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Digestive Disorders / Gastroenterology Forum
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Avatar universal

Upper Right Quadrant Pain

I'm a 36 year old male who eats well, exercises regularly, and lives a reasonably healthy lifestyle.  Four month ago I started having pangs of pain in my right upper quadrant, just under my ribcage.  I couldn't indentify any obvious pattern (e.g. pain after eating a fatty meal), but I did notice I felt it often at night.  Concerned, I saw my primary care physician who suggested it might be a gall bladder problem.  I had a blood test done for liver function, it came back normal.  Next he referred me for an ultrasound.  The ultrasound found nothing unusual so my physician prescribed Nexium and said I was likely flirting with an ulcer or some persistant gastritis.  

Three months passed and I continued to have periodic pain, slowly becoming more persistant.  I checked in with my physician again and he set me up for an upper GI endoscopy.  Fortunately, that came back negative as well. I'm certainly happy that nothing was found, but am left with worsening (almost ever-present now) symptoms and no answers. The pain is typically under the lower right side of my ribcage, but sometimes radiates higher in my chest.  If I curl my fingers under my ribs it is usually quite tender, all the way down the length of my liver.

Two weeks ago my stools had an orange hue to them (I assume this is what is refered to as "clay colored"?).  This lasted for about ten days, but my stool color seems to have returned to normal.

My question is what conditions could be causing this pain if it didn't show up on an ultrasound or an upper GI endoscopy?  Since the ultrasound was performed very early on when I just started feeling the symptoms, is it possible that it could have missed something serious(i.e. small tumor that has since grown)?  I don't think my primary physician intends to do any more tests, so am wondering if I should insist on any others or whether I should see a specialist?  I'm trying not to be neurotic about it, but am growing increasingly concerned.  Any thoughts or advice would be much appreciated.  Thank you.
53 Responses
233190 tn?1278553401
MEDICAL PROFESSIONAL
The ultrasound and upper endoscopy would rule out many of the major GI diseases that can lead to these symptoms.  

Gallbladder-type pain can also be caused by a lower GB ejection fraction.  A HIDA scan with CCK stimulation can be considered if this is suspected.  Small studies suggest removing the gallbladder can be considered if this is the case.  

Clay colored stools can be indicative of bile duct obstruction.  An MRCP can be considered to evaluate for this.  

Cardiac disease can also atypically present this way.  A stress test can be considered if the GI evaluation continues the be non-revealing.

If all the testing continues to be negative, you can consider more benign causes, like musculoskeltal pain.

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.

Kevin, M.D.
kevinmd_b
Avatar universal
I had my gallbladder out almost a year ago now and when I had an ultrasound, DISIDA Scan (which showed sluggish gallbladder but no stones) panendoscopy and bloodwork nothing showed it to be gallbladder related, I was persistant with my GI doctor and was referred to a general surgeon who informed me that all sick gallbladders do not always have stones, when it was removed they found it was diseased and full of stones, so don't always trust the tests, read the symptoms and trust your instincts.
Avatar universal
I am a 31 year old white female.....as I stated previously, I had my gallbladder out almost a year ago and started having very simular symtoms 3 weeks ago, severe URQ Pain, nauseu anytime I eat, I have lost almost 10 pounds and feel miserable...my LFT's were a little elevated, AST 46,  luckily I work for a gastroenteroligist so he has been able to order different tests on me.  I had an ultrasound done which shows a dilated bile duct of 8mm so I had a MRCP for a more conclusive reading.  That showed nothing more than the same reading as the ultrasound so I went for an ERCP looking for an obstruction, possible gallstone post surgery, nothing still....went for a CT Scan which shows wall thickening of the duodenal sweep (not sure what would cause that)....do you have any other suggestions on what could be causing the URQ Pain and extreme nausea, tenderness just under the rib cage toward the esophagus area, it is affecting my quality of life, my daughter is upset because I am always laying down (it hurts worse to sit. I have an appointment with a surgeon on April 5th but really hate the idea of exploratory surgery. I just want somewhere to start so it can be resolved.
Avatar universal
I have the same situation as skyjumper but I used to drink heavily.  I'm obviously slightly paranoid about my liver so I've had every test on the area imaginable to no avail.  (blood work, ultra sound, endoscopy, etc.) I'm relcutant to see my internist again (although he's the most sought after statewide) because he keeps telling me I'm fine.  I feel like a hypochondriac but this pain is ALWAYS there.  What could this be?
Avatar universal
The gastroenteroligist I work for does a procedure called Endoscopic sphincterotomy which is suppose to help drain blocked bile ducts which can cause very simualar symptoms as the gallbladder attacks.  Not sure if this is what you were referring to but this is the technical name of the procedure, thought it may help when you are calling around.  Sphincterotomy means cutting of the sphincter or muscle that lies at the juncture of the intestine with both the bile and pancreatic ducts.
Avatar universal
Approx. 6 yrs ago I started having right upper quadrant pain similar to the pain I experienced prior to my gallbladder removal. My gastroendocronolgist was convist it was Sphincter of Oddi Dysfunction. All my LFPs were normal at the time, CCK Hida normal. He felt I needed an ERCP with spincter of Oddi manometry to test his theory. My insurance at the time would not cover the procedure since it would have been done out of state at the time.
Just yesterday I had my worst attack of six years. I believe my stomach virus and the tylenol/immodium I took added to the problem. When I went to the ER (now I live in a different state) I explained to them what the attack was that I get this on and off for six years. I even showed them my appeal letter written by my gastroendocronologist so they just did not think I was some nut off the street. The doctor on in the ER did not seem familiar with this problem. I tried to explain that my doctor in the past would treat me with Levisin, an antispasmatic and it would help to relax the sphincter. He would not listen all he gave me was phergan (even though I explained that I only vomit when in SEVERE PAIN for a sustained amount of time) and IV Tordal for pain. Even though it helped me to relax enough to get some rest. It did not take care of the spasm. I feel my right side is tight and I am fearful of another attack.
What dialogue could I have used so physcians understand my problem and can be better at treating the cause of my pain?
I am going to follow up with my primary physician and hopefully he can find me a endocronologist who is familiar with this disorder in my area.
Avatar universal
Conniebear thanks for the information. :)
Avatar universal
Hi. I also had pain similar to what you have experienced-under my ribcage. After some(alot) of testing, my doctors discovered a couple of hemangiomas on my liver. I have seen several doctors, some of which believe the pain is associated with the tumor and another that dismissed the pain as arthritis in my rib cage. So, you may look into these possibilities as to what is causing your symtoms.
Avatar universal
I ve been having this pain for a long time. Pills do not help. Somehow I found a solution... When pain is moderate   try to eat something sweet   chocalate can help.   Bread with butter helps.   If that doesnt help   try to vomit, when your stomachspasms when you try to trow up  it reduces the acute pain for some time. It helps me .. Weird solution  but it works.
Avatar universal
I have very similar symptoms. I first notice symptoms during a long distace car drive (Oct. 2005). It started with back pain directly behind the gallbladder, which felt like muscle strain. Within two weeks, I had a sunburn sensation below my right ribcage that has never ended. The sensation is always there with varying intensity. Two weeks after the sunburn sensation began (about 1 month after the original back pain), a physical, knotting pain in the gallbladder area of my abdomen. It felt as if I had a bloated organ, so I went to an ER. There, they did a complete blood count, urine test, multiple x-rays, and a CT scan only to say that nothing was wrong, other than a small amount of white blood cells in my urine (ie, kidney or bladder infection). Since then, the pain has intensified (knotting internal pain, sunburn sensation, and back pain) and I have went to a second ER. This time at the University of Tennessee Medical Center. They too, took a blood and urine sample and confirmed that all counts were within normal limits. This doctor did however palpate the abdomen and pressed on the exact spot that hurts internally, which caused elevated pain. He identified this spot as the area where the gallbladder and liver is located and said that I may have a growth/tumor on the gallbladder or possibly, gallstones. He suggested I go to a family practioner for ultrasound, since there was no emergency to be addressed at the ER.

I have not noticed an increase or decrease of intensity before or after eating. Also, when I sleep at night, it is more comfortable to sleep on the affected side.

Since Jan. 12, 2006, I have seen my family physician who sent me to a gastrointestinal doc for gallbladder testing and probably removal.  After a hidascan, colonoscopy, an endoscope, and many blood test, there are still no answers- everything was normal.  My GI specialist referred me back to the family doc for musculo-skeletal conditions.  Not sure what other test should be done, will take any recommendations and let you know what we find out!
Avatar universal
Had a severe pain in my upper right quadrant, with severe vomiting (continuous for 4 days) and low grade fever.  All blood work, gall bladder, hydra scan, colonoscopy, endoscopy, etc. came back normal, however, this is four years later and I still have a tenderness under my right ribcage.  I feel like there is an object there to this day.  When I first became ill, I almost felt like something was rotting inside of me.  Nothing ever showed up on any tests.  Still no explanation...
Avatar universal
I am reading alot of similarities in everyone's symptoms, and also noone getting any anwers.
I have also been experiencing Right Upper Quadrant Pain for almost a year now. I had my gallbladder taken out in 2002. The pain was so bad at one point, I went to my family doc, he ran a CT with contrast, multiple blood tests, and all came back fine. I missed 4 days of work and almost got fired. I am still in severe pain. He sent me to a GI doc. They did an endoscopy, and a colonoscopy. The only thing they found was mild colitis, an inflammation of the lining of the colon. The pain I have wakes me at night, causes intermittent fever, I am exhausted all the time, want to sleep 24/7, have times when I can't eat at all, am nauseated, and intermittent diarrhea and vomiting. I too have thought it may be Sphincter of Oddi Dysfuntion, but have read that not many docs pay much mind to this. I think too it may be adhesions since I have had 4 abdominal surgeries, 3 of which were open. I have had 5 back surgeries/procedures, and wonder if perhaps that could be playing a part in my symptoms.
I am seeing a surgeon today. I want him to go "look around" and hopefully put a face to this horrible nightmare of pain and disruption in my life and end it.
My heart goes out to everyone who suffers from pain that has no name or answer, and doctors who won't go the extra mile to find out what it is. They would much rather send you to a psychologist or anywhere than give why we hurt a name.

Good Luck To ALL and if anyone has an answer, write and tell us out here!
Mouse907
Avatar universal
So glad to know I am not alone!  I have had this pain for over a
year now. I have had 3 ct's, an ultrasound, a hide a scan, a ged,
a colonoscopy and every lab test known to man.  Nothing was found.  I try to tell the doctor where it is and that he can't feel where it is because it is behind my ribs on the right side.
I really feel like it is my liver.  When I lay down at night if I lay on my right side, I feel like I am laying on a lump!  I have even caught myself checking to make sure I didn't leave a sock in the sheets.  Life goes on..... Guess I will find out when the time comes and I have to go to the emergency room!
                                       Thanks, MARLENE JOWELL
Avatar universal
Greetings from Canada Everyone!

Well, I'd like to join the group of mysterious right upper quadrant pain that has the medical community stumped!
Anyone out there have answers yet?

I am a 37 year old female, who has had a gastric bypass (roux en y) stomach stapling, and removal of gallbladder in 2000. I had four years of great health! Then in the fall of 2004, I have acquired the same symptoms you all describe. It came on suddenly and hasn't left yet.

This nagging 'gallbladder attack' type pain, which never goes away, and is constant. Right under the ribcage, I just want to cut myself open and grab it out and get rid of it. Unfortunately we need our livers I am told. Damn....

Been through all the tests. In the beginning my Amaylase and Lipase were screwy, and then normal. No, I am never jaundiced, though I turn as white as computer paper, sometimes grey.
No fever, no white count, no nothing, HIDA shows some slowness, CAT shows dialation of bile duct, but it's running, xrays (I think I glow now) are good, MRI is good, ultrasound has nothing to say, and I am frankly being told it might be a psych problem.

I am so sick of hearing that. I have lost about 60 lbs, they say there is no cancer, thank god. I live on narcotics just to keep up with the kids (I have 4 under age 12). I throw up whether I take the drugs or not. Drinking liquid is okay sometimes, but anything else just comes back up, I am able to keep a very small part down as I am still having bowel movements. Not that I enjoy looking at the toilet, but I have seen the gamet of colours from white stool to orange, to green and sometimes purple, plus the ususal. This will be two years of illness come October of 2006.

Here's the kicker. They put in a percutaneous transempatic drainage tube which goes through the skin, through the liver, through the common bile duct and mine goes to the bowel, as my stomach pouch is connected differently due to the gastric bypass. I had a sphincterotomy done, but it didn't help with anything. The drain tube was in from Dec 2005 to May 26 2006, with tube changes as required. When the tube was in and draining properly and not blocked with sludge, etc. There was no pain - other than in my tube site!
When the tube became blocked, the old pain returned. So, we had to keep the tube clear. Which can be a pain in the *** at times.
Laying on the opposite side works best for me. Sitting just aggravates the problem. Sometimes the tube change can be a little uncomfortable if it ends up sitting on a rib.

Still waiting to figure out what is wrong. One surgeon says I need a stent put in, the other says a pain management clinic is what I need.  Just wanted to share my story and glad to hear that I'm really not alone with this....

Well, I'll keep you posted and glad to have found you folks.
Take care
(warbirdz - the old warplanes are cool)

Avatar universal
Greetings from Canada as well!  

I used to feel generalized pain in the upper abdomin but now it is localized in the upper left section just below and underneath the ribcage.  I have been through the same test as everyone else!  I have had a barium enema, colonoscopy, ultrasound, you name it.  Everytime I go to my doctor with the problem, I am told that I have spastic colon or "Irritable Bowel Syndrome" and they say that they cannot see anything but they must be able to see something because it feels as if there is an enlarged organ pressing against the ribcage and I feel a constant dull pain in the upper left area.  When I am under stress it gets much worse and more sharp but it shouldn't be aching consistently all of the time.  I share that feeling of a kind of internal sunburn as well!  This is so frustrating.  I am 23 years old and I've had these stomach problems since I was 15.  You'd think by now I'd know what's going on but I have no idea and I'm not sure I trust my doctor's diagnosis.  I'm worried that it may be a tumor forming on the pancreas or where the large intestine bends to descend on the left side of the body.  Does anyone have any ideas as to what I could suggest to my doctor or what I could research myself??  I'm really at the end of my rope here and getting quite fed up with NOT KNOWING ANYTHING.  

Please help!
Avatar universal
I, too, have been dealing with similar symptoms (weight loss, URQ pain, feeling of fullness) for about 7 years.  I went through the list of tests - CT's, ultrasounds, colonoscopy, laporoscopy, digestive tests - all with no solution.  The topper was when I asked to review my records, the gastro M.D. had the line written "possible psychological component"!  I said to hell with it and stopped pursuing it resiging to the fact that the pain will just be there forever.  Well, I had a CT scan for an unrealated issue in which I received a letter stating that I have a hepatic adenoma (benign tumor on my liver).  This apparently is not terribly uncommon for women who have been on birth control for years (I'm 35 and was on them for 10 years, stopping about 5 years ago).  Looking at web info, this condition explains all of my symptoms.  I am going to see my regular doc. on Monday to discuss possible treatment.  At least this gives me confirmation that I am not crazy.  I'll keep you updated.
Avatar universal
HI

I HAD MY GALLBADDER OUT IN 2002. I WAS DIAGNOSIS WITH LIVER HEMANGIOMA IN 1997 OR 1998. LAST YEAR IT WAS ABOUT 8CM LONG. MY DOCTOR THINK THAT'S WHY I AM IN PAIN ALOT. SHE SUGGEST I SHOULD REMOVE MY RIGHT LOBE. I SUGGEST HOW ABOUT RADIO FREQUET ALBATION. SHE GOT BACK SHE SAID THAT WILL BE GOOD IDEA. SO I DID RFA. GUESS WHAT MY PAIN IS BACK!!! SO I WAS DOING RESEARCH COULD BE I MIGHT HAVE SPHINCTER ODDI DYSFUNCTION. IT FEELS LIKE I HAVING GALLBADDER ATTACK OR TUMOR IS STILL CAUSING PAIN. I FEEL LIKING SCREAMING BECAUSE I AM DEALING WITH THIS CRAMP AGAIN. I DO APPT. WITH MY DOCTOR WHO DID THE RFA. IF ANYBODY HAVE ANY IN SIGHT PLEASE GIVE ME SOME ADVICE. THANKS
Avatar universal
Pain under right ribs, constant dull ache, sometimes severe. I am 33 yrs old, was 330 lbs when this began November of 2005. I was having hip and lower back aches. I had been constipated and I gave myself an enema. I woke up a couple hours later and passed out on the bathroom floor, woke up and had diarreah like never before. Haven't been the same since.
  All tests have been normal, tried the naturopath route and did the liver flush, no help. Had my gallbladder out about three months ago, I knew when I woke up from surgery that the pain was still gonna be there. I lost 70 lbs over the first few months of this and have been at about 260 lbs since then. Sometimes I start to feel better but never completely. I just bought a house and have been doing a lot of yardwork and it helps keep my mind off of the pain but it never completely goes away. I had a hard time with the weedeater the other day and all of that pulling the starter cord has seemed to make this condition much worse. I have the bloated organ feeling and also pain in my right side of neck.
  What could it be that we all have in common that may be a factor? I spent a lot of time on the road before this, ate a lot of fast food, spent time on sailboats in south Florida, lot of stress on my job (only stress now comes from this pain!). I think my digestive system is working too slow now. I have to eat very small portions. If I eat too much over a couple of days it really sets my back and I have to struggle through this pain. Being physically active seems to help although it is hard to do when I am hurting. It is a scary, lonely feeling when noone understands your pain and tests show nothing. We have to come together and share our underlying factors which may contribute to this condition. We should start our own group and try to work this out together. My email is ***@**** email me and we can keep each other in the know with new info. Good luck and God bless to us all.
Avatar universal
If you have pain under your right ribs and all tests come back normal then you are not alone!

I am putting together a support group. If you want to call me I will take your name and number and your conditions. I will let you know if someone else with the same symptoms finds any answers. You can email me at ***@**** or call me, Ricky, at 601-657-4587. We can get through this if we work together.
Avatar universal
After eating some breadsticks and pasta from the Olive Garden, I had sharp pains all around my abdomen.  The next three days I felt a sharp pain that came and went under my right ribcage.  I had an ultrasound of the gallbladder, which indicated there was some "inflammation" and "sludge" that was interfering with normal function.  Further testing included a gallbladder scan (not sure what the name was, it was a 1 1/2 hr procedure with contrast solution) and a CT scan of the abdomen.  Both came up negative.  

This whole time, I was advised to follow a low fat, bland diet.  I continued on this diet and the pain lessened considerably.  When the final test came back negative, my specialist suggested going back to a normal diet.  This was ok for about a week, but as soon as I had a greasy meal again (crazy bread from Little Caesar's), the exact same pain was back for another three days.

Today, I had a colonoscopy and a gastroenteroscopy as well as a blood test for the liver function.  The colon was fine, but my stomach is showing some inflammation.  A biopsy sample was sent to a lab to test for bacterial infection as well as cancer (there were some polyps, but they appear benign).  

At any rate, the pain is definitely where my gallbladder and liver are located, so I am not sure if these latest tests will be of any real help.  It
Avatar universal
He guys I really hope you all find out exactly what is wrong because I have been having alot of this pain now for 9 Months  My pain consist of my upper back right between the two shoulder blades,it is mostly on my right side of the upper part of my shoulder blade. I have alot of headaches, pains in my arms, tenderness in the feet, right up the back of my head, sometimes nunbness in the fingers,  experiencing alot of pain, feels like there is something in under my right rib cage.
when I have pain I am not sick. When the pain goes I feel stomache sick like I want to throw up, but I don't. It wears off for a little bit, returns again. Sometimes it feels like it goes to sleep. I get really sick at times it feels like I am about to faint, I also have discoloration on my face. Between the two eyes on my forehead is white , down around my nose goes white and also around my chin. I have nowhere else to turn to.
I am getting depressed and anxiety is setting in. I have been going to the doctors, just like everyone else having all these test done, nothing is wrong they are saying. Had a Hysterectomy, Gallbladder removal. I really haven't got a whole lot left to remove. I have been going to the Ciropractor, thought it was helping until it returned again. Honestly nobody knows what you are going through, they all look at you as if you are going made or something, or they say it is just your mind. I hate it when people say that. You know your own body when something is wrong. We are not stupid!!!!! Hopefully there is someone out there that can help all of us.
Good wealth, health and happiness!!!
Avatar universal
I have to stick my two cents worth in. I have had alien pain prblem under my right lower rib cage for at least 8 or nine years. I first went to gastro doc. Had rib cage pain, stomach pain and dyspepsia at that time. He did blood test, endoscope, colonoscopy, and ultrasound of all organs in stomach. Everything looked good. Gave me pills for dyspepsia. Returned several times over next couple of years with same type of problems. He said I had something going on, but it wasn't gastro. Went to a Neurosurgeon a couple of years later for an MRI on my T spine. He said everything was normal. But, I have no doubt in my mind, after looking for answers everwhere that I have a problem in the T spine between the 6 and 10 vertebre. I have a set of exercises for mid thoacic dysfunction I do and they help. I originally hurt it by swinging a softball bat. I didn't have back pain in the begining. It affected the intercostal nerves which wrap around the rib cage. I still feel it and live with it every day. I still have rib cage pain, and pain fron the area in my back [right side of spine just under my shoulder blades]. It is not debilitating and at least in my mind I know what it is. I have other problems with herniated discs in lower back that I am tending to. I'm sure it is not the answer for most, but if it is the answer for 1 person, I hope it helps. I have been through so many tests and doctor visits over the years, and no one has ever diagnosed my problem. It used to drive me nuts, thinking of all the possible things that could be wrong. Now, I accept the dull ache around my rib cage and go on with life. My dyspepsia has gone away years ago. That was the toughest part. That came with the original trauma. Now I have a dull ache that wraps around my right lower rib cage, and dull pains in back and front of mid body. Hope this helps somebody.
Avatar universal
I started coughing up yellow bile when I got pregnant back in October 2005. I cough it up every single morning. This has continued even after giving birth. I've have test run (GI Tract x-ray and Hydrascan) and everything seems clear and clean. I had my gall bladder taken out 5 months ago (although this doesn't seem to be an indication of the problem). Does anyone have a similar experience? What is causing this? How can I stop it? What other tests need to be run? Please help!
Avatar universal
I couldn' help but join in.  I have additional symptoms to add too.  A couple a months after having my baby in 2004  I had gotten sick.  The Drs. assumed it was my usual sinus infection.  After lingering on for 3 months they treated me for viral bronchitas.  Shortly after that my neck and head lymph nodes would swell up and I would attempt to get sick (sore throat) but never fully.  After the third time (each getting a little worse)of this and worried about cancer I got check.  The Dr. ruled out my seasonal allergies took blood work and said I was normal.  A month later I was sick again, could not get out of bed or open my eyes(sore throat and swollen again).  A couple of days later found out my co-worker had strep.  Went to Dr. same day.  Ruled out strep, suspected mono.  One week later got tonsilitis and was issued prednisone. Got results (by the way my earlier blood test showed some high monocytes) showed that I had tested positive for the Epstein Barrs Virus but in the old age stage of it(mono test).  Had to go back a month later for what seemed like bronchites or sinus issue, another Dr. in firm said that my information showed that I could have had the mono several years ago.  I switched DRS.  At this time I could only stay healthy for one week out of every month.  Went to new Dr. said I looked like I had mono before and then had recurring mono and then the tonsilites.  After a month ended up with the upper abdominal pain in right quadrant under front rib cage and around back.  Also had hard time breathing.  Dr. diagnosed Pleaursys.  Took motrin helped some.  Also gave medicine for allergies for leaukotrines (? if propper term) instead of antihistamines, helped a lot.   Went back to Dr. after several months because, pleaurysis never would get better.  In addition, during pregnancy and all the way to this point, had stomach (contraction like pain).  After preg. had bloating and a lot of weight loss and back and forth weight gain with no effort.  My stomach pain would get so bad it caused nausea, hot flashes and almost passing out symptoms.  This got worse with the pleaursys but the pain stopped being in my front and back of the rib and spine to only the back and spine.  The Dr. ruled it as stress and put me on lexapro.  Through this whole year I have had terrible exhaustion but it got worse with the lexapro and I also gained a concentration problem.  My stomach pain is better and I lost more weight.  However, my back pain which seems to be intermittant now will not go away and seems to be worsening again.  My gynocologyst says my immune is down and that antioxidants should help.  I have been on them for four days now and not even the slightest changes.  I now have lower back pain to boot.  Gyn also said that the first tests that should have been taken were a TB and a thyroid.  So meeting with him after he has pulled my blood work from my other DR to see it that was included with my tests.  By the way may Gen Prac did an x-ray which came out clear.  I am still waiting for an answer.  I think my GP thinks its in my head.
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