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KortneyPA-C, Physician Assistant
Category: Health
Satisfied Customers: 54
Experience:  8+ yrs, Orthopedics, Worker's Comp, general practice
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I was told that I have IBS and Im perimenopauasal. I have

Customer Question

I was told that I have IBS and Im perimenopauasal. I have weeks at a time with upper abdominal pain that leads around to my back. Im not so sure its just IBS. I have abdominal swelling and also now my feet,legs,and anlkes are swelling.Can you help me?
Submitted: 5 years ago.
Category: Health
Expert:  KortneyPA-C replied 5 years ago.

Hello, welcome to JustAnswer! My goal is to provide you with the most comprehensive answer, so if you need more info, please ask!

I think there are a few things going on with you that I would like to discuss. I can provide you with some information about abdominal conditions that are more likely to be associated with the symptoms that you describe, as IBS does not completely explain the symptoms that you have. Also, the swelling in your legs, feet and ankles, could be a separate issue and I can provide you with some information related to that as well.

From my understanding of the information that you provided, you have been previously diagnosed with IBS, for which you take Bentyl, Bisacodyl suppositories and you also use Hydrocort AC for hemorrhoids associated with your IBS. You stated that the medications don't seem to help. When you say they don't help, do you mean that none of them have provided any benefit for you? Did you notice any change in the frequency, severity, or character of your symptoms after starting Bentyl?

When did you start to have the upper abdominal pain? Do you associate the upper abdominal pain with anything, for example, does it get worse after you eat certain foods, drink certain things, or is it better during some periods of the day/week? Have you tried any other medications for the upper abdominal pain? Prilosec, Zantac? Do you also have nausea and/or vomiting when you have the pain? You also mention that you have swelling in your abdomen, is this when your pain is most severe? Have you ever undergone an upper GI study, CT, or x-ray of your abdomen? Is the pain located directly in the center or off to one side of your upper abdomen? Do you or have you taken an anti-inflammatory medication on a daily or long term basis?

Some of the answers to these questions will help me to further clarify what could be going on. I do have some idea of what could be causing your symptoms, other than the IBS, but there are unique characteristics associated with each possibility and I would like to better get an idea of what your symptoms are more characteristic of before I offer you advice and information in this regard. I know that it must be so frustrating for you to have this significant pain and not have any answers about what could be causing it. I am pretty confident that I can provide you with some guidance in this regard, your symptoms are very suggestive of possibly gastritis (inflammation of the stomach lining), reflux disease (acid from the stomach goes up the esophagus and causes irritation), possibly a gastric ulcer, or you could possibly have symptoms suggestive of gall bladder disease and/or stones. The good part about these possibilities is that they are all very easy to diagnose and treat if the right tests are ordered and the right treatment is started.

Regarding the swelling in your legs, I believe this is unrelated to the abdominal pain and will discuss more about this with you after we talk about your abdominal pain.

Customer: replied 5 years ago.
Expert:  KortneyPA-C replied 5 years ago.

Gastritis, or inflammation of your stomach, is a common condition and is also associated with GERD, which you stated that you have. Most people at some point in their lives will have some form of gastritis. Several factors can cause this condition. Primarily, diet plays a big role. Typical foods that irritate the stomach lining, include alcohol, coffee, caffeine, spicy foods, tomato sauce, soda, fatty foods (potato chips, fried foods, French fries), raw vegetables (coarse and raw vegetables are harder to digest and lead to inflammation), mustard, onions, carbonated beverages, and citrus juices. These types of foods MAY cause inflammation of your stomach and would lead to pain. People with gastritis that occurs long term or chronically (as opposed to an acute episode lasting days) should avoid these foods altogether to prevent acute attacks. Another factor, stress, plays a big role. Increased stress causes increased acid production by your stomach, which leads to inflammation of the stomach lining. It is not uncommon for someone with an anxiety disorder or chronic stress to report that the most common symptom associated with his or her stress is a stomachache. Another factor is medications that can irritate your stomach. Most commonly, anti-inflammatory medications, like Ibuprofen, Naprosyn, Celebrex, etc., which, it appears that you avoid. These types of medications, if used daily and on a long term basis, will certainly cause gastric irritation resulting in pain. It is so commonly associated with these medications that most doctors will prescribe a medication to protect your stomach when you are taking anti-inflammatory medications regardless of if there are symptoms or not, taking the stomach medication, Prilosec in your case, and you recently switched to Tagment, which actually prevent the development of gastric symptoms. You likely were switched from Prilosec to Tagment because the Prilosec wasn't helping. Tagment is a similar medication, but can sometimes help better or differently than Prilosec, so give it a good try, take it daily and consistently.

I noticed that you are taking Tramadol, this medication can also cause gastritis and could definitely be causing you to have increased upper abdominal pain. In your case, you should stop the Tramadol for a period of time to see if symptoms improve, I don't think that the majority of your pain is primarily from the use of Tramadol, but it could be just causing further problems and more irritation, it's worth a try to see if stopping it causes any improvement. I personally would not recommend that a patient continue to use Tramadol or an anti-inflammatory medication if they presented with upper abdominal pain that is similar to yours, sometimes it can be okay if used with Tagment for example, but in your case, it doesn't appear that you are getting any relief from the stomach medications and Tramadol could just be causing more symptoms. Smoking can cause gastritis as well.

Gastritis itself is usually self limiting and will get better on its own if you take away the foods or medications that are irritating the stomach and/or use Tagment, but, occasionally, it is not always possible to eliminate the cause of the gastritis. For example, in someone who has a lot of stress, unless the stress is under very good control, it is nearly impossible to prevent the inflammation and pain in the upper abdomen. It is so important to treat the symptoms of gastritis as soon as they are recognized because gastritis can lead to very serious conditions if not treated or if the cause of the inflammation is not addressed. Chronic gastritis can cause ulcers in the stomach lining, a very painful condition in an of itself, but ulcers can lead to possible rupture of the stomach lining, anemia due to blood loss from the ulcer, inability to absorb certain necessary vitamins leading to malnutrition in severe cases, and even cancer. Gastric ulcers can also be caused by a bacterial infection, called H. Pylori, and need to be treated to avoid further complications, noted above. An ulcer can be diagnosed by an endoscopy. Direct visualization of the ulcer is not always necessary though. A breath test can be done to see if H. Pylori is present and if it is, treatment can be started for the gastric ulcer. You stated that you have already undergone a GI (I assume endoscopy), ultrasound and x-ray, but has your doctor sent your for a breath test to evaluate for H. Pylori, it is worth looking into this. How long ago was the endoscopy? Have symptoms significantly changed or gotten worse since the endoscopy? If so, you may want to talk with your doctor about when it would be appropriate to consider a repeat endoscopy given that your symptoms are progressing, it appears.

Ulcers are treated with diet modifications (those reviewed above), cessation of alcohol and/or smoking, discontinuing anti-inflammatory or pain medications that could be causing further irritation, a medication to decrease acid production in the stomach and also antibiotics to treat the H. Pylori infection. You seem to be doing everything that would be necessary for gastritis, including the Tagment, avoiding anti-inflammatories, probiotics, but, are you also avoiding the irritating foods, minimizing stress (or at least considering stress as a potential cause for the ongoing symptoms), and not drinking coffee or alcohol or smoking cigarettes. Sometimes it can take a combination of several of these measures to improve pain even slightly. In your case, since you now have nausea and pain under the breast bone, you may be having some serious and ongoing irritation and inflammation of your esophagus.

Gastroesophageal reflux disease (GERD) is a relatively common condition and is very similar to gastritis. The acid from the stomach is pushed up into the esophagus, and sometimes even the throat and causes irritation and pain. Reflux disease has the same causes as gastritis and usually goes hand in hand. GERD is treated in the same way as ulcers, expect the antibiotics are not necessary. Someone with chronic gastritis will likely also have GERD and this can cause irritation in your throat, voice changes, a bad taste in your mouth, pain when the stomach is empty (behind the breast bone like you describe) or after lying down, and nausea. GERD can lead to very serious complications as well, including changes in the tissues of the esophagus, bleeding in the esophagus, and, even cancer, if it is chronic and not treated. Someone with GERD, gastritis or a history of ulcers usually undergoes regular endoscopy testing, every few years, to be sure that no complications have developed. Again, if you have progressive symptoms and are having increased pain, it may be time to discuss with your doctor the possibility for a repeat GI endoscopy.

It sounds like your symptoms could be any of the above conditions, you may have inflammation in the lining of your stomach as a result of the use of Tramadol or possibly other anti-inflammatory medications or any of the other causative factors. Since you have had symptoms for a long time, it appears that symptoms have been present for at least greater than 6 months, you could be at risk for ulcer, anemia, and other complications. In order to evaluate the cause of your symptoms, besides the tests that you have already been referred for, the only other thing that may be helpful is a breath test for H. Pylori and a possible repeat endoscopy, depending on how long it has been since the first one (usually 2-3 years is necessary). In the meantime, it cannot hurt to stop eating foods that irritate the stomach, stop taking the irritating medications, and avoid coffee, alcohol, stress. Avoid stress, right? Impossible, I can relate! The swelling of your abdomen that you describe (or bloating) is likely related to the inflammation in your stomach with can cause you to feel swollen or bloated when symptoms are most severe. Someone with severe gastritis will usually have a distended abdomen, or they will look like they have a huge pot belly, and it will be painful to push on the abdomen, this is all just related to the inflammation and irritation of tissues.

Expert:  KortneyPA-C replied 5 years ago.

Another less likely possibility for your symptoms could be gallbladder disease or gallstones. Typically, with gallbladder disease, the abdominal pain would be located in the right upper area directly under the ribs on the right side, which you stated was more typical of pain that you previously had, and the current pain is not really on the right side anymore. You don’t necessarily have to have just one diagnosis, however, and if you have had right upper abdominal pain with nausea and pain with pressure just under your rib cage, you may have, at one point, had gall stones. Gallbladder disease can be quite painful and is usually characterized by acute attacks where symptoms are significantly increased for a period of hours to days followed by a period of remission where no symptoms are present. A person with gallstones or gallbladder disease typically has increased pain after eating a meal that is high in fat.

The gallbladder releases digestive enzymes after a fatty meal to help with digestion and, in a person who has stones or inflammation in the gallbladder, this can be quite painful. It is also relatively common for someone to report nausea and even vomiting in the presence of gallbladder disease or stones. A typical presentation is a patient that would come in with periodic right upper abdominal pain that is increased after fatty meals and is sometimes associated with significant nausea and/or violent vomiting. Gallbladder disease is more common in pregnancy, but can occur at any age and does not really have a specific cause for its development. Stones in the gallbladder can develop without any causative factor and would be extremely painful during the time that the stones are passed through the small tubes of the gallbladder and could be followed by periods of no pain at all.

You stated that you have already undergone an ultrasound, which is the study that is recommended to evaluate for gall bladder disease and/or stones. However, just because stones are not found on the ultrasound does not mean that you do not have gall bladder disease. In some patients, myself included, while I was pregnant, there is what’s called sludge in the gall bladder, which is really just a thick syrupy substance that is painful when it passes through the small tubes and ducts in the gall bladder (rather than being a thin, slippery liquid it is thick and syrupy). A stone is easy to diagnose because if it is present it can be seen on ultrasound, and you would have a definitive answer for why you have symptoms, but if you have sludge, the only way to diagnose it is by clinical symptoms and findings. No imaging study can tell you if you are more prone to pain because your gall bladder has sludge. It’s frustrating, I can relate and attest to this. I was in and out of the hospital 3 times while pregnant and all times the ultrasound was normal, but I was throwing up violently and could not even stand up because of the pain. Eventually, a doctor that consulted on my case told me that I had sludge, which can be just as painful as stones.

In your case, the same may be true, you should at least discuss the possibility of this with your doctor if you begin to develop the right upper abdominal symptoms again on a more regular basis. The treatment for this condition is to surgically remove the gall bladder (it is a simple procedure and recovery is minimal). It is taken out completely because it is actually not an essential organ to digestion and only acts as a storage place for digestive enzymes. The theory is that once it is removed, symptoms can no longer occur.

If I were to evaluate all of the symptoms that you have, I would probably think that you are suffering from several different conditions that are very easily treatable. Unfortunately, it does not appear that you are having much benefit with the Bentyl for the IBS, but I would talk with your doctor about the possibility of testing for H. Pylori, the possibility for a repeat endoscopy (provided that at least 1.5 to 2 years have passed), and the possibility that you could have gall bladder symptoms related to sludge and inflammation and not stones. I don’t think that you are going to have one answer that defines your condition, unfortunately, and this can be so frustrating, I know, and hope that you can be provided with a diagnosis to prevent the frustration.

I hope that I was at least able to give you some good insight on what could be going on and have also provided you with some options that can be discussed with your doctor. Is there anything that you want me to clarify for you? Does this make sense? Do you think that any of the conditions that we talked about could be causing your current painful symptoms?

Please let me know if there is anything that you need explained, answered, or clarified in this regard, because I do not want you to feel like you are left hanging with unresolved questions and concerns. It is my goal to provide you with support and guidance and the most comprehensive information, but I can only help you further if you let me know if there is something that we missed.

If my answers were sufficient, please hit accept to indicate that you are satisfied with the information that I have provided. I really do wish the best for you, I have been in a similar situation, although much less severe and persistent than yours, and I can relate to the feeling of helplessness and frustration. Be healthy!