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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Joint pain, chest pain while breathing, coughing up blood and found fatty liver. Treatment to be done?

Answered by
Dr. Charles S Narasi


Practicing since :1962

Answered : 693 Questions

Posted on Tue, 5 Feb 2013 in Digestion and Bowels
Question: Hello, I have been trying to solve undiagnosed chest pain for about 6 years, my symptoms have slowly gotten worse over the years and appeared in this order.

- Joint pain in feet (severe)
- Small amount of "air hunger" only at rest
- Uncomfortable feeling in chest
- More Joint Problems
- High Uric Acid Levels (presumed gout)
- Uncomfortbale with XXXXXXX breath
- Pain with XXXXXXX breath
- Large pains in chest when breathing deeply
- Low 02 Saturation 85 - 95%
- Low Blood O2 gas
- Worsening chest pain
- Very Strange burping - like my body was forcing me to do it
- Squishy feeling inside chestin between lung and chest wall
- Feeling very unwell
- Lipoma growth in chest cavity
- Strange Crackling noise on exhale at night
- Feeling air hunger when lying down
- Worsening chest pain
- Coughing up Blood
- Positive Shunt Study test

I am a 40yr old male - rather overweight 6ft2in 113kg - howewver I am still quite fit and play football 4 times a week - I used to be a pro soccer player (goal keeper).

I smoked in the Army but not heavy and I was a heavy drinker but not currently the only family history is Ulcerative Collitus, Bowel Cancer and Nephritus

History - this all seemed to start back in 2006 after a trip to Thailaind and Germany and after I got vacinated because of the outbreak of German Measles at that time - at this time I was also exposed to
a sex worker who had HIV - I was given Anti Retro Virals for 2 weeks and never caught the disease. IT all started with a strange feeling of not getting enough air, I got a lot of joint pain in my
but as my Uric Acid levels were high they assumed gout, this continued for over 12 months -
I had fluid removed from sore joints and uric acid crystals were found, treatement for gout was started - this did not reduce my Uric acid levels - it continued to get so bad I could not walk,
they did an MRI and a Rheumo said that the damage seen - florid synovitis (or what have you) and other connective tissue issues, looked like it was more than gout.. in the end Prednisone
was administered and within a day I could walk freely with no pain...
The difficulty breathing got worse and worse, I was sent to a sleep specialist, they diagnosed me with Sleep Apnoa and I
have used a CPAP since, during the night of my sleep study, my O2 sats dropped to dangerously low levels - after I started getting pain in the chest I was sent to another rhuemo who thought it
might be Arthritic - but he ruled out Arthrius as the cause, I have been tested for Lupus, XXXXXXX R Facter, sarcoid etc etc I do have bad psoriasis but was told that it was unlikely to be psoriatic
arthritus -
they decided to do a Pulmonary Sprial Angio, which found some dark pathces on the bottom of my lungs, but nothing exceptional, and enlarged lymph nodes (pre tracheal) but nothing significant,
certainly no clots etc, as the pain worsened I had a cardio stress test...and this was fine, they ended up stopping the test as i could run for so long, they then did a spirometry test and it
was ok too, I have now had a total of 6 CT scans, a Galuim scan and MRI, several XXXXXXX tests and 2 cardio stress tests as well as ultrasounds of heart pressures - the most they have ever found
was patchy infiltrates, some fluid like signs (possibly from being stationary) and minor dependant basal atelectasis in the base of both lungs - each time they have assumed inflamation.

The galium scan revealed considerable bowel retention, I had a Endoscopy, which showed mild Gerd symptoms but no hernia - I have since had another which revealed the same with more Gerd,
I decided to see a general physician - they tried prednisone which worked for the first few months, but I grew very fat and it seemed to wear off- they tried methtrexate which did not help -
during this time I caught food poisening and had a vasal vagal black out while driving and was in a serious accident but not injured -

I had a PH Test done to measure acid reflux....
this found that acid was coming up at night and staying up - they decided to do a Fundiplication which did not go well, it took 3 hours and my heart stopped - whenever I drink water now,
it does not go down for ages, it sits high in the chest and I can hear it sloshing around - the strange need to burp has stoped however and I fart a lot more...Since the antiretrovirals my tryglicerides and chol
have climbed even on 80mg liptor -

I have elevated LFT's but this is suggested of fatty liver or the lipitor, My chest became more uncomfortable and i could feel fluid inbetween the lung and
chest wall, but no one could hear any friction rub and it did not show up on CT's - I had a bronchoscopy which was normal and more recently have had two more -
the first of which revealled squamos metaplasia (but no cancer cells yet) and abnormal cell growth in one lung, the second one revealled infections and more metaplasia now in both lungs
as well as chronic inflamation - there were abnormal areas to sample from.

My O2 sats were tested and remained lower than 91 they decided to test my O2 blood gas which was also low
and then performed a shunt study which proved I have a shunt, I was sent to cardiologist who performed more stress tests and untrasounds and said my heart was fine -
a buble study was done with no sign of a shunt. The feeling of being unwell and wanting to pass out continued but joint pain had gone away for some time -
I tried more aggressive treatments for gout - higher doses of allupurinal and other gout meds and anti inflamatories and am currently on Sulphasalazine -

I had strange issues where a bursa on my elbow
would get bumped at sport and my whole arm would get infected for some reason causing eodema. Recently I had a lot of eodema in my legs, especially when sitting for more than 1 hour.

I started to cough up more blood and was finding blood on the pillow in the mornings, it was bright blood and I dont get nose issues, but I got ear and nose checked anyway as I constantly have
a post nasal drip - it was all fine - it was suggested I mght have a pumlmonary eodema but the amount of CT's I have had to date should have shown it by now, The crackling noise at nght on exchale is
causing a lot of stress for my partner as she can hear it quite well - I have grow pretty tired of all the guessing
and personally I was prepared to let it all go as I was sick of the radiation exposure, but it just seems to get worse and now I have pain on both side of the chest when breathing XXXXXXX and it feel heavy
on the left side.

my O2 sats are now down to 92 when lying down, yes it changes a little when lying down
I went to have another PH study done, but they could not get the sensor into my gut - I seem to have a sore upper gut all the time, I tried foods without gluten and this helped for a little bit but
as soon
as I excercised it got worse again - I have tried fluid only diets which help the pain just under the bottom of my ribs (around the upper gut) but does not help with the breathing issue, I have tried a
Asthma challenge test which showed I do not have asthma - the fluid in chest feeling seems much much worse and the feeling of being unwell is terrible, my hands keep swelling up and occasionally my legs
still get oedema - if it would just stop at this level I would feel ok, I have always had a lot of lipomas in the chest and I had one removed by a doctor who to be honest was very sheepish about it all
and swore when he removed it as if he was frightened (this was when it all started too) but these lumps seem to be a lot more and I seem to have quite a few in the abdomen below the ribs.

Thats about all I can tell you - I am NOT a hyperchondriach (spelling) it has just been 6 or more years so I know a thing or two about the issues - there is definately something wrong, but I cant work it
out and neither can the Doctors, so I am asking if there is something else I could try - my bet would have been Psoriatic Arthritus but they say it normally is not in the chest wall and it does not lower
O2 or make you feel unwell - it just causes pain.
The only other thing I could think of is a GUT issue - but not sure how else I can test this. - Could this be a gut issue, as the respiratory guys seem to think the area I point to is upper gastro - dont know how else I could test gerd?

Answered by Dr. Charles S Narasi 17 hours later
I am very much impressed about your very detailed medical
history. As a soccer player I am sure you were very fit and
took care before you got sick. There are numerous issues.
Problem with lungs, probably some restrictive chronic lung
disease which is causing you to have low Oxygen saturation
levels. You are on treatment for high cholesterol and also
high uric acid levels, presumably Gout and related arthritis.
If you have any small hard lumps over the toe joints or finger
joints, a simple biopsy would confirm if it is gouty arthritis.
Then, ther is fatty liver and liver enzyme elevations. It is
very possible that the liver enzymes could be related to
Lipitor, but the finding of fatty liver and your prior history
of heavy alcohol consumption may be related .
Now, coming to your problem of GERD, I see you are taking
Nexium 20mg. daily. You had a failed fundoplication.
I am not sure if you have tried taking Nexium twice a day
about an hour to hour and a half before meals, that's when
it is effective.
Were you taken of statin drug for 4-6 weeks to see if your
liver tests got better?
If you obviously have Psoriasis skin lesions, usually around
the extremities, elbows, shins, scalp area, or even the buttocks,
then you could have psoriatic arthritis. The skin lesions are very
easy to diagnose.
I also recommend that you have screening for Celiac disease.
This can mimick or mask lots of disorders. Inflammatory Bowel
Disease panel of blood tests are also indicated in your case.
Sleep apnea could very well related to GERD, especially during
nights, when you are flat in bed. If you can have your head of
the bed elevated over 4" blocks , this might help.
Make sure that you don't eat or drink for at least 2 hours before
you go to bed.
The other thing you can try is Sucralfate liquid (Carafate-Brand Name)
1-2 teaspoons four times a day. This drug acts through protective
prostaglandins that can prevent inflammation of the lining of the
esophagus and stomach.
I am not sure if you had the ambulatory pH monitoring attempted
I know that you have had upper and lower endoscopies done.
If facilities are available for Capsule endoscopy for evaluation of
your small bowel, that may be worth . That can detect hidden
changes of Crohn's disease or gut tumors.
Long distance diagnosis is always difficult althugh you have
provided excellent data from your medical data file.
I wish you well.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Charles S Narasi 13 hours later
Thanks So Much for the prompt reply -
I have had fluid taken from inflamed knee, ankle, elbow bursa etc, each time there are a very very small amount of uric acid crystals, however that pain is always different to what I feel in my chest - that pain is always more painful and the joint is almost aways hot, the chest thing feels different - and I am told that you can not get Gout in the chest wall.

I did try nexium 20 in the morning and 20 at night, it did sort of help - but I often eat before bed time. I tried elevating the bed already but was getting oedema in my legs by doing this - much more than usual and it didnt seem to make a lot of difference - I am keen to get the inflamatory bowel and celiac test done, can I get this from the GP or do I need to see the Gastrologist - I thought about the capsule option but was concerened that it might not fit through my sphinkter - I have an issue now where when I drink water it doesnt seem to go down it stay in the upper part of my chest, you can actually hear it sloshing around and feel it moving well above my stomach, when I walk it is very audible - eventually it goes dwon, but eating large hard things seems hard since the op. Originally I had the strangest burps before the fundo - it was like my body forced open something in my chest as gas needed to escape, it was not the normal sound for a burp, more like a rapid vibration as air escaped up and it was sore, since the fundo that has stopped but it still feels like something is pushing my gut up and out like it needs to escape. I probably should mention that when they did the bronchoscopy, they found an infection that is usually found in the gut so perhaps I am getting stomach acid into the lungs at night .

I went back to get a second PH study where they put that wire down your throat, the first time they had great difficulty getting it through the sphincter - but they did find that I get too much reflux and at night it comes up and does not clear out -ie it stays in the oesuphagus for long periods - I wanted to get tested again but the second time they tried they could not get the sensor past the sphinkter and gave up.

I can feel cold water soothing inflamation when I drink it sometimes on the way down, becasue I have had infections found in my airways they didnt want me using too much Nexium, in case the less acid was not killing the germs.

I have to add that this all started a long time ago, when I threw up in my sleep after eating and drinking, I am positive some garbage went down my airway, and I am concerned it is still at th bottom of my lungs, hence the crackling sound.

Can that Sucralfate be bought over the counter or do I need to get a prescription from the GP or does the Gastro Doctor have to do it.

I am concerned that the metaplasia could be from constant inflamation from stomach acid but I am not sure how I could test that.

Also have you seen any people with reactions to Allopurinol or Lipitor that may upset the gut.

I also seem to be a lot worse when I eat oyster sauce or fish paaste or fish sauce in fact anything that is seafood related. I never eat seafood as I dnt like it much, but it is in a lot of Thai cooking.

I have found bleeding in my poo - but they assure me this is most likely to be heammarhoids and that does seem to fit.

I also strangely this year got diagnosed with pocket in my bowel, forgot what they call that - its something that usually only older people get.

So now down to the strange stuff - when I lie down, my gut makes the weirdest noises, it sounds like a somone pouring a jug of water slowly into a thin metal is like there is a hole somewhere and thin bits of water are going through and mking this whining sound - I know what stomach gurgling sounds like... but I also get a very loud clunk some times like the food just went past a blockage its not your every day gurgling noise either its a very audible clunk, I also seem to have a lot of fatty lipomas around the area that the clunk comes from - can you get a hole in your stomach or a knot that might push acid up?
Answered by Dr. Charles S Narasi 2 hours later
Presence of uric acid crystals establishes the diagnosis of gouty
arthritis . Chest wall pain may be musculoskeletal , may be a side
effect of lipitor or just non-specific. You can try some local pain
(Analgesic) creams such as aspercrem or Bengay (Mentholatum).
Looks like your fundoplication surgery effect is still there , especially
if you have trouble belching and swallowing. You might have some
scar tissue in that area. All the noices that you hear in your belly
are from trapped gas in the intestines. Make sure you stay away
from carbonated drinks. I am not sure if you were ever put on
a pro-motility drug such as Metoclopramide , small doses to help
contractions of the stomach and intestines.
Your GP can prescribe Sucralfate , worth a try.
Pockets in the colon (Diverticulosis) can sometimes cause irritable
bowel symptoms such as constipation and bloating and gas.
If there is infection in those pockets (Diverticulitis) then you need
You mention that you do eat late at nights. I really think that is
adding to your reflux of acid problems at night. Try to work on it.
I don't think I have much more suggestions for you.
I wish you the very best.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

The User accepted the expert's answer

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