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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest treatment for severe back pain

Answered by
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Dr. Ramesh Kumar

Gastroenterologist

Practicing since :1986

Answered : 1956 Questions

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Posted on Mon, 3 Apr 2017 in Digestion and Bowels
Question: Hello Doctor,
I have been having back pain for quite some time now. I usually get it in the morning when I wake up. I am not sure if it is related to acidity. I had an endoscopy (and stomach biopsy) a couple of months back. The result was that there were no ulcers or H pylori infection present in the stomach. I did an MRI a few weeks earlier. I had a very minute lesion in the pancreas and the doctor told me that may not be causing the back pain. He advised me to take MRI in the next year to check the status of pancreas. I recently did a stool test for fecal calprotectin and the result is that the fecal calprotectin is high at 266. I have not experienced any diarrhea as such.
Can this cause my back pain? I was thinking of taking Endoscopic Ultrasound to detect any issues with my pancreas, colonoscopy for checking my large intestine and capsule endoscopy for checking my small intestine. As I am thinking of pregnancy in the near future, I am avoiding CT scan. Also, I noticed that I do not get the back pain symptom if I sleep for a shorter period of time. Furthermore, I sleep on a bed with an incline to avoid back pain. However, on nights when I sleep on a flat bed, I experience the back pain problem recur the next day morning. I am essentially taking colonoscopy, capsule endoscopy, and Endpscopic Ultrasound tests to figure out the root cause for my back pain. Can you please let me know if these tests are required? Also, can you please short list the root causes for my back pain? What would be the tests that you would advise?
doctor
Answered by Dr. Ramesh Kumar 15 hours later
Brief Answer:
Pain is related to spine.

Detailed Answer:
Hi again,
And thank you for choosing this forum again,
Most likely your back pain is not related to your gastritis or other gastric issues.
However it' very likely related to your spine.This pain may be caused by a small stress fracture in the back of the spine called isthmic spondylolisthesis. Lower back pain that is worse in the morning due to stiffness is likely Isthmic spondylolisthesis.
Pecautions
When sleeping on your side, place a pillow between your knees. Try to keep your top leg from falling over your bottom leg.When sleeping on your back, place a pillow under your knees. You also can put a small, rolled-up towel under the curve of your back.
The most common form of morning stiffness and pain is due to muscle imbalances and poor conditioning of the muscles themselves.
As per your query colonoscopy etc has nothing to with your back pain and is not required.
General advice-
Ensuring optimal spine alignment and comfort through an elaborate set-up of pillows,Always readjusting and correcting body position when sleeping
,Finding the ideal mattress, pillow top cover, foam cover, etc.
Finding the optimal climate with constant adjustment of temperature, humidity, clothing wear taking over-the-counter medications and muscle relaxants before bed

Test advice
MRI whole spine to rule out cause od pain
Serum uric acid.
Rheumatoid factor.
Serum calcium and Vitamin D.

I hope i was helpful,Feel free to question.

Regards.
Above answer was peer-reviewed by : Dr. Remy Koshy
doctor
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Follow up: Dr. Ramesh Kumar 2 hours later
Hello Doctor,

Thank you for your reply. I missed to mention few things in my previous question. I have been experiencing lot of burping, heart burn and indigestion for the past couple of months. I was taking ppi like omeprazole, pantoprazole and raboprazole for the past couple of months. The symptoms started with severe middle back pain in the early morning(pain intensity was 7 on a scale of 10). I was feeling a little better when I was taking those ppi medications. Now I am completely off from those medications and now I have again started feeling the middle back pain. I feel a strong pressure all around the rib cage in the early morning and it lessens when I sit erect and burp. The pain is also lesser if I sleep with the head of the bed elevated. This has made me to think if the back pain is caused due to the acid reflux or the pancreas. Sometimes during the day, when I have severe heartburn on empty stomach, I feel the burning sensation also radiates to the left rib cage and left middle back. But I also wanted to mention that my vit D level when tested was also low (10). But given my symptoms I am quite confused if the middle back pain is ortho related or gastro related. The MRI abdomen indicated a 9.5 x 7.5 mm small hyperintense ovoid area in the tail of pancreas. This is of low signal on T1 and shows bright signal on diffusion. Rest of the pancreas appear normal and there is no duct dilation. On ultrasound screening, the lesion was not visualized.

My questions are the following.
1. Since the back pain seems to be reduced by taking ppi medications. Do you think that it may be related to some gastric issues?
2. Is the lesion in pancreas significant in causing symptoms? As pancreatic pain is usually in the middle back. My doctor suggested that I do an endoscopic ultrasound to get more information about the lesion. Is it very essential that I do the test immediately?
3. Further does high calprotecten level (266) indicate any possible inflammation in the GI tract? My doctor suggested that I may have to do a colonoscopy and capsule endoscopy to observe the large intestine and small intestine. Do you think that I need to do these tests?
4. Since endoscopy and colonoscopy are invasive techniques, I am not sure if it very required that I do them now.

I have been having the above issue for quite sometime and I am very worried that I still do not have an answer to what is causing the symptoms. I would be very grateful if you answer my questions and clarify my doubts. Please let me know if you need any further information about my medical history.
doctor
Answered by Dr. Ramesh Kumar 4 hours later
Brief Answer:
Most likely pain is related to spine.

Detailed Answer:
Hello again,
As per your query.
1)-Most lokely the pain is related to orthopedics however as pain settles down on taking PPI's it can be ralted to Gastric issues also.
2) Immediate ultrasound is not required but please,It can be because of pancreatic lesion also but chances are very low.However to be on safe side a USG can be repeated.
3) Yes high fecal levels are no doubt an indicator of inflammation in gastrointestinal tract.Colonoscopy and endoscopy should be done to rule out anti inflammatory disease.So yes it should be done.

Possiblities are
Either othopedic pain or pain due to gartritis
Only tests can provide a definite answer.
please do all adviced investigations and follow up with reports

Thanks.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Ramesh Kumar 13 hours later
Thank you for your response doctor. I sincerely request you to recommend me the list of tests that I need to take and the order I should be taking these tests?
doctor
Answered by Dr. Ramesh Kumar 1 hour later
Brief Answer:
Follow up.

Detailed Answer:
Hi again,
The order of the test should be-

MRI spine
Followed by Serum calcium and Vitamin D levels.

If nothing is wrong with these tests-
Proceed for Endoscopy,Colonoscopy as you want.

Please mention history oF G.I polyps cancer gastritis etc in your family.
Any smoking or alcoholic history in your family.
What are your levels of anxiety.
You sleep cycle
Exercise schedule.
What improves you symptoms and what increases it.

Waiting
Regards


Above answer was peer-reviewed by : Dr. Remy Koshy
doctor
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Follow up: Dr. Ramesh Kumar 3 hours later
Hello doctor,

Thank you for getting back to me. The MRI abdomen mentioned "Disc dessication with degenerative disc disease is seen in the visualized lower lumbar spine (L4-5 and L5-S1 levels)".But I guess that this is only the lower part of the spine. Do I need to do another MRI to visualize the upper part of the spine?

I recently tested vit D levels and had severe deficiency of 8ng/ml. I am regularly taking vit D supplements. I have hypothyroidism and take 25 mcg levo thyroxine.

Family history: My mother has asthma and acid reflux issues. My father had IBS for a shorter duration during his younger age. None of my family members smoke/drink alcohol.

Anxiety level:I did go through lot of family and work stress recently. But right now I feel a little anxious about my health conditions. I am worried that I am having these symptoms for almost 4 months now and do not have an answer yet for the cause.

Sleep pattern: I sleep for 6-7 hrs between 12 pm – 7 am. Now my sleep is affected by the middle back pain which I get in early mornings.

Exercise schedule: I do yoga almost 5 days a week. I was doing lot of abdominal exercises and some mild exercises with weights but I stopped them after I started having the above symptoms. Now I walk every day for 30 mins.

I feel better if I stick to bland diet and take regular meals every 2-3 hours. I feel that the symptoms worsen if I eat foods like onion, tomato, spices, milk, peanuts. I used to take lot of spices but now I am on bland diet since 4 months. It is quite surprising to me that the symptoms have not subsided despite being on strict diet. I also feel that the symptoms worsen at night especially if I eat heavy/late dinner. If I have heavy dinner, I feel heart burn and lot of burping. I was feeling better when I was taking ppi. Now I am completely off it. I stopped them with great difficulty and do not want to start taking them again.

I am eagerly looking forward to your reply.

Thanks,
XXXX



doctor
Answered by Dr. Ramesh Kumar 2 hours later
Brief Answer:
Follow up

Detailed Answer:
Hi again,
As MRI reveals that spines are degenerated hence definitely a MRI whole spine shhould be repeated.Most likely as i already said pain was due to spine and calcium and vitamin D levels.
However severity is can be overlapped with acid peptic disorder.
So start taking PPI's and get all the tests advised above done to rule out the cause.

What are you taking for you severely low levels of vitamin D.
whats your calcium levels as calcium is often deficient with vitamin D

Does the pain ever radiates to thigh or neck nape.?
Have you ever tried pregabalin for pain?
Apart from PPI's which medicines helped you the most???

waiting
Thanks
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Ramesh Kumar 20 hours later
Hello doctor,

Thanks a lot doctor for your detailed answer. I really appreciate all your efforts. I was taking ppi for around 4 months now. Does taking them for a long term weaken the bones? I did not test the calcium levels yet. I took an injection for vit D with strength 6 lac 1.M once and now I am taking D rise 60 k every week. My doctor advised me not to take calcium supplement as it may aggravate the gastric issues. I also wanted to mention that I did take endoscopy 3 months back to check if the heart burn was due to ulcer/H-pylori infection. It showed that the esophagus, stomach and duodenum were normal and H-pylori was absent. I was wondering if the burping and heart burn can still be caused due to acid reflux as the tests were normal?
Sometimes I do feel leg pain and feel my hamstring is stiff but I do not think it radiates from the back. I have not tried any medications for pain. I did take pankreoflat, Acotrust , Rifaximin for indigestion and bloating and got relief from those issues. I am just taking probiotics and folic, zinc multivitamin tablets right now.
If the pain is due to some nerve inflammation, can MRI of the spine also show it?
doctor
Answered by Dr. Ramesh Kumar 1 hour later
Brief Answer:
Answers are in detail below.

Detailed Answer:
Hi again,
1) As per vatious trails in long term use of PPi's may cause weakening of bones(Theoretically).Practically its some thing very rare.
2)Calcium supplements should never be taken without advice,Excess calcium is excreted by kidney which may deposit leading to renal calculi.Calcium should be supplemented only after measuring current calcium levels.
3) Endoscopy means use of camera to see inflammation by H.pylori or due to gastric ulcers.They are just among one of the numerous causes which can cause acid peptic reflux.
4)Yes pain from back radiating to thighs is called sciatica and MRI is the gold standard test to rule out herniated disc or inflammed compressed nerves.

Please feel free to ask!
Regards.
Above answer was peer-reviewed by : Dr. Kampana
doctor
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Follow up: Dr. Ramesh Kumar 18 hours later
Hello Doctor,

Thanks a lot. I just had few follow up questions.

1. Apart from stress and h-pylori what are the other possible causes for increased stomach acid? I was wondering what could be the reason for my burping. I have heard about ph test being done to quantify the stomach acid levels. Will that be of help to my case?

2. I have been diagnosed to have few hemorrhoids and they are painful sometimes. Can they cause increased Calprotecten?

3. Can the lesion in pancreas be due to some inflammation? Does the pancreatic inflammation also cause increased calprotecten?
doctor
Answered by Dr. Ramesh Kumar 15 hours later
Brief Answer:
Follow up answer.

Detailed Answer:
Hello again,
As per your query answers are-

1) The long-term use of certain medications, such as aspirin and ibuprofen. excessive alcohol consumption, smoking.

Beverages: Whole milk and chocolate milk. Hot cocoa and cola. Any beverage with caffeine. Spices and seasonings, Black and red pepper. Chili powder. Mustard seed and nutmeg. Foods like Dairy foods made from whole milk or cream. Chocolate. increases acidity.

Autoimmune gastritis
Dyspepsia causes excessive burping-GERD is caused by an increase in intra-abdominal pressure . Acid reflux occurs when pressure causes gastric distention (stomach bloating) that pushes the stomach contents, including acid, through the XXXXXXX into the esophagus.
Suggestion-
Gaviscon antacid can be taken along with Nexium 40mg for symptomatic relief.

Ph testing a very old and insignificant test, you can go for Manometry and Ambulatory Ph monitoring, they are latest and will help.

2) Fecal calprotectin is a marker of inflammation any where along the full G.I tract. Hemorrhoids are dilated venous plexus; in layman's language, they are swelled and inflammed veins,

3) Pancreatic inflammation can increase calprotectin but it's not a very specific test. MRI of pancreas should be done to rule out exact pathology.

In case you need any other help I would be glad to help.
Thanks

Above answer was peer-reviewed by : Dr. Arnab Banerjee
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