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Getting stomach ache. Ultrasound, blood test normal. No relief from levsin and clonidine. Prognosis?

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Internal Medicine Specialist
Practicing since : 1996
Answered : 961 Questions
She had been doing sit ups at school, 1 week later stomach flu, 1 week after that this pain had started. The pain feels like it is ripping her stomach apart and sometime like it is being shredded. It is located on either side of her belly button but does not go to the flanks. The pain does not spread to other areas of her body. She has really bad spikes in pain. She had an MRI and CT 1 month after this started. Ultrasound of pelvis area 1 month later. January had standard Ultrasound of abdomen and pelvis. Blood work for h pylori, gluten, inflammation, lactase and thyroid. Waiting on stool results for inflammation, infections and h pylori. MR Enterography of abdomen and pelvis. All test are normal. She stomach is distended to the extent that she looks 5 months pregnant all the time now.

Medications currently Valium, Levsin, Naproxen, Evail and Prolsec. Past meds Toradol, Tylenol #3, Cyprojeptadine, and Clonidine. Nothing has changed the pain or resolved the problem. She has had PT for 1 month and the therapist stopped because it was not helping. We use hot towels and TENS with message at home. No relief. Walking, climbing stairs and bending makes matters worse.

No fever, rash, diarrhea. Bowel movements 2-3 times per day with normal in size and color. I give her Miralax twice per week to avoid constipation from all the meds.

The guesses were stomach migraine, and female issues. Cardio was re-run because the first one said arrhythmia and was repeated with a quick look and EKG. Cardio said elevated heart beat was from pain, no arrhythmia.

She has seen GYN, Neurologist, GI, and Cardio. The area has not changed and the pain levels have gotten worse over the last 2 months. Has seen a Psychologist but it was initial consult with no new RX or coping techniques. Next appointment is end of May.
Posted Sat, 30 Mar 2013 in Medicines and Side Effects
Answered by Dr. Prasad Akole 23 hours later
Dear friend,

Thanks for entrusting your query here. I am Dr. Prasad Akole (Critical Care Expert- and am glad to address to your query here.

I am deeply concerned about the child’s pain and no diagnosis even after so many tests…!
I learn from your description that all scans are normal and those medications are not working, neither physiotherapy and psychology counseling have benefited.

If the tummy has distended so much as to look 5 months pregnant, it is surprising that CT/ MRI/ USG have not shown any abnormality.

I would be greatly helped if you could upload a photograph of her distended abdomen and any reports that you may have (using the uploading feature available on this website located near your text box). If you have any difficulties uploading you can mail them to my attention (Attn: Dr. Prasad Akole) at YYYY@YYYY

I would appreciate if you could answer a few questions to help me localize the problem.
Is there any nausea/ vomiting?
Is there any back pain, tingling, numbness/ weakness in the lower limbs/ legs?
Is the area around the belly button discolored, abnormal, discharging any fluid?
Did any doctor suspect any hernia / divarication of recti (muscles in front of the tummy)?
Was a muscle tear/ sprain considered?
Any collection found on the USG in the abdominal muscles?
Is the pain electric like, or dull and constant?
Is it colicky, episodic? Comes and stays or comes and goes off soon?
Is there any associated sweating, flushing?
Was an endoscopy (OGD scopy, enteroscopy performed?)- not MR enteroscopy.

Dear, abdomen is a Pandora’s box for medicine and too many differentials are to be considered in such tricky case.
Rectus sheath injury, hematoma, paraumbilical pathology, mesenteric angina etc. could be the differentials among many.

Please upload the required information and revert for any more queries.
Would be glad to offer any help.

Thank you and Good luck!
Above answer was peer-reviewed by
Follow-up: Getting stomach ache. Ultrasound, blood test normal. No relief from levsin and clonidine. Prognosis? 4 days later
Dr. Akole

These are the pictures that you requested about 12 year old female with chronic abdomen pain for over 5 months. I tried to answer you questions but I don't know if you received my answers. I also have all the reports but I need to know if this is how I should re-send them to you.
Answered by Dr. Prasad Akole 11 hours later
Thanks for the photos. I saw them and found it to be a generalised abdominal distension rather than a localised swelling.
Indeed it is a considerable distension.
I am really surprised how the scans are not showing any pathology.
How long back were the scans done?

Also I can not see any reports or answers attached here. If you find difficulties while uploading to me, you can email them to my attention (Attn:Dr.Prasad Akole) at YYYY@YYYY .

Does she have any swelling of the feet/ legs?
I would like to read your answers and reports and then decide if we need to repeat an ultrasonography of the abdomen / pelvis.

How is her pain now? Has she tried any abdominal binders to reduce the pain?

Will await the reports and answers.

Above answer was peer-reviewed by
Follow-up: Getting stomach ache. Ultrasound, blood test normal. No relief from levsin and clonidine. Prognosis? 4 hours later
Dr Akole,

She has swelling in her feet and ankles. Her pain is constant with spike of ripping or shredding.

The MRI/CT were done in Oct. UT was done is January, MRE in February. She has been on a list of meds with no success. She started feeling nausea and vomiting last night. NOTHING HAS CHANGED IF 5 MONTHS AS FAR AS HER PAIN LEVELS. I will attach all the report via attachements email.
Answered by Dr. Prasad Akole 17 hours later

Thanks for the reports. I saw them and they are all normal, except some small lymph node enlargement seen on MRI in ileocolic region. They seem non significant.
The reports and scans are not contributing to the diagnosis.
This is a tricky case indeed..

There is no ascites (free fluid in the abdomen ), but she has legs swelling you say.
Does the swelling increase in the evening or on standing long and decrease on lying down for long?
Is there any discoloration, itchiness over the swelling?
Does it pit on applying thumb pressure?
Does she get any breathlessness on activity? Did she have any heart related event apart from some tachycardia?
Distension of abdomen and swelling over legs would result from kidney, liver or heart failure. But surprisingly all scans have ruled out any ascites that should be present in such cases. There are no masses or bowel distension to cause abdomen to distend and pain is also unexplained by common causes.
I would still request you to answer few questions that I asked in my first answer.
I did not see any report of a hemogram and differential white cell count and urine routine exam. I would like to have them.
We should now concentrate on rare causes which are tricky and would need further investigations. Let me have your detailed answers to see if I can pinpoint something.
Something like eosinophilic enteritis should be considered. (with pain on and of, small mesenteric lymphadenopathy, history of ? fever/ flu, and leg swelling nad now nausea/ vomitting). It may be evaluated by an endoscopy of the bowels and biopsy of the mucosa.
You can stop all other medicines except tramadol and Levsin (if it helps relieve the pain). Else she may benefit by narcotic based pain killers like butorphenol or fentanyl skin patch. Symptomatic treatment of vomiting with anti-emetics like ondansetron and Prilosec can be continued.
Please re-consult the GI specialist if required. Has she been given any course of antibiotics?
It would test everyone’s patience. Will wait for your answers and any remaining reports.
Above answer was peer-reviewed by
Follow-up: Getting stomach ache. Ultrasound, blood test normal. No relief from levsin and clonidine. Prognosis? 4 hours later
Dr Akole,

My mistake--She has NO leg swelling or swelling anywhere.
The urine and WBC reports were sent to you in the YYYY@YYYY
ATTACHMENT 11 and 12

Her HCG, HCT, and LYMPHO PCT are high. Neutro PCT is low. Others have changed a lot in five months either up or down. Report that you have rules on IBS, Celaic, Chron's and Lactose.

No ONE has given her antibotics becuase they say she has no infections or parasites.

NO back pain, tingling, numbness, discharge, swelling, heart problems or breathing. She has A LOT of pain in her abdomen after standing for awhile (1 hour).

I was told a hernia would have been felt and would have shown on MRI which was done 1 month after pain started and NOT since.

Her pain is constant 7-8 with spikes to 10 with a feeling that her insides are shredding. Nothing seems to change her pain. The hospital gave her 30mg Toradol and she got some relief from that until it wore off. We are currently using hot packs and TENS with no relief. The lymph nodes were not present in January but were there in Feb.

We give her ondansetron for nausea. She can't take Ultram because after 4 days on it she complains that she can't breathe.

No endoscopy or enteroscopy has been done since this pain started. Only MRI, CT, UT and MRE. MRI showed no muslce tear 1 month after pain but no test since then. She has trouble bending, twisting, walking and standing for more than 1 hours. Pain get REALLY BAD for hours.

GI doctors don't want to run anymore tests cause they say it could be 100 things but that doesn't solve what is wrong. Ped doctor doesn't know what else to do.

She is home schooled, has friends and has a nice life. Both parents in home, married for long time, stable environment. Her only anxiety is that no one can't find what is causing her pain.

Could it be a vitamin or mineral problem or needs more test with heart doctor? I am guessing.
Answered by Dr. Prasad Akole 59 minutes later
I read ALL your reports, saw the photos, read all the communication again. Labs are all normal.
Like all the experts who checked her, I am clueless as to the exact cause.
However, I cannot physically examine her. Therefore, I have to rely on your description and other expert’s opinions. All the things are quite atypical and it is a diagnostic challenge.

My gut feeling is that it could still be a small bowel problem. We had a doctor colleague with such unsettling pain, which was unbearable. After a LOT of tests, we could label and treat it as eosinophilic enteritis after bowel biopsy.

I feel, a second GI opinion (especially at a reputed academic tertiary care hospital) is worthwhile. Pan –endoscopy and multiple bowel biopsies may be done. Consider enteritic causes. Mesenteric angina?? Mesenteric adenitis?

See if Pregabalin helps her pain. (Steroids are choice for eosinophilic enteritis)
She may be offered narcotic painkillers like butorphanol or fentanyl skin patch under supervision to help with her pain, ondansetron and Prilosec.
In the end, pain may be functional (psychological causes)…but you told that she is in a stress free environment.(please explore this possibility also, especially if nothing else is working).

I would possibly discuss this all with my paediatric colleagues and see if more help can be gathered.
Keep patience. Things do get sorted out.

Will be back.
Above answer was peer-reviewed by
Follow-up: Getting stomach ache. Ultrasound, blood test normal. No relief from levsin and clonidine. Prognosis? 43 minutes later
Dr. Akole,

I really appreciate all that you are trying to due for my daughter because we have been dealing with this for 5.5 months. Summer is coming and she wants to get back to swimming and riding horses. I will search for another GI Ped and see if they will listen to me about the tests.
Could she have an Abdominal Aortic Aneurysm due to the "Ripping and Shredding Pain"?
You can reach me at the email from the attachments or YYYY@YYYY
Answered by Dr. Prasad Akole 12 hours later
An AAA would have been pulsating, does not cause such symptoms and distension
and would have been picked up by so many scans long ago.

Pancreatitis, appendicitis may mimic her pain, but have not been shown by any scans, nor has she any fever or worsening general condition.

She has to have a mesenteric/ small bowel pathology. Regional enteritis should be considered.

Dr. Akole
Above answer was peer-reviewed by
Follow-up: Getting stomach ache. Ultrasound, blood test normal. No relief from levsin and clonidine. Prognosis? 10 hours later
Dr Akole,

For the last 2 days she is very nausea and won't eat or drink. She is very pale. She said that eating makes it worse. I have given her the ondansetron.

Would a small bowel problem have shown up on UT, CT or MRE?

Since what you think is the case then I will have to find another GI doctor because the last two won't run anymore tests since everything is coming back normal. What type of test would show this problem?

I am scared because I know something is very very wrong. She is an active, energetic young lady with being an A-B student.

Answered by Dr. Prasad Akole 45 minutes later
Hi again,

Scans generally pick up obvious masses, thickenings, obstructions, dilatations, fluids collections etc..
Non-raised intestinal involvement will not show up on scans.

Actual endoscopy (enteroscopy,/Oesophago -gastro -duodeno scopy) would actually show the XXXXXXX lining of the GI (Gastro intestinal) tract and enable biopsies from the gut wall which sometimes are the only source of diagnostic yield. Also small erosions/ ulcerations may show up only on endoscopy.

If she has developed vomiting, has any fever and if not passed motions or gas since 2 days. She will need urgent medical attention.

Keep a watch on the abdominal distension and urine output.

Also try psychological counselling. I feel most other possibilities have been ruled out well.

If there is any fever, please ask about antibiotics. May consult a good paediatrician again.

Why don’t you admit her in a good academic hospital and do all the tests and treatment under one roof.
She may need IV(intravenous) fluids if she does not eat and vomits more.

Hope I answered your query.

Wish her you good health.
Above answer was peer-reviewed by
Follow-up: Getting stomach ache. Ultrasound, blood test normal. No relief from levsin and clonidine. Prognosis? 1 hour later
Dr Akole,

I really appreciate all the time that you have put in reviewing her case. It is just aggravating when a doctor just wants to stay in their comfort zone before they have ruled out other possibilities. I have found 1 GI at a children hospital who was willing to run just the basic blood and stool tests but since they came back negative she won't do anymore.

I have been able to get her to eat applesauce and drink some. I will watch her but no fever. I will call her pediatrician on Monday and see about antibiotics. We have been to the psychologists for consult but can't see her until end of May.

Unfortunately, I will have no way of letting you know what the actual solution is because I can't pay the $35.00 fee again since I am not working. I have printed out all your suggestions and recommendations and now the fight will begin to get it done.
Answered by Dr. Prasad Akole 7 hours later
Good to read that she has no fever yet and has drunk some liquids.
Keep the morale up and see what best can be done.
I know it is difficult to keep meeting doctors every now and then.

Also, you can always let me know the progress by routine email which does not cost anything?!!
You can contact the customer support team of XXXXXXX for assistance here.

Anything for a child !!
keep in touch..
Wish her luck and tell her that she is going to be alright soon...

Dr. Akole
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