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Doctor Nash
Doctor Nash, Professor of Medicine (MD)
Category: Health
Satisfied Customers: 616
Experience:  I've been teaching and practicing medicine for more than 40 years.
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Upper Abdominal Swelling/Pain

Customer Question

I have been suffering with upper abdominal pain & swelling for almost 3 weeks now. I went to the ER after the 1st week. Blood work was done & was 'okay', even though my liver function was elevated, my sodium was a bit low, and potassium a bit high. (I don't know exactly what was checked or any more specific information). I was given the 'best guess' diagnosis of a gallstone stuck in the bile duct - despite having had my gallbladder removed nearly 10 years ago (diseased), and no gallstones - (I had an ultrasound for that purpose back at the time). I followed up with my primary dr who insisted on an ultrasound to rule out the gallstone. Results were okay. (All I know that was to be checked with the test was for a gallstone in the ducts. I don't know if the liver or anything else was evaluated. All of the time was spent over the middle & right side). My Dr. has since had me try a medication for ulcers, which hasn't helped any, and has spoken with a GI specialist who, according to her, had 'no idea' what could be wrong. I did inquire as to whether my pancreatic enzymes were tested in the blood work & my doctor said they were and were normal. ((From my own researching, I thought it possible that I have acure pancreatitis because of my symptoms)).
Btw, the Dr.'s I have been in contact with thus far have been very 'dismissive' towards my problem.

My symptoms started, suddenly & for no apparent reason, as a hard 'fist' in the center of my upper abdomen, about 2 inches above the navel. Since, it has spread to include part of the right upper area, and lately over to the left a bit. The pain has been constant, being a 'there' kind of ache/throbbing type pain with times of very sharp, piercing pains in more specific areas (which vary about every time the pain hits). My abdomen, when standing, is very hard to touch and noticeably swollen, (despite my being overweight). I have several places that are sore/tender to touch, mainly in the upper middle area and then down 2 or so inches in a diagonal line from there. Also, around week 2 I noticed the pain began to often radiate/bore through to my back and I have had some pains on my right side, at the waistline area.

Loss of appetite has come & gone (some days being noticeable, other times I eat fine). No food seems to make it better or worse. I tried antiacids for a few days during the first week & they didn't help. I have had nausea on & off, but not to the point of vomiting. I have periods where I feel very weak and am more tired than the 'usual' during any given day. If I try to do very much (exercise, etc.) the pain gets worse, so I have not had a lot of activity since this started.

Are there more specific tests that should be done (blood work or other) ? Is it possible that I might have peritonits? Any ideas or suggestions would be VERY greatly appreciated!!

Sincerely, XXXXX
Submitted: 8 years ago.
Category: Health
Expert:  Doctor Nash replied 8 years ago.
Dear XXXXX,

Thanks for a very well written and informative message, a rarity on this site. I'm an very senior doc and was on my way to bed. But I opened your message and decided to respond.

I believe you and will not dismiss you. Why? Well, it's not nice, but also....

Many years ago, at a VA hospital, I was asked to see a man, an army vet, late at night. Everything pointed to a gall bladder problem, but after contacting the VAH in his home town, we found out that his gall bladder had been removed. They faxed us the op report and the path report. I was a very young surgery resident who convinced his staff man to let him look in there anyway.

When the gall bladder is removed, the common bile duct takes over its function. During the operation, you have to be careful to take the organ and the cystic duct which drains it into the common bile duct. Sure enough, the original surgeon has left one-half inch of cystic duct; this had become a second gall bladder and was markedly inflamed.

There are other considerations. The common bile duct may be intermittently blocked by spasm of the spincter of Odi at the intestinal end, and the sphincter can also develop a tumor, a terribly hard thing to find. If it is spasm of the sphinter, morphine derivitives can make it worse.

Another I don't like is a tumor of the head of the pancreas.

Perhaps your doctor will consider a CT of the abdomen. In the case I described, ultrasound would not have helped. Anyway, that was before my classmate and colleague, Dr. Feigenbaum, devloped echocardiography, which led to abdominal ultrasound.

Then, the gastroenterologist can always look at the sphincter and the ampulla of Vater surrounding t.

Peritonitis? Well, you're just not sick enough, but....

As for the other complaints, I can't tie it all together. And I'm too old not to be able to say I don't know and get away with it.

If you wish, you may show this to you doctor; I have nothing to hide.

I'm off to bed now and will be back on line later today.

Best wishes from

Teaching Doc



Customer: replied 8 years ago.
Reply to Teaching Doc's Post: I don't think this answer will help me because my Dr. was supposed to order that all the ducts be checked in the ultrasound I had (that came back okay), so I would think that maybe an inflammation in one (or part of one) might have been caught.. (Or should have been, anyway).

To ADD to my original post ((that I forgot)):

* My pain has generally been a 6 (out of 10), but ranges from 5 to 8. Also, it has been worse since the ultrasound was done (on May 30)

* I've had low-grade fevers that have come & gone, with the average being 99.1 and the highest being 100.1 -- (my 'normal' temp runs about 97.6)

* I have gotten 'cold & clammy' several times.
Expert:  Doctor Nash replied 8 years ago.
Dear XXXXX,

Thanks for the additional information.

Ultrasound is not the gold standard. ECRP (direct vision using a fiberoptic instrument passed through the mouth), and CT/MRI are a far better combination and show more detail.

I have people who suffered for months before ECRP showed the answer.

I love medical ultrasound. My friend developed it. But it's not the best for everything. What you had is okay for stones, complete obstruction, and non-functioning gall bladder. But there are causes of periodic and/or incomplete obstruction that may not be picked up that way.

Was the decision to stop after ultrasound made by your primary care physician or a gastroenterologist (or radiologist)?

Best from

Teaching Doc
Customer: replied 8 years ago.
Reply to Teaching Doc's Post: Funny you should ask about the decision in regards XXXXX XXXXX to do next.. It was mine, mainly due to the - dare I say, incompetence - of my primary Dr. and the GI specialist she says she 'consulted' with. My Dr. named off about 3 different tests to 'choose' from, saying it was up to me which one to do, if any at all. (paraphrasing, but that was the jist of it). She didn't bother to tell me why each test would be done (what it would show, WHY it should be considered, etc.).

Also, she told me that upon talking with the specialist that he had "no clue" as to what could be wrong, but that the ultrasound was a waste of time, especially since I had no previous history of gallstones when I did have a gallbladder.

I have since found out it would cost me a minimum of $200 just to talk to the specialist, and being without insurance (and currently out of work), there's no way I can afford it. Hindsight always being better, I wish now I had insisted that a CT scan (or the scope-type test) be done & that they check for a variety of things, rather than the cost & waste of an ultrasound.

Are there any other possiblities as to what could be going on that you can think of? Or anything I should make sure that the bloodwork was checked for? ((Oh, and I told the ER nurse that cancer is what has killed nearly every single person in our family - both sides - but don't know if the bloodwork was tested for anything along those lines. A (shudder to think) possiblity?))

Thanks for your help!

Jennifer
Expert:  Doctor Nash replied 8 years ago.
Okay, Jennifer, now it's time to play guts baseball (if you don't know the idiom, ask some kid, a boy).

If everything you tell me is factual (I don't care about paraphrasing), I smell incompetance and negligence.

Your consent for the ultrsound was not informed. In many states this is battery and malpractice. You should not have been given choices since you have not the knowledge to know the value and usefulness of, or the indications for, each. Did your doctor tell you what she would be looking for with each modality? Did she explain the costs of each and dicuss the cost effectiveness? Did she tell you what plan she had for followup of each if the result were positive or if negative?

Ask her the name of the gastroenterologist and for a copy of the consultation report. If she says it was oral, call the specialist's office to confirm that indeed a consultation occurred. Were you charged for a consultation?

Ask her office staff for a copy of the ultrasound request. What did she tell the radiologist? What did she give as the indication for the study? Request your entire file.

If your request is refused, present the staff with a written request for your file. They must give it to you. The patient's file is the patient's property, not that of the doctor or the practice. This has been upheld by judges in every state in which I have practiced or consulted in health care malpractice cases.

If you are told that they will forward it to the office of the doctor of your choice, get back to me.

We will work together to evaluate your care to this point and to have you undergo a complete and thorough evaluation at a center of excellence. You might end up traveling to Columbia. (I do understand the financial constraint. Ours is a state-owned organization. The hospital must be self-supporting, but about half of our patients have no insurance and have limited funds; they are cared for under special arrangements.)

I never claimed to work miracles, but I've never walked away from someone in need. (I just received a message from a lady, thanking me for "forcing" her mother to call an ambulance.)

By the way, I don't charge for this kind of activity. However, if you were Bill Gates' wife, no, Steve Jobs' (I'm a Mac man and hate Windows), I'd ask for a new MacBook (joking, I have one).

Feel free to show this to your doctor.

To contact me away from JA, useXXX@XXXXXX.XXX orXXX@XXXXXX.XXX.

The web site is http:/web.mac.com/wisenash/

Teaching Doc (retired professor)
aka / Frank Nash
Doctor Nash, Professor of Medicine (MD)
Category: Health
Satisfied Customers: 616
Experience: I've been teaching and practicing medicine for more than 40 years.
Doctor Nash and 3 other Health Specialists are ready to help you
Customer: replied 8 years ago.
Reply to Teaching Doc's Post: Thank you VERY much for this information... I was thinking along the same lines. =o) I will follow up with getting the necessary info at the first of the week and let you know what I find out. Again, I truly appreciate your time & effort to work with me on this - It's so comforting to know that there ARE good & caring doctors out there!!

Sincerly,
Jennifer

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