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Dr. Stan
Dr. Stan, Medical Physician and Surgeon
Category: Medical
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Experience:  Johns Hopkins Fellowship Trained, Certified and Licensed Medical Physician and Surgeon
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severe cramping and pain..which has become quite irregular

Customer Question

1 week after returning home from Riga, Latvia (and I stupidly broke the #1 travellers' rule in Riga by drinking an iced coffee but my husband also had one and has had no problems) I started having severe, uncontrollable, pyroclastic/explosive, nearly pure liquid diarrhea with very little gas and little to no pain, mainly at night, regular loss of control (I love the new Depends for women!). Now, 1 month later, it strikes approximately 4-6 hours after eating anything solid, I am noticing swelling feeling in upper right quadrant with achy pain, gas is now severe, gas and diarrhea now have strong H2S odour, severe cramping and pain with episodes, lasts 2-4 hours then lets up until I eat again though I occasionally still have "squirts", especially while sleeping (which has become quite irregular), and I'm starting to feel really worn out. Neither simethicone nor loperamide faze it. I am living on liquids, supplemental vitamins, and probiotic capsules until I get so hungry I simply have to eat something! I have been in pain management for 10 years but usually have constipation from meds, not diarrhea. I am living in Russia, may have to somewhat self-diagnose, then decide if I should return to US or a western European country for treatment. Please help!
Submitted: 4 years ago.
Category: Medical
Expert:  Dr. Stan replied 4 years ago.
Hello,

Welcome to Just Answer:

Recurrent diarrhea with right upper abdominal pain and aches especially after eating is suggestive of gallbladder and/or liver problems. This can be caused by either bacterial, fungi or viral infections from the water contaminants. I suggest that you follow-up with your doctor in Russia for closer evaluation with tests including stool for ova and parasite, stool leukocytes, stool gram stain and culture, and check for toxins, chem-12, complete blood count, abdominal ultrasound, LFTs, serum amylase and lipase levels. Another condition, carcinoid syndrome, which tend to be associated with periodic diarrhea should be excluded with test for 24-urine 5-HIAA if other possible causes are excluded. In the meantime, I suggest continue bowel rest, blend liquid diet, and regular electrolyte drinks (such as Gatorade), electrolyte imbalance from the initial diarrhea episode which may have not been corrected could be exacerbating the problem. Also, the gallbladder and liver needs close evaluation.

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Customer: replied 4 years ago.
I had what I am quite sure was a gallbladder attack when I was 33. Since then I have had ultrasound and CT scan, both of which were negative for I assume gallstones. I have still felt for the past 6 years or so that my gallbladder just isn't right because I keep having that achy pain and swelling feeling. Is it possible for it to be full of sludge and not show in imaging? I had the 24 hr urine test about a year ago and all was fine there. Due to my pain management (I have 3 artificial discs in lumbar and 2 herniated discs in my neck) the docs have kept a pretty close watch on liver function. This diarrhea thing for such an extended period is new. Every time I've had a bout of diarrhea it has turned out to be my body needing a rest from one of my meds like anti-inflammatories which is why I stopped all suspect meds one at a time. The frequency of bouts has improved to just right after I eat, but the overall problem hasn't. It was today that I realized there was such a strong H2S odour. I suspect that is significant. I need to be careful because my husband works as a contractor for the US Embassy and the less the med unit knows the better. We simply cannot lose this job! It seems odd that this came on so fast and has been so persistent for it to be a liver issue. There is no blood, mucous, or odd colour. If it were giardia from water in Riga I would think my husband would have been affected, too, and he's fine. My gut feeling is gallbladder but I suspect the tests would come out the same since the only symptom that has changed is the diarrhea. This is making me crazy because we are supposed to go on a "once in a lifetime" fossil hunting trip in a couple weeks and I need to get this under control! Would a list of my meds help with dx?
Expert:  Dr. Stan replied 4 years ago.
Thank you so much:

It is likely to be related to gallbladder which was recent exacerbated by an infectious attack since the trip. Giardia should be excluded with stool testing for giardia antigen even though your husband does not have symptoms. Your immune system may be weaker than his own, and so explain why you have symptoms. The ultrasound can miss the gallbladder inflammation and/or problem, so HIDA scan testing should be considered to definitive diagnosis. The treatment for giardia is metronidazole 500 mg 3-4 times daily for 10 to 14 days.

It was a pleasure to assist you. Please, allow me get credit for my time and effort in assisting you and press the ACCEPT button for this assist. Thank you so much.

A Positive Feedback and/or Bonus is welcomed and appreciated.

Please note that this answer is for information only. It cannot be substituted for the visit to or the recommendation of your doctor.


Edited by Dr. Stan on 8/17/2010 at 3:06 PM EST
Customer: replied 4 years ago.
What is the possibility of SIBO due to my trying to control it with loperamide? If so, what would be the antibiotic of choice to get it under control? Antibiotics are OTC here. I am allergic to sulfa, PCN, and react badly to erythromycin. I can take Cipro and Clindamycin, though Cipro is hard to find. Does the giardia med have a base of anything I'm allergic to that I mentioned? I don't know about his immune system being better...he's had 3 major surgeries in the past 18 months. 2 lumbar artificial discs, 2 cervical artificial discs plus 1 level fusion, and hand surgery. He gets sick a lot more than I do. He can't go back to the work he did in the US even though he's about 75% improved over his pre-op status so this job is important. I'll see about that gallbladder test. It may not be available here. I just hope it doesn't affect my ability to stay here! Thanks.
Expert:  Dr. Stan replied 4 years ago.
Thank you so much:

Small intestinal bacterial overgrowth (SIBO) with diarrhea complication as a result of use of loperamide is a possibility. The best diagnosis for SIBO is a combined nuclear medicine transit scan/glucose H2 breath test. In the meantime, the best antibiotics is Cipro. Since it is hard to get Cipro you should consider use Clindamycin (however, if the diarrhea or any stomach pain occurs with clindamycin use, I suggest that you stop immediately. Metronidazole has some sulfur group, and since you are allergic to PCN (which has sulfur group), I suggest you avoid metronidazole. I wish you a speedy recovery soon. God bless.

It was a pleasure to assist you. Please, allow me get credit for my time and effort in assisting you and press the ACCEPT button for this assist. Thank you so much.

A Positive Feedback and/or Bonus is welcomed and appreciated.

Please note that this answer is for information only. It cannot be substituted for the visit to or the recommendation of your doctor.



Dr. Stan, Medical Physician and Surgeon
Category: Medical
Satisfied Customers: 2701
Experience: Johns Hopkins Fellowship Trained, Certified and Licensed Medical Physician and Surgeon
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Customer: replied 1 month ago.

If you're still around Dr. Stan, we narrowed it down to giardia contracted by brushing my teeth on board the ferry from Stockholm to Riga . I rinsed using the ship's tap water. However, since then I had a major gallbladder attack and several stones showed in ultrasound this time. Gallbladder removed in December 2011. Diarrhea is still chronic and my doctor has pretty much decided the whole mess triggered IBS. I am controlling it fairly successfully with Cholestyramine and a low dose of methadone. The combination works pretty well though neither worked alone. I have hereditary high cholesterol anyway so the Cholestyramine does double duty along with krill oil. I avoid spicy and fatty foods, too. The up side is it took over 6 months (and several rounds of treatment) to kill off that nasty little parasite and I have dropped from nearly 180 pounds to 125 on my 5'0" tall frame (yes, menopause clobbered me with weight gain!). I do so appreciate your advice as diagnostics is not a strong suit in Russian medicine! You gave me a direction of attack. I am now back in the US permanently as my husband was seriously injured in an MVA in Moscow in July 2011 and is now wheelchair bound. He is fighting chronic constipation and Miralax has been a godsend there. Thank you so much for the detailed response as it helped tremendously upon return to my regular PCP upon my return to the US. You were spot on. Thanks again, Gayle

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