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Dr. Phil, MD
Dr. Phil, MD, Medical Doctor
Category: Medical
Satisfied Customers: 56575
Experience:  Medical Doctor Trained at a Top Academic Institution
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I am a 40 yo female G1P1 with 2 month hx of abdominal

Customer Question

Hello,
I am a 40 yo female G1P1 with 2 month hx of abdominal discomfort. Initially started in LUQ as focal, point tender area along ribcage assoc with some "burning" sensation. Thought to be 2/2 to MSK d/t shoveling snow. Pain did not subside within 2 wk, eval sought with IM MD. Started on Protonix 40mg qd. No improvement in burning sensation, though point tenderness no longer an issue. Treated empirically for possible H Pylori with increased dose of PPI to 40mg BID; Clarithromycin 500mg BID and Amox 1g BID. Day 7 of therapy, increased epigastric pain, "burning and cramping." ED eval with mildly elevated lipase to 75 and eosinophils on DIFF. RUQ US with 3mm gallbladder polyp, no wall thickening; ducal dilitation or cholelithiasis. CT w contrast done for elevated lipase-pancreas normal size & attenuation; no fat stranding or fluid or focal lesions. No other abnormality noted save for a small L ovarian cyst. Given Carafate, stopped abx and noted marked improvement in symptoms. 2 days later, 1 episode of apparently self-limited melena. EGD done & was normal, no ulcers or esophagitis; bx negative. Tried to stop PPI, had increased, diffuse "burning" in abdomen with new pressure like sensation around right side of navel with some radiation to right side. Pain improves when laying flat; gets worse by end of day. GI eval suggests colonoscopy to complete w/u despite no weight loss, changes in bowel habits or significant decrease in intake. Trailed restarting PPI w improvement in symptoms. Best guess (I'm a PA) is I had MSK pain initially that was treated erroneously as GERD/ulcer & I've had reaction to meds. Since stopping, lipase back to normal as is eosinophil count. Cut PPI dose in half, but still with navel pain (LUQ and epigastric mostly resolved, though occur intermittenly) and now some flank pain bilaterally. I am assuming this is rebound reflux, though an undetectable pancreatic mass is in the back of my mind. From you, I'd be searching for:
1. any experience you have with rebound reflux after discontinuation of med (on for 2.5 months at 40mg qd with 7 day increase to BID during H Pylori therapy)
2. If <2cm pancreatic mass, which could be missed by CT, should be a concern despite a healthy appearing CT scan. GI MD wants colonoscopy before any other considerations
Thanks!
Submitted: 2 years ago.
Category: Medical
Expert:  Dr. Phil, MD replied 2 years ago.

You seem to have excellent knowledge of medicine. Are you a doctor?

Expert:  Dr Basu replied 2 years ago.

Hi there,

I understand your dilemma.

Most likely your initial symptoms were indeed MSK or pinched nerve related.

However, you are describing a burning pain with activities with imprvement on lying down.

This can be still reflux related --most likely biliary reflux or non acid refluxx disease.

PPIs do not help in that case.

However, you can try ranitidine as a step down therapy from PPI to avoid withdrawal symptoms.

Biliary reflux improves with bile acid sequestrants like cholestyramine.

Baclofen also has been used with non acid reflux disease also known as functional dyspepsia.

2. regarding your < 2 cm pancreatic mass --that sounds like benign as with most cases.

However, a MRI scan of the pancreas can be considered for further evaluation to monitor any increase in size.

Colonoscopy is not necessary as such.

Best wishes,
It was my pleasure to help you today.
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Customer: replied 2 years ago.
Thank you for your response. I will look into functional dyspepsia, though I never had symptoms such as I am experiencing now until after I was exposed to PPI.Of note, I do not have a pancreatic lesion, I am concerned CT might have missed a lesion if it was <2cm. and wonder if I should suggest EUS for further eval, or if that would be ridiculous.
Expert:  Dr Basu replied 2 years ago.

That is a good thought regarding pancreatic issues.

Your CT scan was completely normal.

Still, EUS is atleast better than colonoscopy given the elevated lipase.

Or a MRCP which is noninvasive test.

At least that will put your mind to rest regarding any possibility of chronic pancreatitis as well.

Best wishes,

Customer: replied 2 years ago.
To answer the question asked by Dr. Phil, I am a PA-C.
Expert:  Dr Basu replied 2 years ago.

Yes I saw you already mentioned--and that helps a lot to make informed decision :)

Expert:  Dr. Phil, MD replied 2 years ago.

Thank you for requesting me. I was locked out of answering. You seem very knowledgeable. I am impressed!

I think you need to consider endometriosis and SOD. Sphincter of oddi dysfunction. Have you considered that?

Expert:  Dr Basu replied 2 years ago.

Hi there,

This is not related to endometriosis or SOD since you do not have any CT findings suggestive of that.

MRCP or EUS will be ok given your elevated lipase level.

Best wishes

Expert:  Dr. Phil, MD replied 2 years ago.

CT would not show SOD or endometriosis as you already know. ERCP would show SOD. That should be done. If it persists you may need an ex lap.