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Suffering from depression, anxiety and abdominal pain under ribcage. Had hiatal hernia. Getting nauseated after eating. Advise?

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General & Family Physician
Practicing since : 2007
Answered : 301 Questions
First of all, I suffer from depression and anxiety. I have had terrible time treating this. About 2 1/2 years ago I started to get abdominal pain right under my rib cage like somebody racking a dull knife across my belly. Constant, and persistent severe nausea. It gets so bad it takes my breath away. I am 6'10" and used to weigh 250 pounds, I now weigh 220 pounds or less, I am not trying to lose weight. At the beginning of this ordeal, the psychiatrist told me this was just anxiety, and my family dr said that too since I have a history of depression and anxiety. No tests at that time. So I went for about 6 months and it got worse, which increases my anxiety and certainly the depression. The pain becomes disabling.
I started to see a Gastroenterologist starting in late 2011. I had an esophagram upper GI which showed maybe a little GERD but nothing major. I was told to take Prilosec twice a day. No help. I had an UpperGI/T/Small Bowel Series which showed a small sliding hiatal hernia which I guess is common, was told this was not my pain problem. Had my stomach scoped and it only showed a couple of shallow areas but not ulcers. I had a stomach scope (a push endoscopy this time) again where they checked for H. Pylori, which was negative, but was told I might have a mild case of reactive gastropathy, but nothing series. Just told to keep taking the Prilosec twice a day. I had a Celiac Disease Panel which showed negative. I had a liver profile done next and it was normal. I then had a colonoscopy which came up normal. I have had blood work done more than once with nothing standing out than the ocassional Creatine level being a little high, they said probably dehydrated (that was at the ER once). A Gallbladder HIDA W/Ejection was done and came back with a gallbladder ejection fraction of 5%. So, this was thought to be my problem. They then took my Gallbladder out in May of 2012. No help. Lost more weight after that. I end up in the ER for pain numerous times, so I have had 2 or 3 CAT scans which show normal. The pain then started radiating to my mid back and upper shoulder area. I then had a Gastric Emptying study done and they show normal. 68% retention at 1 hour, 52% retention at 2 hours, and 1% retention at 4 hours, again normal. I had two epidurals and a doctor with no help. I then had an upper endoscopic ultrasound which just said mild lobulation of pancreas in the head other wise unremarkable examination of pancreas and CBD and ampulla. They then checked my thyroid levels, a full thyroid panel, came back normal. They then sent me for an MRI of the abdomen, again normal. Had an MRI of the back, just showed some mild degenerative disk disease but in lower back, not the mid back where I hurt. They did not think this was causing my abdominal and mid back pain. I had a blood allergy and Skin Allergy Food test, nothing showed up. I had an ERCP done then which also measured pancreatic SOD pressure of 12 mmHg, and biliary SOD pressure up to 36 mmHG. I was told if this last one was 40 mmHg or above they would have cut the sphincter muscle. This ERCP caused me to get acute pancreatitis. The pancreatitis pain I had was a little worse than usual, but in the same general areas that I usually hurt. When I went to the ER the day after the ERCP, I said I hurt a little worse, but its in the same spots as usual when I come in to the ER. I figured they would send me back home like usual when I go to the ER. But this time, I had acute pancreatitis and was admitted to the hospital for 1 week. I have had a CAT scan and another electronic ultrasound since this pancreatitis episode. The gastro dr here thought I might have autoimmune pancreatitis but was really guessing big time, so I was referred to Mayo Clinic. Mayo Clinic pancreas division dr looked at my records, and had a Mayo Clinic surgeon do another endoscopic ultrasound, and they concluded I was not having autoimmune pancreatitis. They specifically said the examined esophagus was normal, the stomach was normal, the duodenum was normal, there was no sign of significant endosonographic abnormality in the pancreas. Echogenic foci and strands, no lobularity, normal pancreatic parenchyma. No masses, cysts, the pancreatic duct was thin in caliber, the pancreatic duct was regular in contour. There was no sign of endosonographic abnormality in the common bile duct post cholecystectomy, there was no sign of significant endosonographic abnormality in the left lobe of the liver. I also had a assay, elastase, pancreatic, fecal collection, which showed 336 ug, normal pancreatic elastase, fecal is >200. So that was normal as well (that was done at home, not at Mayo).
I seem to get more nauseated after eating, but the nausea and pain is so very constant. I only had one time the past 2 1/2 years where I had a little relief, and that's when I started taking Remeron, but that only lasted about 8 days and the pain came back. I have taken many different medications like Bentyl, Levsin, Donnatal, Elavil, Pamelor, some pain medication but I try not to take pain meds very often, numerous other psych drugs for the anxiety and depression this is causing with limited results. Prilosec, Previcid, Dexilant. Drugs like Neurontin as well. Zofran a ton. I am currently taking Cymbalta, Klonopin, Remeron, Claritin, Prilosec, and a little Sudafed once and a while (I have had four sinus surgeries as well). I have tried to wean off of Klonopin but was not successful. I was concerned Klonopin might be causing this problem, but the drs tell me probably not. I don't abuse it, it is prescribed to me for severe anxiety and panic, partly anxiety due to this disabling pain. I take 1mg a day.
I have tried a gluten free diet for a month but did not notice much. I am at a loss, this is disabling me. I have wondered if the Sphincter of Oddi that measured 36 was high enough to cause me pain? A gastro dr here said he could cut the muscle, but there is a very high chance I will get acute pancreatitis again. I don't know. This is disabling. I work full time, but have been on short term disability off and on due to this condition. Is there anything else, is Klonopin the problem, or just anything I am missing. By the way, the drs don't seem to spend much time with me, I have to keep asking if they have run various tests, and then they say, yeah that would be something good to check, lets check it. I don't know about all these tests, why should I have to look them up and ask about them. I feel somewhat hopeless about this not getting better. My quality of life is terrible.
Posted Sun, 8 Sep 2013 in Medicines and Side Effects
Answered by Dr. David Okia 1 hour later
Brief Answer:
You need services of good clinical psychologists

Detailed Answer:
Good evening
You have mental health problem that needs very good patient clinical psychologist to do a lot of discussions(talking) about your condition with you.
More counseling by clinical psychologist is necessary, less drugs for psycho therapy are required.
The investigations you underwent are as per recommended guidelines and were useful for ruling out other conditions.
You need to gain confidence and belief in your self that you will be healthy, DO NOT LOOSE HOPE IN LIFE.
hope I answered your question ,if you have any more questions I am ready to help you.
Above answer was peer-reviewed by
Follow-up: Suffering from depression, anxiety and abdominal pain under ribcage. Had hiatal hernia. Getting nauseated after eating. Advise? 17 hours later
I have been in counseling once a week the past two years. I am trying to do that, I have worked on mindfulness, cognitive behavioral therapy, biofeedback, guieded imagery, etc. Some helps a little, but it is unrelenting. So basically you are saying I have a functional disorder that is psychosomatic. Which has caused me to lose 50 pounds and is disabling me. If that is the answer, that is fine. I don't have a lot of stress, I have a job, a family, a daughter, no legal troubles, I don't know where the stress would be coming from. The pain and nausea is certainly real, I am coming to the conclusion that yes depression and anxiety make it worse, but today's medical field is just not to the point where they can determine why I hurt so bad and am nauseated constantly. Medicine has come a long way, but there is still much they don't know. And when they don't know, they say its psychological, that's an easy out. If anybody here has any more feedback other than that, I would appreciate it. Thank you.
Answered by Dr. David Okia 30 minutes later
Brief Answer:
Intensive counselling 4 times week for 5 month

Detailed Answer:

Good evening,

I had a similar patient with exact complains like you. We did series of investigations all turned out negative. I am not saying you will be having the same. But, the probability of having such an issue is more with all investigations turning negative. You are right in saying that present science is in its infancy. But, we do not have any other option other than to trust on research data and practical experience available at the moment. I do understand your concern.

Good counselor, intensive counseling daily for 8 weeks and acupuncture solved the problem and he no longer has any pain. With all investigation already done, pathology would have been discovered by now, the only additional test missing is an HIV test. Please have it done and if it is negative, have an intensive counseling and acupuncture. Once a week is inadequate.

Hope I answered your question, I am happy to help if you have more questions.

Above answer was peer-reviewed by
Follow-up: Suffering from depression, anxiety and abdominal pain under ribcage. Had hiatal hernia. Getting nauseated after eating. Advise? 4 hours later
Unfortunately, I cannot afford that much counseling. I don't have enough money. Insurance gives me a hard time just to get once a week. Without insurance, I could not pay the counseling XXXXXXX but once a month. I have tried acupuncture as well. Little benefit. I did 20 sessions. I'm sorry for being frustrated, it gets old being sick. is there any depression med that would help more than another, I am crossing over from Klonopin to Valium and going to try to taper off of Valium, I still wonder if benzos are my problem (even though I don't abuse them at all), and I have read per Dr. XXXXXXX XXXXXXX who ran a benzo clinic in England, that Valium is better to taper off of. My family doctor has told me to try Elavil in low doses to see if it helps the pain, I can try that, I have taken it in the past, but it was before all of this pain and nausea started in. I don't drink, smoke, or do any street drugs, never have. I doubt I have HIV, have never had a blood transfusion, and have only been intimate with my wife, that's it for my entire life, just my wife. I can have it checked though. Any other feedback is appreciated on what could help with this pain, if its of a psychological nature, I will continue the 1 time a week counseling, I can't afford anything else. I would like a little help, most people probably just drink beer, but I don't do that. Could Klonopin be causing these problems and could a low dose of Elavil help me any? Any other med that's not a benzo that could help the severe anxiety? Buspar did not work, and I have taken multiple antidepressants, some of them make me worse. Lexapro was ok, but I could not ever tell if it was doing anything. Sorry for the long questions.
Answered by Dr. David Okia 1 hour later
Brief Answer:
Osteopathic medicine

Detailed Answer:

Good evening,

I surely understand the pain and difficulties you are going through. You can always write to me in detail about your difficulties. I am happy that you are opening up yourselves to me.

I rarely recommend my patients to go and see osteopathic doctors but in certain situations I have referred and some have reported marked improvement as far as pain in concerned.
I would recommend you see an osteopathic doctor, get their opinion and try their therapies.
There are also herbal preparations for pain relief. Unfortunately, there is less published research on these.

I do not think HIV is a cause for your problems. Neither your symptoms nor your history suggests that. Doing the test would be a waste. But, in case you feel that doing HIV test would alleviate your anxiety, then you should get it done.

Regarding the change of medications, it is always better to get it done under a registered psychiatrist care. If Klonopin is not helping much you may discuss this with your treating psychiatrist. He/She may change the medication so that your anxiety can be controlled better.

I am willing to help you, if you have more questions.
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