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.
"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.
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 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.
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.
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.
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.
Clarification of Answer by
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:
- adult, young (18-40yo)
- generalized myalgia
- fever, recurrent
- chronic (> 4weeks)
Here is what the program came up with:
regional enteritis (Crohn's disease)
lyme disease, late
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.