time this is taking to narrow down and whether I might be in danger of a blockage or infection (if that's not what I'm already experiencing). I mean, what do I do next if the HIDA doesn't show anything wrong with my gallbladder other than wait for him to suggest yet another procedure?

[Kevin Pho, MD]

I agree with the CT scan and ultrasound.  The HIDA scan with CCK stimulation can evaluate the gallbladder ejection fraction.   A low number there can be an explanation for the symptoms.  

Another consideration would be an upper endoscopy, which can exclude GERD or inflammation of the upper digestive tract.

A referral to a GI physician would be appropriate in this case to discuss the aforementioned options.

This answer is not intended as and does not substitute for medical advice - the information presented is for patients education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
www.kevinmd.com

[Leslie44]

I am a 44 year old female and am experiencing seemingly the exact symptoms that revjr posted on May 6, 2008.Tightness/pain beneath right rib radiating to mid and lower back. I have been suffering for approximately 3-4 weeks and am going for an x-ray and pelvic/abdominal ultra sound.  I recall that I had a similar episode about 2-3 years ago, which eventually went away but did not seek medical attention for at the time.  Signed LR

[revjr]

Hi Leslie:

How long did the previous episode 2-3 years ago last if you don't mind me asking? This is a very disconcerting, curious sensation. I hope all goes with your x-ray and ultrasound.

revjr

[Leslie44]

I can't really remember but I think it was at least several weeks.  Now, the symptoms are still occurring and at times are not as severe or maybe its just I am used to now.  I will be having my ultra sound/x-ray on Tuesday and i will let you know the results.  For several days during this I could not wear underclothing as it was so uncomfortable.  The feeling is hard to describe, but has gone away since. It is very strange as I was feeling fine the day before and then woke up with the pain in the morning which seems to get worse as the day goes on.  It however does not seems to bother me while sleeping? I don't know if this is related but on a couple of occasions I had a feeling of overheating.  PS - I mentioned to my dr. the possibility of shingles as i understand that a rash is sometimes not apparent and is difficult to diagnose.  The dr. seems to think it's related to either gallbladder or liver.
Oh, one other thing, do you ever have an uncomfortable feeling of hollowness in the middle of your chest?

[revjr]

It does sound very similar to mine. Mine is more of a tightness as opposed to pain, but I have become worried since it's spread through to my back and side now. Just like you, this doesn't affect my sleep. It's very noticeable when I'm sitting up or lying in bed...the hollowness you mention in your chest - I have had a sensation like a warm liquid spilling over my chest on occasion (not like reflux or GERD, though). I had a stress test and echo a few months ago for some tightness then but supposedly the results were normal. Now, oddly enough, the chest tightness has vanished and been replaced by this mess.

[JimK3145]

I've been following your comments as well as those of Leslie44. I have had similar symptoms of pain under my right front rib cage and well as on my back right rib cage. This started about 6 months ago. At first, it was really intense, happened about 1-2 times a week. Then in January thru March of this year, it became more frequent. But starting in April, it turned into more of a stiffness similar to what revjr is reporting. This stiffness is now very low level, lets me sleep at night, but I always know that it's there. I've had an abodomen sonigram, HIDA scan and CT scan and all say that my gallbladder and liver are okay. I had blood work done and that says that my liver seems to be okay also. My current gastroenterologist is stumped as to what is causing this pain/stiffness so he wants me to see another gastro doc at a teaching/medical hospital which I'm scheduled to do in late May. My primary care doc thinks it might be related to IBS but my current gastro doc doesn't seem to be convinced. I'll keep you both posted as to what the new gastro doc says at the end of May in regards to diagnosis, further testing , etc, Hopefully, the three of us will get this figured out.

[Leslie44]

The tight uncomfortable feeling is constant for me except while asleep, but it makes it very difficult to get into a comfortable position at night.  Yesterday it seemed that this uncomfortableness was more moderate and is now not half as bad as it was in the beginning, but still there.  I also noticed that it feels like I have some muscle strain in my lower back right side, maybe due to the continuous clenching.  Hope we can all resolve this sooner than later! Regards

[JimK3145]

I also have experienced the muscle strain in my lower back on the right side. During the day, the stiffness is very low but when I wake up after sleeping, I often note that the stiffness is more pronounced. After I'm up for about an hour, the stiffness returns to the low level state. Like I mentioned in my earlier post, my primary care doc thinks it might be related to IBS, but I would think that if it was, the stiffness would come and go rather than be present all of the time. Lets keep our fingers crossed that one of us three gets some good explanation!

[mikcin]

I like you and Leslie44 went thru like symptoms for 5 years only after the GB removal.  It took this long for anything to surface.  I would definately go to another gastro who should consider an ERCP.  I just had to have 3 of them done to clear the CBD.  The first attempt to get the impacted stones failed, then on to another gastro who could get them, then had to go back 6 weeks later and have yet another to clear out sludge in the CBD and this sludge did not show up on the last CT scan either, but CBD was full of sludge.  Believe me I had been thru every test in the book before this was done.  Several hospitalizations and trips to the ER in pain.  Evidently this was built up for quite some time and my liver enzymes finally went very high when the stones were impacted.  So I would keep trying to get to the bottom of this before you have to go thru all the pain.  It really sounds like you are experiencing something disfunctioning in your GB.  I also had the knot just before the emergency GB removal.

[JimK3145]

Thanks for the info about the ERCP. I will definitely mention it to my new gastroenterologist. I do have one question for you. Did you ever have a HIDA scan with CCK stimulation done before your gallbladder was removed? This test will give an indication of the Gallbladder ejection fraction (GBEF) which tells how much bile the gallbladder ejects during digestion. Supposedly, a good gallbladder has a GBEF of about 70% and if this percentage falls below 40%, that this is an indication that the gallbladder is not functioning properly. The cause of this could be sludge (actually, tiny crystals) which from what I'm led to believe is not picked up on a sonigram. This sludge has the potential of eventually forming gallstones. I had a HIDA scan done but without the CCK stimulation and all the results said was that the gallbladder was functioning okay but it did indicate the percentage. I have seen a surgeon about having the gallbladder removed but he said that based on the tests that I had done, (abdominal sonigram, CT scan, and HIDA scan without stimulation) there is currently no surgical justification to have it removed, but he did mention that I might want to have the HIDA scan rerun but this time with the CCK stimulation. So when I see a new gastroenterologist at the end of May, I will mention the ERCP as well as the HIDA scan with CCK stimulation. Thanks again for the comments!

[mikcin]

No they did not perform the HIDA scan before the emergency GB removal and I believe if they had I would not have suffered all of this for 5 years, they only did a sonogram.  I am not a Dr by any means, but I just am stating what all unnecessary pain that I suffered.  A year and a half ago I was admitted thru the ER where they performed all the tests including the HIDA scan and all tests came back fine. My GB was removed 3 1/2 yrs prior.  They ended up diagnosing me with messentary lymphrodonitis, which is something that children get.  There were 6 docs standing around scratching their heads not know what to do.  None of them were gastros.  Some even mentioned IBS.  Let me tell you it took 5 years and 3 different gastros to get to the bottom of it.  Not to mention all the bills and trips to ER and pain meds.  I am hoping that this last ERCP cures everything.  I hope you also can get to the bottom of this to be pain free.  Let me know what you find out.

[Leslie44]

I had my ultrasounds and x-rays done today, hopefully will get the results soon.  After I had the x-ray the technologist was looking at the pictures and it appeared that there was some type of mass there but of course they never give you any info.  I'm a little worried.

[mikcin]

Did they say where the mass was?  Hopefully you will get the results soon.  I hope they get it all taken care of soon.  I understand the feelings and pain you are experiencing which only gets worse as time goes on.  When I had all of my tests the technologists never uttered a word.  I was always in the hospital at the time of the tests (because of my pain level) and they ususally told me the next day.  Are you supposed to call to get results?  They are usually available the next day.  We live in a very rural community which does not have any real specialists and it took forever to get an appointment with a good gastro.  I had to go to three different ones before I had the right procedure to get rid of the pain.  It is so awful that it takes so long, and sometimes they look at you like you have two heads and you are just making things up.  But do not give up, there is hope.  I know how frustrating and nerve racking it all is just have the fear of the unknown.  I have ended up losing about 40 pounds thru all of this, but now for the first time in 5 years (so far)  I am able to eat without bloating.  The best thing to do when you go for an appointment is write up a list of questions before you go because the docs usually rush thru, then you leave not knowing what you need to know.  Let me know what you find out.

[Leslie44]

Does anyone know if calcified gall stones show up on x-rays?

[mikcin]

Mine showed up on the CT, but did not know which kind they were, was just told they were stones.  They were impacted in my CBD.  They were 7mm, and 6mm.  During the ERCP they found more of them (smaller) that did not show up on the CT.  The second CT that I had after the ERCP did not show the sludge though, but was found during the third ERCP.  Did they find some on your CT and where are they?  

[Punkygirl]

7 mo. ago I experienced a sudden pain starting near my right ear, radiating thoughout my upper right quadrant.  It was about a 6-7 on a 10 point scale.  It lasted approx. 1 hour.  I wasn't sure if this was the "big one" or not.  However, I am a nurse, and I didn't think it was heart related.  No shortness of breath, sweating, pressure, etc.  I sat it out and it eventually left.  Since that time, and many, many tests later, I have this experience about 3-4 times a month, but sometimes more often.  The ear thing doesn't always occur.  My abdominal CT done yesterday shows some liver cysts, no apparent gall bladder problem, no pancreas problem, etc.  Lately, the pain comes dead center under my solar plexus, radiating up and through the back.  Oddly, I can drink something cold for some momentary partial relief.  I've seen the general doctor, the gastro, the heart specialist.  Had the Hyda scan with the CCK stim, ultrasounds of everything, upper endoscopy, chest and abd. CTs, heart stress test.  The only thing showing up are a few small liver cysts.  Any thoughts?  Can the gall bladder show up normal in all of these and still be the culprit?  It sure seems like the pain is right there.

[Leslie44]

I received my test results, Gallbladder, Spleen, Stomach are all clear. I was told I have a fatty liver and that they had discovered a leaking cyst on my right ovary, My blood and urine was tested and found that there was blood in the urine. I am now going to have a CT Scan on my kidney's to check for kidney stones and she put me on some antibiotics to be on the safe side.  It's strange but oddly enough the pain has become somewhat less severe but still uncomfortable.  The dr mentioned that the cyst on the ovary could cause deferred pain.  I also asked about what I had scene on the x-ray and she said that it was probably my liver as she only had the report from the radiologist. I guess I'll have to take a wait see attitude.  I mentioned before that I had these exact symptoms a couple of years ago, which did eventually go away.  I would like to get to the bottom of this as I do not look forward to future episodes. If I have been passing a kidney stone or the duct is blocked, you would think there should be more symptoms  than this knawwing pain that's driving me crazy.   Maybe your on to something Punkygirl! I agree, the pain is right there. It's possible that these other "problems"  I mentioned could be independent of each other. Hope you are all are feeling better.  I'm going to start trying to take better care of myself, I have been feeling quite stressed about this, and I have 3 little ones that depend on me.

[JimK3145]

Glad to read that your getting tested. Which tests were done for the gallbladder? Sonigram, HIDA scan with CCK stimulation? If you had the HIDA scan with the CCK stimulation, what was your gallbladder ejection fraction (GBEF). It's usually given in %. Based on what you were told, I'm assuming that they found no gallstones? For your upcoming CT scan, is it going to be conducted with contrast? I had a CT scan done in March but it was without contrast but it had only with the barium solution. My report from the CT scan said that some items found on the scan couldn't be evaluated due to lack of intravenous contrast. I might have to have another CT scan done but this time it will be with contrast so ask your doctor if it's going to be with contrast.

[revjr]

Leslie:

I wish you well with the CT kidney scan. I agree with your point - it seems unlikely it's a kidney stone since the symptoms would have intensified, i.e., the stone would either pass or require intervention. I mentioned this possibility in my own situation in my original post to Dr Pho - I had a stone in 06, not the colicky "take me to the ER and give me morphine" nightmare I've heard so much about, but a severe pain in my groin (sorry if that's too much information) for about a week. Anyway, I guess my family doctor doesn't consider it likely, either.

I had the HIDA scan today, which wasn't as unpleasant as I thought it would be. The symptoms actually disappeared for a couple days earlier this week but then returned in full force yesterday, so I guess the merry-go-round continues. I emailed a physician (his brother is my boss) and he suspects the HIDA results will be normal and that my symptoms are caused by GERD, so maybe the next step is an endoscopy. I'm glad I met my out-of-pocket because this is getting ridiculous.  I wouldn't be surprised to find I have GERD, but it's difficult for me to accept that GERD is causing these particular symptoms. They seem too unlike those so typically produced by GERD (as I understand it).

[Leslie44]

Thanks for the support.  I am lucky as far as medical attention and costs go as I live in Toronto and we have a funded Health Plan.  I'm assuming that you live in the US?
I'm not sure what type of scans etc are being done, as I'm leaving it up to my physician to make those decisions.  I am through guessing and stressing over what it might be. I spent quite a bit of time researching possibilities - gallbladder and stones have distinctive symptoms which I only have one (pain) .
I was speaking with my mother and she was telling me that when she was younger she had an acute appendicitis curiously enough the pain was on the left side and not on the right side???? If everything has been explored and cleared in the locations of the pain it might be possible that the pain that we are experiencing could be referred pain from another existing condition which in my case is a strong possibility due to their findings, otherwise " We just don't know" may suffice.  If my CT Scan is clear, then I guess I will, like you, have to exhaust every test known to mankind! or accept this alternative theory. Its unbelievable that with all the medical knowledge known, something that might be quite simple cannot be diagnosed, and on the flip side, this unknown pain could be far more complex involving multiple variables. Are you both dealing with a GP or do you have a specialist?  I hope that we will find our answers and get some relief.  PS have you had a colonoscopy?

[JimK3145]

I am currently seeing a Gastroenterologist but after 8 months of tests and visits, he told me that he was stumped as to what is going on, so he recommended that I go to an academic/teaching hospital to get another opinion. So I have an appointment with a new gastroenterologist on May 28. As to your other question, yes, I have had a colonoscopy done in 2005 and everything was okay. All clear, no polyps, etc. I was told to come back in 10 years. That seems a little too long to me so I might go back after 5 years for my next follow-up.

[mikcin]

I think you are doing the right thing at not giving up and I agree it gets rediculous with all the tests etc. not to mention all the money before you hit the max out of pocket.  I am finally starting to get back to normal after my 3rd ERCP and trying to rid my body of all the inflamation that is there due to all the drugs, dyes, and the 2 ERCPs.  It just took me 5 years to get to the bottom of all my digestive problems and I hope and pray they never come back.  I hope everyone else in these posts will find the end to all your pain, etc.  I do feel stress also does play a part, just worrying about the unknown.  I was ready to just accept the pain and try to live with it the rest of my life.  Until I found the right Dr.  Good Luck everybody.

[Kimi44]

Hi; hope you all are still here; just found this forum.  I have also had a dull, nagging pain under my right rib.  Had this last fall (07); then it went away for several months and now I've had it again for the past 5 weeks or so.  My father was diagnosed w/ lung cancer last August, and passed away in late April.  So needless to say, my stress and anxiety level has been at an all-time high.  But can that actually cause my condition?  I certainly think it can make "it" worse, but what is "it"?  Seems like many of us have this unsolvable mystery which is extremely frustrating.  Like some of you, the pain radiates to my back.  I've been going to a chiro for the past 3 weeks, which seems to alleviate it, but not make it better completely.  My tests so far include an ultrasound, chest x-ray, CT scan, and endoscopy.  The only thing "off" is my liver is "slightly enlarged."  I freaked at that, as I am extremely fearful of something being wrong with the liver.  My father died from liver cancer (which had spread from the lung).  I do drink (although I've cut back significantly since all this started), and I smoked when I was younger (have quit for 20+ years).  So what do you all think?

[JimK3145]

Hi Kimi44, Firstoff, do you still have your gallbladder? if you do then I'm assuming that the ultrasound did not show any gallstones? You might want to have a HIDA scan with CCK stimulation conducted. That test will give you an indication of how well your gall bladder is functioning (Gallbladder ejection fraction (GBEF)). Normally a good gallbladder has about a 70% GBEF while a GBEF under 40% means that it is not functioning properly. Are you seeing a gastroenterologist? He might want to have a blood sample taken which could be tested for liver enzymes and other blood properties which would give him an idea of how your liver is doing. Another test that a gastro doc might conduct would be a ERCP which is another type of endoscopy which could check for crystals (sludge) in the common bile duct (CBT). These crystals are a precursor to gallstones. If your gallbladder has been removed, there is about a 10% chance that over the years that gallstones could reform in the common bile duct and the ERCP could clear these.
I'm curious about the chiropractor. Did he say what he thought might be causing the pain? Maybe it's outside of the digestive system? Pinched nerve? I'm just pitching ideas here! That's all I can think of for now. Keep us posted! Good luck!