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Suggest Treatment For Severe Right Upper Quadrant Pain And Diarrhea
Question: I am having a gi Endoscopy at the end of this week. I have been having severe right upper quadrant pain and diarrhea for 3 months. The pain goes through to my back. I can't eat anything without increased pain. Even swallowing hurts. I'm in pain continuously even without eating or drinking. Tylenol with codeine does little to help with the pain. Could it be possible to have a ulcer in the duodenum penetrating into the pancreas? This pain feels like acid in dripping on a open sore even breathing hurts. The pain is sharp and stabbing at times. I have a history of gastritis, esophagitis and gastroparesis but I've never had pain this severe. I also have severe burning pain in my throat. I am not vomiting blood or have bloody stools. No fever. Abdominal ultrasound was negative. Stool sample negative. Blood work normal. Labs were done 3weeks ago. Ultrasound 2 weeks ago. I have to wait awhile to see a gi doctor. Symptoms have worsened since last week when I saw him. I have 3 more days before scope is done. What does abdominal pain radiating to the back mean if it's a ulcer. This is not gallbladder pain because I already had it out. I'm concerned about the severity of the pain. What are the risks, complications?
Brief Answer:
Stomach ulcer on posterior wall or pancreatitis .
Detailed Answer:
Hi.
Thanks for your queries and an elucidate history.
To Recapitulate: Female /58 - upper Q pain and diarrhea - 3 months - goes thr' to back - eating increases pain - continuous / ''sharp and stabbing sometimes'' - like acid dripping on an open sore - even breathing hurts - gastritis, esophagitis and gastroparesis - burning in throat - gall bladder removed - Ultrasound negative as are the blood tests, stool normal - no history of vomiting blood, no bloody stools, no fever - planned Upper Gi Endoscope next week -worried about duodenal ulcer / referred to back / severity of pain - wants to know the risks and complications...
Also read your Medical history and medications and known Allergies.
The commonest causes of pain in upper abdomen causing pain in the back are :
-Gastric Ulcer on the posterior (back part) wall of the stomach
-Pancreatitis
-Other causes can be aneurysm of the abdominal aorta
I would advise the following in such a case:
-Ultrasonography already done showing that there may not be stones in the bile ducts (gall bladder already removed), Liver and pancreas may be normal and has to be confirmed by a CT scan of the abdomen.
-Tests of blood already done / stool samples are negative/ Blood for thyroid function tests
-Upper GI Endoscopy planned ..
- Barium swallow, meal and follow through for esophagus, stomach, duodenum and the small intestines, although old-fashioned do sometimes give nice corroborative evidence.
- Colonoscopy: to decide the cause of diarrhea, to see condition of the colon,
These investigations can help us to get a confirmed diagnosis and gives a plan for further management.
Medicines :
PPI like Pantoprazole
Antacid gel
Probiotic
Soft bland diet - small and frequent meals.
Role of anxiety, stress and depression are very well known to give or enhance the problems.
The severity and character of the pains may indicate the Neurological factor , hence an MRI of the whole spine should be done.
Risks and complications: I was just wondering which risks and complications would you like to know. Please specify.
I hope this answer helps you, please feel free to discuss more if you need to or if you feel that there is a gap-of-communication; we can certainly discuss further.
Stomach ulcer on posterior wall or pancreatitis .
Detailed Answer:
Hi.
Thanks for your queries and an elucidate history.
To Recapitulate: Female /58 - upper Q pain and diarrhea - 3 months - goes thr' to back - eating increases pain - continuous / ''sharp and stabbing sometimes'' - like acid dripping on an open sore - even breathing hurts - gastritis, esophagitis and gastroparesis - burning in throat - gall bladder removed - Ultrasound negative as are the blood tests, stool normal - no history of vomiting blood, no bloody stools, no fever - planned Upper Gi Endoscope next week -worried about duodenal ulcer / referred to back / severity of pain - wants to know the risks and complications...
Also read your Medical history and medications and known Allergies.
The commonest causes of pain in upper abdomen causing pain in the back are :
-Gastric Ulcer on the posterior (back part) wall of the stomach
-Pancreatitis
-Other causes can be aneurysm of the abdominal aorta
I would advise the following in such a case:
-Ultrasonography already done showing that there may not be stones in the bile ducts (gall bladder already removed), Liver and pancreas may be normal and has to be confirmed by a CT scan of the abdomen.
-Tests of blood already done / stool samples are negative/ Blood for thyroid function tests
-Upper GI Endoscopy planned ..
- Barium swallow, meal and follow through for esophagus, stomach, duodenum and the small intestines, although old-fashioned do sometimes give nice corroborative evidence.
- Colonoscopy: to decide the cause of diarrhea, to see condition of the colon,
These investigations can help us to get a confirmed diagnosis and gives a plan for further management.
Medicines :
PPI like Pantoprazole
Antacid gel
Probiotic
Soft bland diet - small and frequent meals.
Role of anxiety, stress and depression are very well known to give or enhance the problems.
The severity and character of the pains may indicate the Neurological factor , hence an MRI of the whole spine should be done.
Risks and complications: I was just wondering which risks and complications would you like to know. Please specify.
I hope this answer helps you, please feel free to discuss more if you need to or if you feel that there is a gap-of-communication; we can certainly discuss further.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Posterior wall gastric wall ulcer seems more likely due to the burning acidity pain and pain when swallowing and eating. If a gastric ulcer penetrates into the pancreas will your blood work show elevated enzymes if it is a sealed Off penetration? Basically the pancreas is the base of the ulcer, seems to me that would be pretty painful. Can a abdominal ultrasound show a penetrating ulcer? can this cause a hemorrhage? What would be the treatment? Surgery?
Brief Answer:
Reduce stress and anxiety.
Detailed Answer:
Thanks for your feedback.
Before I answer your queries I would like to sort of assure you that a penetrating ulcer of the posterior gastric wall into the pancreas would not allow the patient to move or sit and type on computer. This is a very very rare form of a problem we are thinking of.
Yes I can understand that you are undergoing severe pains and Upper GI Endoscopy which you are scheduled for, can get you the perfect diagnosis.
If the posterior wall gastric ulcer penetrates the pancreas, you will have to get admitted in a serious condition as this will eventually lead to acute pancreatitis which is a very severe condition; blood work will show elevated enzymes.
Only very high resolution ultrasound (US) may show ulcer if the Radiologist can take time and the ulcer is big enough. Yes, Endoscopic Ultrasonography can show pancreas very well. Discuss about this at your center if they have Endo US.
Abdominal US may not show penetrating ulcer.
Hemorrhage may occur only if the blood vessels get eroded.
Oh, let us wait for the Ultrasound report and then only a diagnosis and further management discussion is legible.
I am saying this as I want you to keep calm, reduce your anxiety and stress to most minimum level, as this is the first treatment of gastric ulcer. You may please ash your Doctor to give you one medicines to control this as this will help you directly to reduce your problems.
Reduce stress and anxiety.
Detailed Answer:
Thanks for your feedback.
Before I answer your queries I would like to sort of assure you that a penetrating ulcer of the posterior gastric wall into the pancreas would not allow the patient to move or sit and type on computer. This is a very very rare form of a problem we are thinking of.
Yes I can understand that you are undergoing severe pains and Upper GI Endoscopy which you are scheduled for, can get you the perfect diagnosis.
If the posterior wall gastric ulcer penetrates the pancreas, you will have to get admitted in a serious condition as this will eventually lead to acute pancreatitis which is a very severe condition; blood work will show elevated enzymes.
Only very high resolution ultrasound (US) may show ulcer if the Radiologist can take time and the ulcer is big enough. Yes, Endoscopic Ultrasonography can show pancreas very well. Discuss about this at your center if they have Endo US.
Abdominal US may not show penetrating ulcer.
Hemorrhage may occur only if the blood vessels get eroded.
Oh, let us wait for the Ultrasound report and then only a diagnosis and further management discussion is legible.
I am saying this as I want you to keep calm, reduce your anxiety and stress to most minimum level, as this is the first treatment of gastric ulcer. You may please ash your Doctor to give you one medicines to control this as this will help you directly to reduce your problems.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I had a upper endoscopy today. Multiple ulcers were found. One in the cardia, fundus and duodenum. Gastritis and duodentitis also. Cardia ulcer was deep and was bleeding but controlled with endoscope treatment. I'm Still scheduled for a gastric empting study and a repeat stool test for the diarrhea. I can't understand how this could happen when I was already on zegrid twice a day. He changed meds to protonix and carafate suspension. I guess this explains some of the pain. Repeat egd in 12 weeks. How often does one have multiple ulcers at once? If one ppi failed to work what are the chances another will work? Could the Gastropareis be the reason my stomach fails to heal itself?
Brief Answer:
Pain due to ulcer, add-on treatment will help you more
Detailed Answer:
Thanks for your feedback.
Read the report of multiple ulcers as you have noted.
It is difficult to explain why do you get so many changes in spite of Zegrid twice a day.
Yes, the multiplicity of the ulcers with evidence of gastritis and duodenitis was the reason for the pains you have.
This is rare to have multiple ulcers at once.
This is the question of doubt about how effective would be another PPI (Protonix- Pantoprazole) be effective if the first failed.
> For how long were you taking Zegrid ? And were you using it off and on or absolutely on regular basis?
Gastroparesis alone may not be the reason.
Stress, anxiety, eating habits, loss of integrity of the gastric and duodenal mucosa due to known or unknown reasons too add on the problems.
I would advise you the following- this is in my opinion as per the experience and knowing the patho-physiology of your problems.
-Add Ranitidine 150 mg at 12 hourly interval as this controls the acidity in a different way.
-Antacid at 3 hourly intervals, particularly when you are on empty stomach (Carafate)
-Vitamin A capsules one twice daily for 3 days and Calcirol (Vitamin D 3) one XXXXXXX every week for 3 weeks. These help to increase the integrity of the mucosal lining so much important for early healing.
-Control of anxiety and stress- very important by natural ways or by prescription based medication under your Doctor's guidance.
-Soft bland diet and small frequent meals.
-avoid late nights, need serene sleep of 6 to 8 hours.
I hope this helps you, please feel free to ask for more if you need to or if you feel there is a gap-of-communication.
Pain due to ulcer, add-on treatment will help you more
Detailed Answer:
Thanks for your feedback.
Read the report of multiple ulcers as you have noted.
It is difficult to explain why do you get so many changes in spite of Zegrid twice a day.
Yes, the multiplicity of the ulcers with evidence of gastritis and duodenitis was the reason for the pains you have.
This is rare to have multiple ulcers at once.
This is the question of doubt about how effective would be another PPI (Protonix- Pantoprazole) be effective if the first failed.
> For how long were you taking Zegrid ? And were you using it off and on or absolutely on regular basis?
Gastroparesis alone may not be the reason.
Stress, anxiety, eating habits, loss of integrity of the gastric and duodenal mucosa due to known or unknown reasons too add on the problems.
I would advise you the following- this is in my opinion as per the experience and knowing the patho-physiology of your problems.
-Add Ranitidine 150 mg at 12 hourly interval as this controls the acidity in a different way.
-Antacid at 3 hourly intervals, particularly when you are on empty stomach (Carafate)
-Vitamin A capsules one twice daily for 3 days and Calcirol (Vitamin D 3) one XXXXXXX every week for 3 weeks. These help to increase the integrity of the mucosal lining so much important for early healing.
-Control of anxiety and stress- very important by natural ways or by prescription based medication under your Doctor's guidance.
-Soft bland diet and small frequent meals.
-avoid late nights, need serene sleep of 6 to 8 hours.
I hope this helps you, please feel free to ask for more if you need to or if you feel there is a gap-of-communication.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you doctor chandrakant for your helpful suggestions. I think they will be very helpful in addition to the treatment my doctor has already prescribed. In answer to your question I have been taking PPIs for about 25 years since I have been suffering from gerd and gastritis since my 20's. I was taking the zegrid daily, religiously because l'd have stomach pain without taking them. In fact I was even taking more than the recommended dose. I eat a pretty healthy diet overall but do indulge in sweets and some wine a couple times a month. I'd been cutting thoughts down recently because I noticed they were causing problems. I can only eat about half a meal anyway before I'm full. I wasn't eating soft frequent meals though. I was eating even when I was in pain. I hadn't seen my gastroenterologist in years because there wasn't anything new that could be done. I let the symptoms go for months because I thought it was just gerd or gastritis which I had before anyway.
As far as stress I recently herniated 3 discs in my back. I have been in a lot of pain with that. I've been getting frequent epidural steroid injections that have only given me short term relief. I've been dealing with three chronic pain conditions, neuropathy, back pain and ulcer pain which have taken a tole on me. I avoided nsaids but I've been taking Tylenol with codeine which was prescribed for my back once or twice a day and flexril a couple times a week.
I think I will have to be much more careful about my diet, keep follow up appointments with my gi and trying to reduce stress. Rest does help. I slept for 12 hours yesterday and feel better. Just knowing what has been causing the problems is a great relief.
I've noticed some difficulty swallowing with this. My throat feels tight as food moves through. Hot and cold makes it hurt more so I am only eating cool or warm things. I tried to eat some white rice yesterday and that hurt so today I've only had fluids. Hopefully this will improve as things heal.
I glad you responded to my questions as I wouldn't have thought of the additional things you added. XXXXXXX XXXXXX
As far as stress I recently herniated 3 discs in my back. I have been in a lot of pain with that. I've been getting frequent epidural steroid injections that have only given me short term relief. I've been dealing with three chronic pain conditions, neuropathy, back pain and ulcer pain which have taken a tole on me. I avoided nsaids but I've been taking Tylenol with codeine which was prescribed for my back once or twice a day and flexril a couple times a week.
I think I will have to be much more careful about my diet, keep follow up appointments with my gi and trying to reduce stress. Rest does help. I slept for 12 hours yesterday and feel better. Just knowing what has been causing the problems is a great relief.
I've noticed some difficulty swallowing with this. My throat feels tight as food moves through. Hot and cold makes it hurt more so I am only eating cool or warm things. I tried to eat some white rice yesterday and that hurt so today I've only had fluids. Hopefully this will improve as things heal.
I glad you responded to my questions as I wouldn't have thought of the additional things you added. XXXXXXX XXXXXX
Brief Answer:
Control of stress and / or anxiety is the key - no steroids in any form
Detailed Answer:
Thanks for your appreciation and feedback, Madam XXXXXXX XXXXXX.
It is really doubtful whether new PPI will work for you as you have been taking Zegrid for such a long. I think Ranitidine 150 taken twice daily at 12 hourly interval should help you.
Another important point is Steroid injections, since they are not helping, please avoid them altogether, they are known to give multiple stomach ulcers, and / or cause delay in healing. No steroids in any form.
Diet: Simple fundamental is the observation by you, what suits you and what does not. No to take anything which causes or instigated the problem. I think you should avoid wine and all such things which you must have noticed to increase your problem.
Control of the stress and anxiety is the key to success for all the pains you have - of ulcers, neuropathy and back pain.
Yoga, meditation, alternative therapy like acupressure helps a lot.
Break the routine of the life and avoid all such situations / thoughts / conditions which increase stress and anxiety. (the life is full of it , I know).
Please follow the additional treatment schedule as already explained and I am sure you will be fine very soon.
Vitamins as said and addition of any multivitamin in the form of antioxidants should help healing faster and good for life at 58.
Wishing you an early and complete recovery and healthy happy life.
Please feel free to discuss anything you would like to, I would really be very happy to assist you more.
Control of stress and / or anxiety is the key - no steroids in any form
Detailed Answer:
Thanks for your appreciation and feedback, Madam XXXXXXX XXXXXX.
It is really doubtful whether new PPI will work for you as you have been taking Zegrid for such a long. I think Ranitidine 150 taken twice daily at 12 hourly interval should help you.
Another important point is Steroid injections, since they are not helping, please avoid them altogether, they are known to give multiple stomach ulcers, and / or cause delay in healing. No steroids in any form.
Diet: Simple fundamental is the observation by you, what suits you and what does not. No to take anything which causes or instigated the problem. I think you should avoid wine and all such things which you must have noticed to increase your problem.
Control of the stress and anxiety is the key to success for all the pains you have - of ulcers, neuropathy and back pain.
Yoga, meditation, alternative therapy like acupressure helps a lot.
Break the routine of the life and avoid all such situations / thoughts / conditions which increase stress and anxiety. (the life is full of it , I know).
Please follow the additional treatment schedule as already explained and I am sure you will be fine very soon.
Vitamins as said and addition of any multivitamin in the form of antioxidants should help healing faster and good for life at 58.
Wishing you an early and complete recovery and healthy happy life.
Please feel free to discuss anything you would like to, I would really be very happy to assist you more.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thanks again for your helpful advice. That was my concern about PPI's. I think I 've taken them for so long they are no longer working for me. I had a concern about the steroids having a systemic effect long ago and I asked my pain specialist about it. He assured me they only have a local effect. It does make sense though that they would enter your blood stream at some point. As I trace back my worsening symptoms it does seems to be a link to when I started getting injections three years ago. They can also be linked with a decreased ability to handle stress too, right? So it's best to avoid them.
I have an appointment next week with my pain doctor and he was thinking of going the route of radio frequency ablation and since that doesn't involve steroids it may be a better option along with the other suggestions you gave me (yoga etc).
I'm so glad you gave me the info on the steroids as I might have continued with them. That's something my own doctors didn't pick up on.
Thanks again my starting to better already!
I have an appointment next week with my pain doctor and he was thinking of going the route of radio frequency ablation and since that doesn't involve steroids it may be a better option along with the other suggestions you gave me (yoga etc).
I'm so glad you gave me the info on the steroids as I might have continued with them. That's something my own doctors didn't pick up on.
Thanks again my starting to better already!
Brief Answer:
Ranitidine - No steroids / no stress
Detailed Answer:
Thanks for your appreciation again and insight you have got.
Take Ranitidine and this will help you.
No steroids in any form till your ulcers are declared to be completely healed.
Yes, it has this effect of decreased ability to handle stress too.
Let us see what does your Pain-Doctor has in mind other than Radio frequency ablation. If possible try to avoid anything new till your ulcers heal completely. In fact avoid everything possible in the world that can increase your stress and / anxiety. Just relax and let the major problem be tacked first.
May I please know the exact location of the herniated discs ? MRI report or so ? Its relation to the pains you have ? Does the pains correlated with the level of the discs that have prolapsed ?
Ranitidine - No steroids / no stress
Detailed Answer:
Thanks for your appreciation again and insight you have got.
Take Ranitidine and this will help you.
No steroids in any form till your ulcers are declared to be completely healed.
Yes, it has this effect of decreased ability to handle stress too.
Let us see what does your Pain-Doctor has in mind other than Radio frequency ablation. If possible try to avoid anything new till your ulcers heal completely. In fact avoid everything possible in the world that can increase your stress and / anxiety. Just relax and let the major problem be tacked first.
May I please know the exact location of the herniated discs ? MRI report or so ? Its relation to the pains you have ? Does the pains correlated with the level of the discs that have prolapsed ?
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Reports attached
Brief Answer:
Thanks for the report.
Detailed Answer:
Thanks for the report. Read and understood it. It was done for the worsening low back pain and left leg radiculopathy- Read the reports and yes, you may be needing a treatment.
Were you tried with Gabapentin or Amitryptilin for pain ?
They are stomach friendly too. Gabapentin SR can be taken once in one to two days so have a good control over the pain and hence discuss this with your Doctor/s
Say NO to the steroids in any form.
I hope you are better than before.
Thanks for the report.
Detailed Answer:
Thanks for the report. Read and understood it. It was done for the worsening low back pain and left leg radiculopathy- Read the reports and yes, you may be needing a treatment.
Were you tried with Gabapentin or Amitryptilin for pain ?
They are stomach friendly too. Gabapentin SR can be taken once in one to two days so have a good control over the pain and hence discuss this with your Doctor/s
Say NO to the steroids in any form.
I hope you are better than before.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I'm on lyrica 50mg three times a day. I've been on gabapentin before but had to take a high dose in order for it to work after taking it for many years. I've been on aminotryptiline too but had to stop due to side effects. In fact that was the first drug I was on. I have not heard of the sr form. I'll have to ask my doctor about it. The lyrica is pretty expensive. I wonder if gabapentin sr works just as well and is less expensive. I'm on Medicare and I usually run out of the 2500 allowable drug costs before the end of the year. I'm not eligible for any further help with medications. I pay 45.00 per specialist visit so this month alone gi Dr - 45.00 plus 250.00 for the scope and if I see the pain Dr it will be 45.00 for the pre TX visit and 45.00 for the TX. I'll have to pay for another copayment of 250.00 at a out PT surgery center and not a the office. I've already spent out of pocket 170.00 for medications this month. My 14000 per year is gone pretty quickly. Still I,m not complaining. My husband and I use to pay 10,000 per year for family coverage and he worked for state farm insurance which had better coverage than most. Sorry for the ranting. I just got my credit card XXXXXXX in the mail today. Talk about stress! XXXXXXX
Brief Answer:
I do understand.
Detailed Answer:
This is so true.
The stress.
Well Lyrica 50 is Pregabalin and if this is working, please continue.
I am sorry that I really do not know the costs of these medicines in your country, trying to go through and find out.
Please inquire about the availability about the SR forms of Gabapentin. SR means Sustained release.
All these medicines do have reduced efficacy over time, hence we do advise to change from time to time.
Cost-effectiveness is also a main part of the treatment that every Doctor has to consider when prescribing a particular medicine, and must be done.
I do understand.
Detailed Answer:
This is so true.
The stress.
Well Lyrica 50 is Pregabalin and if this is working, please continue.
I am sorry that I really do not know the costs of these medicines in your country, trying to go through and find out.
Please inquire about the availability about the SR forms of Gabapentin. SR means Sustained release.
All these medicines do have reduced efficacy over time, hence we do advise to change from time to time.
Cost-effectiveness is also a main part of the treatment that every Doctor has to consider when prescribing a particular medicine, and must be done.
Note: Revert back with your health reports to get further guidance on your gastric problems. Click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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