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Dr. Arun Phophalia
Dr. Arun Phophalia, Doctor (MD)
Category: Health
Satisfied Customers: 29546
Experience:  MBBS, MS (General Surgery), Fellowship in Sports Medicine
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Hello. I am a 39 yr old female diagnosed with Crohns disease

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Hello. I am a 39 yr old female diagnosed with Crohn's disease in 2007. I have struggled a bit with this since Dec 2011 being in a constant flare. I do take remicade infusions every 8 weeks. In Jan of this year while laying in bed watching a movie I experienced severe chest pain, right underneath my breast bone that radiated down my right arm, into my right jaw. I was rushed to the ER, every thing checked out ok. A month later another attack and since then it's become weekly and briefly became several times a day. Initially it hurt to drink water while this was happening and I was told Ita probably esophagul spasms, was prescribed nitroglycerin and that never helped. I continued to have the attacks. Now when I drink water it seems to make the severe pain subside. I had my Gallbladder removed in 2006. My GI did a sono, barium swallow test, X-rays, blood work and nothing came back abnormal. Out of frustration I decided to start the Gerson therapy. I am on day 11. I had none if these attacks while on this new diet til today. I forgot to mention at the same time water helped, a new symptom appeared. I know I am about to have an attack because my throat gets a very tight feeling. I had upper & lower scopes done end of Jan & found I had some gastritis but very minor. I also was found to have inammation in the colon. In mid Feb I ended up getting extremely sick & found I had developed sepsis. I recovered from that. During this time from mid Jan of this year to now these attacks have never gone away. There seems to be no rhyme or reason. Nothing provokes or stops them. Sometimes when I bear down While having a bowel movement I can actually bring one on half the time. It's so odd, my doctor said he has no answers. It's a very painful attack and I am worried as I know this is not normal. Any ideas?
Submitted: 11 months ago.
Category: Health
Expert:  Dr. Arun Phophalia replied 11 months ago.

Hello Wendy,
I am Dr. Arun and will be helping you today.

What did your esophageal motility study and CT scan of chest show?
Any history or anxiety or panic?

Thank you for using Just Answer.

Customer: replied 11 months ago.
My upper GI at that time showed some gastritis but nothing major. My lower GI showed some minor inflammation in my colon. The confusing part is 2 weeks later I thought i was coming down with the flu but when i started running 104 i went to the ER. Their cat scan showed inflammation in 3 areas of my small intestine and found out I had sepsis. i have recovered fine since. I have no history of anxiety or panic attacks or anything of that sort. To reiterate, these attacks started mid Jan out of the blue. The first one felt like I was having a heart attack. I was cleared and told I had a well functioning, healthy heart. These attacks have changed a little over time. There was also a small time frame of a
Couple days where I was unable to eat because of pain in that same area- feels like it could be right where the esophagus meets the stomach. Thank you for your help.
Expert:  Dr. Arun Phophalia replied 11 months ago.

You are very welcome, Wendy.

I am sorry about the recurrent undiagnosed attacks. Following would be the further work up to diagnose the issue (if not yet done);

1) Esophageal manometry evaluates esophageal motor pattern, contraction amplitude, and LES (lower esophageal sphincter, where stomach meets stomach) pressure and function.

2) CT scan and MRI of the neck. A spondyloarthrpathy is common with the Crohn's disease which can cause nerve radiculopathy symptoms in chest and upper limbs.

3) Nerve conduction velocity study and electromyography of the chest and upper limbs.

4) Ambulatory esophageal manometry:and High-resolution manometry:; this will further confirm the high pressure in LES (hypertensive LES) and esophageal motility disorder.

5) Chest CT scan

Consulting at a teaching hospital where gastroenterologist, rheumatologist and neurologist work under a single roof and have more opportunities to discuss your case would be recommended, as this need an integrative approach for the diagnosis. Crohn's disease can involve spine and nerves and initial changes in these are subtle to cause definite symptoms and thus may remain unrecognizable unless thorough investigations are done in all the organ systems in the vicinity.

Please feel free for your follow up questions.

I would be happy to assist you further, if you need any more information.

Thanks for using Just Answer.

 

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Customer: replied 11 months ago.
Thank you for those suggestions. I realize you cannot diagnose me via the Internet but I am curious if anything stands out? One thought is perhaps an ulcer in my esophagus which is maybe why drinking water during these attacks helps me. It's a bit strange to feel a tightness in my throat a few seconds before the attack although I do realize referred pain is possible. I can definitely tell its centered around my esophagus/ start of my stomach. The ulcer theory doesn't really make sense tho because it has never really let up and any other times I've had a flare up of the crohns the ulcers heal typically within a few weeks. I did forget to mention I do have NA fatty liver disease which is why I have started the Gerson Therapy with detoxing my liver. My GI originally thought I had stones in my bile ducts or the tube that runs from the liver into the stomach however after a sonogram he decided not. I didn't think you could see that on a sonogram unless it was calcified? Does anything jump out at you with possible suggestions of what could cause these painful attacks? I have searched & searched online but can find nothing that relates to my situation. I do not have heartburn or GERD & that's never been an issue for me. When I was first diagnosed I was throwing up blood but scopes at that time confirmed I had an esophagul tear from the severe vomiting. My doctor can probably run more tests however I am curious if any conditions or anything possibly stands out to you with what possibilities can be? The pain radiates to my back and sometimes to the right or left sides of my chest. I can always feel where it centers and sometimes it feels like a lot of pressure yet hurts at the same time. Thanks again and I am looking forward to hearing anything else you can add to this mystery!
Expert:  Dr. Arun Phophalia replied 11 months ago.
You are most welcome, Wendy.

An ulcer usually in the lower esophagus would be visible in the endoscope so an high pressure LES would be another possibility. Please remember that esophageal motility disorders are very common in Crohn's disease and it too can involve esophagus.

You may get an HIDA scan which can identify the poorly functioning or non functioning gall bladder and which can't be diagnosed by a CT or an ultrasound. A MRCP (magnetic resonance cholangiopancreaticography) also would be recommended to understand the sphincter of Oddi spasm (through which pancreas juice and bile flows).

I would consider these diagnosis in this order;

1) esophageal motility disorders
2) cervical radiculopathy
3) Non functioning gall bladder
4) Sphincter of Oddi spasm.

It is a great privilege assisting you.
Expert:  Dr. Arun Phophalia replied 11 months ago.
Hello Wendy,

Your symptoms are called as non cardiac chest pain. Noncardiac chest pain (NCCP) is defined as recurring angina-like substernal chest pain of noncardiac origin. Here is a list of non cardiac chest pain;

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093002/table/T1/


GERD has been reported to be the most common esophageal cause of NCCP. Non-GERD-related NCCP are commonly evaluated for esophageal dysmotility, which are diffuse esophageal spasm (DES), nutcracker esophagus, achalasia, long-duration contractions, multipeaked waves, and hypertensive lower esophageal sphincter (LES).
Treatment with a double-dose PPI for a period of 2–4 months should be considered in those with GERD-related NCCP. In patients with non-GERD-related NCCP, smooth muscle relaxants may be tried. Another common cause of noncardiac chest pain is musculoskeletal problems located anywhere on the chest wall. The chest contains many muscles, bones, tendons, and cartilage.
Dr. Arun Phophalia, Doctor (MD)
Category: Health
Satisfied Customers: 29546
Experience: MBBS, MS (General Surgery), Fellowship in Sports Medicine
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