Dr. Ajeet Kumar
Medical Gastroenterology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I was initially in the hospital with heartburn. They performed a CT scan and ultrasound, and it showed a mild fatty liver. Bilirubin levels were 2.2, with unconjugated being high. I followed up with MD and did bilirubin again, and it was 1.6 with elevated unconjugated levels. She then ran tumor markers and CA 19, which were initially 71 and when repeated was 35. I also had an upper EGD with chronic esophagitis. After this, I went for another pancreatic protocol CT with contrast and MRI and MRCP without contrast. Everything was normal. I am now having constipation, and the stool color is yellow to light brown, with no blood. I am also currently getting stitching-like pain right under my left rib cage in the back as in the flank area. I am chronically nauseous. Lethargy and fatigue are overwhelming, and I also have a dull pain in my legs. Please help me with this.
Hello,
Welcome to icliniq.com.
I can understand your concern. However, I do not think that the information you provided is enough to make a diagnosis. I would need a complete history of your problem. And all the investigations that have been performed. For example, endoscopy images with biopsies reports, if any. I want to see the hospital's discharge summary where you got admitted and the reason for performing all those investigations mentioned.
Chronic nausea may be a secondary symptom associated with the primary underlying condition. Lethargy and fatigue are vague symptoms that can accompany various processes such as anemia (low hemoglobin), infections, and any disease of chronic nature.
I want you to describe the pain in your upper abdomen in more detail, such as onset, severity, radiation, association with a meal, progressive nature, how it is relieved, duration of pain if episodic, and timing of this pain in a day?
You can contact me while providing the above information using chat, phone, or video consultation. It would be easy for me to wrap things in no time, and I can give you my best opinion at the end of the consultation.
Patient's Query
Hello doctor,
Thank you for your response.
The onset appears when I eat meat or greasy food and is rather random in nature. The severity of the pain is usually tolerable. Although uncomfortable, I would say it is a 6 out of 10. There is no radiation in pain. It only seems to be in my back, directly under my rib cage, just above the navel. Or in the epigastric area, where it is very painful to even touch the region. I also bloat and develop gas. The pain seems to be the same each time I have it. It is relieved by laying on the opposite side of the left side pain, and when I lay on my back, the left side pain is enhanced. The duration of the pain varies. It is episodic and comes and goes. Sometimes I have pain for a day and other times for a few hours or days. I do not have anemia as my hemoglobin is normal. I was tested for multiple myeloma. It came back as polyclonal hypergammaglobulinemia, and they are unsure what is causing this as well.
I went into hospital for the heartburn, and they diagnosed it to be dyspepsia. They checked the regular laboratory tests, such as comprehensive, metabolic, and urine tests. With these tests, they noticed hyperbilirubinemia and wanted to check further for direct and indirect, but instead, I followed up with my doctor. While in hospital, they checked for cardiac enzymes, which were normal. They also did a CT scan to rule out cholelithiasis. The reports are uploaded for the CT scan and ultrasound.
I have a history of premature ovarian failure, so to go on HRT, they wanted to check my coagulation panel, and it showed elevated factor VIII levels. So my primary MD sent me to a hematologist to do further testing regarding factor VIII. I am also concerned about my weight loss of 5 to 8 lbs within about nine months. I was 98 lbs and went down to 90 lbs. Currently, I am 94 lbs. So my hematologist stated I had cachexia and hyperbilirubinemia, and I am assuming that this is why tumor markers were tested. I followed up with the hematologist and did all tumor marker tests. All were negative except for my initial CA 19, which was at 71, and bilirubin was at 1.6 seven months ago. I was told to get another CA 19 test at a different laboratory three months later, and it was normal.
During this time, I was sent to also do the CT scan pancreatic protocol with negative contrast, and MRI, MRCP without contrast, and the results were normal for all. No other tests have been performed aside from colonoscopy. The EGD was normal, aside from chronic esophagitis. I was on tablet Prilosec 140 mg and tablet Pepcid 80 mg, and tablet Gaviscon, and the heartburn was still relentless. I am worried if it is some cancer of the colon, pancreas, or liver as my initial CA 19 levels were elevated. I have attached my CA 19 test reports. Can I upload a picture of my stool as well, doctor? I have been to several doctors with no answers. I hope you can help me out.
Hello,
Welcome back to icliniq.com.
I have reviewed your history and all the investigations which you have shared. To summarize, you have left side upper abdominal pain, which is more like a gaseous discomfort rather than a pain actually. The pain does not seem to be of pancreatic or stomach origin, given the fact that your endoscopy did not show any ulcers. You have low weight. However, not a significant weight loss. Some people are skinny to start with, and this is more genetic rather than disease-related.
In the laboratory tests, there are certain things like osteopenia at such a young age that is concerning. But since you have a primary ovarian failure, it makes me think there is a problem with the endocrine system that includes parathyroid hormones or the pituitary gland in the brain. Since I am not an expert on that, I can not comment on that. But want you to check with an endocrinologist for that.
Other laboratory values which are a little bit out of range are bilirubin, of which the indirect component is slightly raised. It might be Gilbert's syndrome, where the asymptomatic elevation of indirect bilirubin is raised. I do not think the pain and indirect bilirubin are related. However, there is another condition which is called functional gall bladder dyskinesia, where there is an abnormal contraction of the gall bladder. An associated diminished or abnormal flow of bilirubin across the common bile duct is a condition called sphincter of Oddi dysfunction (SOD), which can cause pain as well as slight elevation of the bilirubin. Again it is the direct component of the bilirubin that is elevated, not indirect bilirubin. But yes, we can look for it through a test called gall bladder scintigraphy, which is also called a HIDA (hepatobiliary iminodiacetic acid) scan. I also see that your lipase, which is a pancreatic enzyme, is elevated to 169 IU/L. However, I could not find the reference value of that test. Kindly send me the reference value. If it is abnormally raised, it raises suspicion of sphincter of Oddi dysfunction ( SOD).
Lastly, to conclude, in terms of my overall assessment. You probably have SOD, or gall bladder dyskinesia, maybe both combined. Or the second possibility is functional abdominal pain syndrome (FAPS). Otherwise, I am not concerned about CA 19-9 (Carbohydrate antigen 19-9) since it is in normal ranges. Secondly, both your CT (computed tomography) scans are normal.
Patient's Query
Hello doctor,
Thank you for the response.
I am unable to see the lipase range as they are not in the hospital-based laboratory tests. It just says 165 without range. Would biliary dyskinesia cause the symptoms that I am having? What is SOD? Were you able to look at the color of the stool, doctor? This is a consistent color. Would the MRCP or CT scan have not detected the SOD? Does the upload state that I have Gilbert's syndrome? Can I take Caltrate safely right now for my osteopenia dr?
I will speak with an endocrinologist. No tumor pituitary as I had a head CT, but I will more than likely get laboratory tests done soon. I know that your specialty is also not hematology, but did you see the polyclonal hypergammaglobulinemia? I just wonder if this is all related.
I have pressure now and pain when I feel like I need to have a BM. I have been on high doses of PPI with no relief of symptoms. My whole body hurts everywhere, doctor. I do not know what to do anymore. Thank you.
Hello,
Welcome back to icliniq.com.
Yes, gall bladder dyskinesia or Sphincter of Oddi dysfunction (SOD) and functional abdominal pain syndrome (FAPS) can explain your symptoms. The color of stools is normal. Polyclonal gamma globulins suggest chronic inflammation. However, monoclonal antibodies indicate multiple myeloma, which you do not have.
Yes, you have Gilbert's syndrome. But it is entirely benign, and you should not be worried about it. This level of indirect bilirubin would not harm you. However, you should be cautious of any medications which impair the liver because, in that case, the bilirubin can jump to high levels, which can be toxic.
Yes, you can take tablet Caltrate twice daily for one month at least. Check your vitamin D and bone mineral density at the end to see if it improves your osteopenia. Your body ache can be a part of an overall functional syndrome.
The treatment of functional abdominal pain syndrome is low-dose antidepressant medications. They are given to modulate the pain perception in the brain from the abdomen.
SOD is the dysfunction of the valve in between the pancreatic head and common bile duct when it meets the small intestine called the duodenum. The abnormality cause spasm of the muscles around this area.
MRCP (magnetic resonance cholangiopancreatography) and CT (computed tomography) scans are static investigations. That is why they can not detect gall bladder dyskinesia and SOD. Gall bladder scintigraphy (HIDA) scan is a dynamic (real-time) investigation that shows the timed flow of bile from the liver to the gall bladder to the common bile duct to the small intestine. Thus, we can interpret the function of the gall bladder and common bile duct.
Patient's Query
Hello doctor,
Thank you for your response.
So your recommendation is to get a HIDA scan and take Caltrate daily? Is there anything else I should do or be concerned about? Is there anything I can take for the heartburn and nausea at the moment because double-dose PPI has no effect on my symptoms? Would the calcium in Caltrate have any bad effect on me due to the slightly elevated calcium levels in the blood? Also, if my magnesium is normal, can I take a supplement, and if so, how much? I will also do laboratory tests for the endocrinologist. Thank you.
Hello,
Welcome back to icliniq.com.
Yes. But I also suggest that you should have an endoscopy since your acid reflux is not controlled with double-dose PPI. It can be a bad gastroesophageal reflux disease (GERD), or it can be something else. I did not see your endoscopy report. Please let me know whether you had an endoscopy in the course of your illness. And which PPI are you using at the moment?
Patient's Query
Hello doctor,
Thank you for your response.
The report is there for endoscopy. If you are able to address my other concerns, which were mentioned above, please do so. I was using Prilosec but switched to Dexilant and Pepcid, and Gaviscon with no relief.
Hello,
Welcome back to icliniq.com.
No, Caltrate would not have effects on your health. It is ok and safe to take that. And your endoscopy is fine. You should start capsule Esomeprazole 40 mg (Nexium 40 mg) once daily. If there is no improvement after 72 hours, take twice daily.
Patient's Query
Hello doctor,
Thank you for your response.
Should I follow up on getting CA 19-9 tested again, or can I now just forget about that?
Hello,
Welcome back to icliniq.com.
Forget about it. No need to repeat it.
Patient's Query
Hello doctor,
Thank you for your response.
So, to summarize. I should take Nexium 40 mg daily. If there are no improvements, take 40mg 2 times a day? Should take Caltrate daily. Repeat DEXA in possibly three months? I should forget about Ca 19-9 and should get a HIDA scan to check the biliary system?
You mentioned how the polyclonal hypergammaglobulinemia is due to possible inflammation, but My ESR, ANA, and some other inflammatory markers were done and were negative. Is there anything else that can cause this that you are aware of? I am sorry that I have so many questions.
I was researching that some cancers do not show up on CT scans. As with pancreatic, some patients need a EUS, and some patients need a liver biopsy. Do you think I would need something like this to rule out an occult malignancy that may have shown up with a CT scan and or MRI or MRCP? How do you determine who gets these tests in a similar situation?
I have a friend that had advanced liver cancer and unfortunately passed away. I ask this because I would rather want it diagnosed early. Her symptoms were similar to mine, such as nausea, body aches, lethargy, fatigue, and loss of menstruation. So, of course, this is on my mind, especially with the initial elevation of CA 19-9. I appreciate your help. Thank you.
Hello,
Welcome back to icliniq.com.
Yes, you should take capsule Nexium and tablet Caltrate D as advised. Get a HIDA scan as advised.
Polyclonal hypergammaglobulinemia is a non-specific thing, and usually, the causes are an autoimmune disorder of any sort like a bowel inflammatory disorder, liver disease, thyroid disorder, or chronic infection of the urine. Since you do not have symptoms of fever, and the symptoms you mention and laboratory tests you have done did not show any abnormality, this is reassuring, and you should not be worried about that anymore.
I do not think repeating a CT scan, MRI, or MRCP would give any additional information, especially where your two imaging and repeat ultrasound did not show anything specific. EUS (endoscopic ultrasound) is an invasive test, and it is the second step if we have found anything on CT images. So it is not necessary at the moment.
Yes, there are tumors that do not secrete these hormones, but two CT scan abdomen images should have shown something if there were a problem. CT scan can detect a small lesion as small as 1 cm. If you are still concerned, I suggest you just ask the radiologist to review it once more. That would be a wise step, and we often do that in our practice.
A liver biopsy again is not required at the moment.
Patient's Query
Hello doctor,
Thank you for your response regarding my concerns. I will do all that you have suggested. I would like to follow up with you once I get a HIDA scan. Would that be ok?
Hello,
Welcome back to icliniq.com.
Sure. It is my pleasure. Take care till then.
Patient's Query
Hello doctor,
Thank you for your response.
You take care as well, doctor.
Hello,
Welcome back to icliniq.com.
Thank you.
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