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    Suggest medical tests to rule out abdominal cancer

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Posted on Sat, 28 May 2016 in Bones, Muscles and Joints
Question: Hello,

I just came back from a doctor's visit regarding
my symptoms, some of which have been going
on for several years. Mainly, the problem is
pain at and below the ribs, mostly on the right
side, which gets worse after eating or taking
medications or any kind of pill. I've also been
losing too much weight, which is alarming.

My weight was stable at about 150 for a few years,
then 2 years ago it dropped to the mid 140's. In the
last few months it dropped down to the upper 130's.
I am 5 11 inches tall, so this is abnormally low.

The doctor today seemed fairly alarmed by this last
drop in weight, and wants to do a ct scan of the abdomen
and pelvis. I'd be okay with that, except for the fact that
I've already taken 6 ct scans in my life(most of them in the
last 4 years), and I feel this amount of radiation in itself
is creating a high risk for cancer.

My question to you is: is there any other test or combination
of tests which could diagnose/rule out cancer in that region?
For example, an ultrasound or MRI in combination with tumor
cancer markers(I already have a baseline established for those,
so that should make these tests more relevant).

Also, there might be some explanation of this last drop in
weight: during this period, I stopped lifting weights, eliminated
most dietary fats and all fruit consumption(because both were
aggravating my stomach). Also, it's become fairly hot here where
I live in Arizona, and I've spent alot of time lately walking in the
sun and sunbathing(which probably burned some extra calories).
Do you think this would explain an 8 pound drop in weight in
a few months?

For completeness, I should also mention that in the last 3 years,
while I was having all these same symptoms, I took quite a few
tests, none of which showed cancer or any major abnormalities
(eg. ct scan of abdomen/pelvis in 2013, MRI in 2013, MRCP in
2014, numerous blood tests).

Thank you very much,
XXXXXXX
doctor
Answered by Dr. Abhijit Sonawane 2 hours later
Brief Answer:
Kindly read ahead

Detailed Answer:
Hello XXXXXXX
Thanks for posting in HCM. I went through your whole query and also went through all the reports that you have attached with.
All your blood work is almost perfectly normal except for AST which is very borderline high which is not much significant.
So as you mentioned that you get pain in right side of stomach after eating and also there is significant weight loss of almost 15-20 pounds.
The weight loss reason might have been what you mentioned that you have stopped weight training, cut down on fat diet and other reasons which might be the reason of your weight loss. If your body has always been the slim type or leaner then as you stop working out or cut down on diet, body has tendency to go back to the normal baseline weight. Or it could be because of your decreased food intake as it causes pain and hence due to calorie deficit you might be loosing your weight.
So for now we will focus over your pain part. There could be some reasons-
1. Peptic ulcers- The most common reason for pain after having food is attributed to peptic ulcers in stomach. So have you done any endoscopy to look at any presence of ulcers?
2. Usually after having fat food diet, there is high concentration of bile acids secretion from gall bladder and liver hence it might give rise to pain in right upper quadrant. So USG scan of gall bladder will help a lot to tell whether it is functioning normally or not.
3. Just for the sake to rule out any presence of cancerous condition of liver, have you done alpha- fetoprotein marker?
Kindly answer above questions so I can get more idea about it.
If you have any more questions kindly write back.
Thank you
Above answer was peer-reviewed by : Dr. Sonia Raina
doctor
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Follow up: Dr. Abhijit Sonawane 2 hours later
Thanks doctor for your thorough attention to
my concern.

In answer to your followup questions...

1. Peptic ulcer: I did have an endoscopy about 2 1/2 years ago.
It showed "mild erosion" in the stomach but otherwise
nothing. I should mention that about a year after that,
I was diagnosed with an H Pylori infection. I took the
antibiotics for it and further tests have showed
negative for it. I think it's also important to mention
that taking antacids gives me temporary relief from the
pain, even the RUQ pain.

2. Gallbladder: I had several ultrasounds in the last 3-4
years. The first one showed an enlarged fatty liver, but
this condition gradually resolved itself. No gallstones ever
found. Also had an MRCP about 1 1/2 years ago and it
was perfectly normal.
I think it's also important to mention a few other things:
- back in 2012 I experienced a period of very rapid
weight loss(due with withdrawal from beta blockers,
which caused fatigue and lack of appetite). Shortly
after that is when the RUQ pain started up. Some
have speculated that the sudden weight loss might
have impaired my gallbladder/liver function, but not
enough to show structural damage.

- I've had numerous liver panels done in the last few
years. This latest one was the only one in about
2 years that showed any elevation of enzymes.

- one thing that really increased my stomach pain
in recent months was the introduction of a drug
called low dose Naltrexone. Its known to be hard
on the liver. I stopped taking it a few weeks ago,
but my stomach pain still has not receded to the
level it was before taking it. So maybe it caused
some liver damage and thus the elevated ALT?

- Liver cancer: I did take an Alpha Feto Protein test about
3 years ago and it was normal. Its possible I've had
one since, but don't recall for sure.

Thanks again,
XXXXXXX
doctor
Answered by Dr. Abhijit Sonawane 5 minutes later
Brief Answer:
thank you for reply. please read ahead

Detailed Answer:
Thanks XXXXXXX for answering my questions.
1. You had H pylori infection in past and you also mentioned that you felt better with antacids. This pain which you have now might be reccurent infection or gastric erosion which is giving you the pain after eating.
2. Naltrexone is a drug for specific cause. Why was it prescribed to you? Did you had any dependence on any substances? Because if you did had alcohol dependence then that might well answer for your fatty liver and slightly raised AST.
3. AFP was normal so cancer can be ruled out.
I would like to advice you to get a repeat endoscopy for presence of ulcers or erosions.
Meanwhile also let me know about your alcohol or opioid use history if any.
You can take a course of tablet pantoprazole 40mg once a day half hour before your food in morning. Take this for 15 days and see if it helps. But take the prescription from your gastroenterologist after endoscopy to rule out other reasons.
I want to know the alcohol history to see whether it answers the part of fatty liver and raised ALT and also gastric erosion.
Awaiting your answer.
Thank you
Above answer was peer-reviewed by : Dr. Sonia Raina
doctor
default
Follow up: Dr. Abhijit Sonawane 1 hour later
Hello. I should have mentioned I was prescribed low dose naltrexone for my chronic inflammation. At low doses (1 to 4 mg) its been shown to help with this. I currently dont drink alcohol or take drugs although I was rather a binge drinker in my twenties.

And I took the AFP test 3 years ago, so do you think im due for another one?

So do you think I can skip a ct scan for now? What about testing for pancreatic cancer? Would an mri, ultrasound or ercp be a good substitute?

So do you think I can skip a ct scan for now?
doctor
Answered by Dr. Abhijit Sonawane 2 hours later
Brief Answer:
Yes, you can skip a CT. please read further

Detailed Answer:
Thank you for answering XXXXXXX
Thanks for clearing the indication for naltrexone use.
1. As the last AFP was done 3 years ago you can repeat it now once.
2. Pancreatic cancer doesn't fit with your blood reports as it causes deranged LFT. But as you are getting done AFP, alongwith it you can get a CA19-9 done which is a good marker for pancreatic cancer.
Seeing all the discussion we had I would like to give you advice as follows.
1. Consult your gastroenterologist and get an endoscopy in view of ulcers or erosions in stomach.
2. Get AFP and CA 19-9 done to see for hepatic and pancreatic cancers. It will be unlikely to be positive as your LFT is pretty much OK.
3. Post pone CT for now as you are getting radiation exposure too many times which itself is harmful if overdone.
4. If you do want to you can get an MRI abdomen plain + IV contrast so it will be better visualized if at all any pathology has been missed prior.
5. Start with tablet pantoprazole 40mg once a day half hour before food in morning. Continue this for atleast 15 days and see how it works for you.
After all workup you can get back with me with all the reports and we will take further from there or you can consult your physician if you want.
I hope I have answered your query satisfactorily.
If you have any questions kindly ask me back will be happy to answer them.
Thank you
Above answer was peer-reviewed by : Dr. Deepak
doctor
Answered by
Dr.
Dr. Abhijit Sonawane

General & Family Physician

Practicing since :2011

Answered : 601 Questions

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