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Q: GI question for Kevin MD ( Answered 3 out of 5 stars,   4 Comments )
Subject: GI question for Kevin MD
Category: Health
Asked by: pm01-ga
List Price: $15.00
Posted: 19 Feb 2003 16:39 PST
Expires: 21 Mar 2003 16:39 PST
Question ID: 163662
This is a question for Kevin, MD. 
I am a 31 yr. old female. Married with no children.  I have been
running low grade fevers off and on for the last 6 years.  When it
first started, I only noticed a little stomach burning.  By the way, I
took Naproxen the year before and treated for HP in that same year. 
Anyway, I didn't start experiencing any real pain until 2 years ago. 
I was able to confirm that stomach inflammation was causing my fevers,
yet my doctors say that I don't have the kind of Gastritis that would
cause fevers.  I have chronic gastritis,Barrets disease and
inflammation in the colon without evidence of IBD.  When the gastritis
is bad, I get muscle aches, joint pains, chills, and hot flashes also
with or without the fever.  I have suffered a lot only to be given
answers such as "you shouldn't feel this bad".  I have spent hundreds
of my own hours researching and I can see why my doctors have been
little help.  I have been tested thoroughly.  Cat Scans, ultrasounds,
Hida Scan, Colonoscopy, endoscopy of stomach 3 times in last 2 years,
along with many blood test.  Amylase and Lipase are normal along with
Gastrin levels.  The most boggling part is that my sed rate has been
good.   That is good, but you would think with the inflammation and
pain that I experience it would be slightly high.  Another problem is
my difficulty with meds.  I have flu like symptoms to a lot of
medication.  I can only tolerate about 20 mg of the nexium, aciphex,
prevacid, or any acid blockers.  I have had a tough time taking them,
yet that and the carafate are the only things that help relieve some
of the discomfort.  These are the only positive blood test I have had:

ANA (4 high positive test, one normal when I was feeling well)
Borderline Thyroid
slightly low red blood cell count on all of my test
mild hypertension on the right side of my heart
chronic gastritis
barrets disease
small amounts of blood and protein in urine (never a big concern)

I am doing everything I can to help my body heal.  I eat a lot of
baked salmon, chicken, baby food carrots, potatoes, bland cereal. I
only drink milk and water. In my case milk helps.

Well, after that long history... My question is "with everything ruled
out, is there anything rare that could be missed here?"  I could deal
with the Gastritis much better if it weren't for the other pains and
aches that come with it.  Any ideas?  Thank you for your time.
Subject: Re: GI question for Kevin MD
Answered By: kevinmd-ga on 19 Feb 2003 18:17 PST
Rated:3 out of 5 stars
Hello - thanks for requesting me to answer your question.  Although I
am an internal medicine physician, please see your primary care
physician for specific questions regarding any individual cases –
please do not use Google
Answers as a substitute for medical advice.  I will be happy to answer
factual medical questions. 

You asked the following:
"My question is "with everything ruled out, is there anything rare
that could be missed here?"

Given the fact that you have already gone through a multitude of tests
(endoscopies, ultrasound, HIDA scan, CT scan etc.) without a
definitive diagnosis, I will skip over discussing the common causes of
epigastric pain such as dyspepsia, GERD, pancreatitis, gastritis, or
cardiac causes (i.e. pericarditis).

As you requested, here are the rarer causes of abdominal pain that you
may want to discuss with your personal physician.

From UptoDate:
"Rare causes of abdominal pain should be considered in the following

- Patients with repeated visits to physicians or emergency rooms for
the same complaint without a definite diagnosis
- An ill appearing patient with minimal or nonspecific findings
- Pain out of proportion to clinical findings
- Immunocompromised, HIV-infected, or elderly patients" (1)

Celiac axis compression syndrome:
The celiac axis compression syndrome is a rare condition that
typically occurs in healthy young and middle-aged individuals. It is
thought to be caused by narrowing or occlusion of the celiac artery.
It presents as chronic, intermittent, colicky upper abdominal pain
that typically occurs after eating. It is often associated with an
epigastric bruit and weight loss. The diagnosis is suggested by
narrowing or occlusion of the celiac axis on angiography (2).

Painful rib syndrome:
The painful rib syndrome is an increasingly common condition
characterized by discomfort in the lower chest or upper abdomen,
tenderness over the costal margins, and reproduction of the pain by
pressure on the ribs. This syndrome accounts for as many as 3 percent
of new referrals to surgeons for the evaluation of upper abdominal
pain. It is most common in women. The syndrome has a benign outcome
and is important to recognize and diagnose to avoid unnecessary
testing and treatment and to provide reassurance to the patient. In
one review, 8 of 76 patients underwent noncurative cholecystectomy

Wandering spleen syndrome:
The wandering spleen syndrome is a rare cause of acute abdominal pain
that is most typically seen in younger adolescents and children,
although it can occur in adults. Patients typically present with acute
left upper quadrant pain associated with an abdominal mass. CT imaging
confirms the diagnosis. The treatment of choice is splenopexy;
splenectomy may be required if the spleen is infarcted and there is
torsion and absence of splenic blood flow.

Abdominal wall pain:
Pain emanating from the abdominal wall may be difficult to distinguish
from deep visceral pain. The pain can originate from a hernia,
hematoma, the abdominal wall musculature. Abdominal wall hernias can
be difficult to diagnosis clinically, and CT scan of the abdomen and
the abdominal wall are often required. Hematomas of the abdominal wall
occur spontaneously or after unrecognized trauma. Abdominal pain
originating from the abdominal musculature can be diagnosed by finding
a focal area of abdominal tenderness that remains unchanged or
increases with abdominal muscle contraction.

Abdominal migraine:
Recurrent abdominal pain may occur in patients with abdominal
migraine. These patients usually also suffer from typical migraine
headaches, although occasional patients present with gastrointestinal
symptoms only. (4)

Eosinophilic gastroenteritis:
Eosinophilic gastroenteritis is a rare condition that may present with
variable symptoms including abdominal pain, nausea, vomiting, and
diarrhea. The signs and symptoms are related to the layer(s) and
extent of bowel involved with eosinophilic infiltration: mucosa;
muscle; and/or subserosa (5). The diagnosis is suspected in patients
with abdominal pain, diarrhea, and peripheral eosinophilia; it may be
confused with the irritable bowel syndrome.

Fitz-Hugh-Curtis syndrome:
The Fitz-Hugh-Curtis syndrome, or perihepatitis, is a cause of right
upper quadrant pain in young women. It occurs in approximately 10
percent of patients with pelvic inflammatory disease caused by
Chlamydia trachomatis or Neisseria gonorrhoeae. Physical examination
typically reveals marked right upper quadrant tenderness.

Other Causes:
Abdominal pain can be caused by illnesses including metabolic
disorders ranging from diabetic ketoacidosis to acute intermittent
porphyria; abdominal malignancies; irritable bowel syndrome; lactose
intolerance; and helminthic and other tropical infectious diseases.
Abdominal pain may also be psychogenic in origin; this is a diagnosis
of exclusion and is most common in adolescents.

I stress that this answer is not intended as and does not substitute
for medical advice - please see your personal physician for further
evaluation of your individual case.
Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.  
Kevin, M.D.  

Search strategy: 
No internet search engine was used in this answer.  All sources are
from physician-written and peer-reviewed sources.

1) Fishman.  Approach to the patient with abdominal pain.  UptoDate,
2) Holland, AJ, Ibach, EG. Long term review of celiac access
compression syndrome. Ann R Coll Surg Engl 1996; 78:470.
3) Scott, EM, Scott, BB. Painful rib syndrome a review of seventy-six
cases. Gut 1993; 34:1006.
4) Santoro, G, Curzio, M, Venco, A. Abdominal migraine in adults. Case
reports. Funct Neurol 1990; 5:61.
5) Klein, NC, Hargrove, RL, Sleisenger, MH, et al. Eosinophilic
gastroenteritis. Medicine (Baltimore) 1970; 49:299.

Request for Answer Clarification by pm01-ga on 22 Feb 2003 06:52 PST

Thank you for your time and research.  You certainly mentioned some
things that I have never heard of.  I think I may have worded my
question wrongly.  I really wanted to know if anything rare could be
causing the Gastritis/muscle aches/joint pains/FUO?  I rarely have
severe abdominal pains and when I do it is usually gas related.

Clarification of Answer by kevinmd-ga on 22 Feb 2003 08:44 PST
Thanks for the clarification request.

To find diseases that may cause your symptoms, I used a computer
program called DXplain:
"DXplain is a decision support system which uses a set of clinical
findings (signs, symptoms, laboratory data) to produce a ranked list
of diagnoses which might explain (or be associated with) the clinical
manifestations. DXplain provides justification for why each of these
diseases might be considered, suggests what further clinical
information would be useful to collect for each disease, and lists
what clinical manifestations, if any, would be unusual or atypical for
each of the specific diseases. DXplain does not offer definitive
medical consultation and should not be used as a substitute for
physician diagnostic decision making."

I typed the following symptoms into the database:
- female
- adult, young (18-40yo)
- generalized myalgia
- arthralgia
- fever, recurrent
- dyspepsia
- chronic (> 4weeks)

Here is what the program came up with:
regional enteritis (Crohn's disease)
gastritis, chronic
systemic lupus
lyme disease, late
stomach carcinoma
tuberculosis, pulmonary
arthritis, rheumatoid
chronic fatigue syndrome
mediterranean fever, familial

Note that some of these diseases are rare.  You may want to discuss
these options as well as further testing with your personal physician.

Kevin, M.D.
pm01-ga rated this answer:3 out of 5 stars

Subject: Re: GI question for Kevin MD
From: surgeon-ga on 20 Feb 2003 21:19 PST
one source for low-grade fevers and abdominal symptoms when other
explanations don't seem to fit is occult gallbladder disease. It can
be hard to confirm, absent obvious gallstones; but occasionally a
situation like yours turns out to be due to gallbladder infection. It
can be investigated by various means, including (assuming there are no
gallstones) a HIDA scan which evaluates gallbladder function
Subject: Re: GI question for Kevin MD
From: pm01-ga on 22 Feb 2003 06:45 PST
Thank you so much for the additional follow-up.  I am appreciative of
any extra information.  The Hida Scan showed my gallbladder
functioning at 86%.  The only thing they have found with my
gallbladder is a small polyp???  It seems that my body reacts to the
Gastritis like it is an infection. I just keep hoping that I can find
somebody who has a similar situation with the Gastritis, muscle aches,
joint pains, FUO, so that we can exchange ideas.  I have a few
Internet contacts, but none with exact symptoms.

Thank you again and any additional ideas are welcomed.
Subject: Re: GI question for Kevin MD
From: pm01-ga on 22 Feb 2003 14:36 PST
Thank you...

I will research them and if anything sounds similar, I will discuss it
with my GI specialist.
Subject: Re: GI question for Kevin MD
From: arsenic-ga on 09 Mar 2003 11:05 PST
I noticed you've had Eppstein-Barr; you should take a look at . Myalgic Encephalopaty
(a.k.a. Chronic Fatigue Syndrome) causes some of your complaints; and
since this is a very variable diagnosis... Symptoms can include
stumach upset, low fewer, muscle aches and a general feeling of being
sick. It is probably worth ruling out, at least.

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