I am a 27-year-old male. My primary symptoms are large amounts of gas produced in stomach and/or intestine. I feels like stomach acid becomes carbonated, pain and pinching feeling from gas. I also have tingling, spasms or pain in pectoral, armpit, calf shoulder stiffness or aching in right arm, usually on the right side of the body. These symptoms are relieved upon belching and are likely due to pressure on the nervous system. Gas in stomach occurs simultaneously with sinus sweating, thin watery mucus. Later that mucus will dry and obstruct the nasal passage way in a dry plasticky film that must often be manually removed. Gas appears in much greater quantities in episodes, often followed by by constipation and/or diarrhea.
Medical history: I had walking pneumonia 15 years ago. After which a history of sinus headaches in childhood. I thought it to be the result dehydration, cured only by vomiting or sleep. Allergic reaction with facial swelling and butterfly rashes, compromised immune response 11 years ago, and cured by Prednisone. EKG five years ago (results normal) prompted by muscle spasms and random aforementioned pains (absence of gas at this stage) followed by upper endoscopy with biopsy and first of three tests for H pylori (negative, only abnormality was patent and malformed pylorus).
Blood tests came back normal. Calprotectin, negative (no inflammation). H Pylori, negative. Candida, negative. Ultrasound came back normal besides massive amounts of air pockets in the stomach and large intestine. Origin of the air is unknown, repeatedly presumed to be fungal or bacterial. Fecal occult blood came back positive. Two years ago, after throwing up blood. This was the only time the condition ever induced vomiting. Effective medications: Sucralfate.
PPIs appear ineffective, at least without the aid of sucralfate. Magnesium and Aluminum appears wholly ineffective even at the highest medically prescribed doses. Simethicone does not reduce the gas. Domperidone, prescribed to treat a previous, abandoned diagnosis of aerophagia, only served to increase pain and force more gas to be released rectally and orally.
Due to testing negative for candida, anti-fungals were never prescribed. Due to testing negative for calprotectin and appearing to lack inflammation, a recent diagnosis of gastroenterocolitis was abandoned. The source of the bacteria, if any, could not be determined, and thus antibiotics were never prescribed for anything more than diarrhea, however, this did appear to help.
Knowing what to test for at this stage would be invaluable towards prescribing the right antibiotic, anti-fungal, or antiviral to treat the source of this condition.
More details about the presenting complaint:
Current medications: Sucralfate is the only one that works, also taking Pantoprazole and Spazmex currently.
Past medications of the same issue: Omeprazole, Domperidone, and Simethicone.
Lab tests performed: Endoscopy, fecal occult blood, H.pylori test (biopsy and 2x fecal test) blood test, candida test, and ultrasound.
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Thank you for providing a detailed history. There are a few details I would have appreciated.
Have you lost weight during any of the periods? Does your weight keep swinging from gain to loss? Any history of iron deficiency anemia in the past? Have you ever been advised to keep or kept a food diary to identify probable food culprits? Any history of lactose intolerance? Have you ever tested for Celiac disease- any serum antibodies or duodenal biopsies?
Have you ever had a CT scan or MRI of the abdomen or fecal elastase test done in the past? Do you consume alcohol, if so what would be the volume in a week (and what type of alcohol)? Any association of alcohol with symptoms? Have you ever had hydrogen (glucose or lactulose) breath test or duodenal aspirate for culture? Are the symptoms associated with any diarrhea?
If I could have the details for the above, I would much appreciate and would help me to provide a comprehensive opinion.
Thank you doctor,
Not really weight loss. I cannot seem to lose weight even though my appetite changes and some days I eat much less. As for iron deficiency/anemia, I do not know, but all my blood tests came back normal, even perfect as the doctor said, so I assume if i was iron deficient that would be detected there. There is a history of stomach issues in my family, my father found out he was lactose intolerant but it turns out the PPI they had him on was causing an inability to process lactose and making these nodule things in his stomach.
I have paid strict attention to my diet, and it does not seem to be corollary to my symptoms. The condition seems to come and go almost semi-seasonally and is worst in fall or winter, and when it fades and is almost gone. Consuming lactose or gluten does not cause it to come back faster. Additionally, refraining from lactose or gluten when the condition is at its worse does not cause it to fade.
No I have not tested for celiac disease. Also no, I have not done a CT scan or MRI, only an ultrasound. I do not know what benefits they would offer over the ultrasound or what they would be able to detect. The ultrasound only found massive pockets of gas around my digestive tract. No one has recommended a fecal elastase test so I did no't think to. It makes sense, however, during the ultrasound they did note that my pancreas looked normal. Everything looked normal besides the gas.
Yes, there is a direct reaction to alcohol consumption, which causes the worst symptoms besides carbonated soda, both of which I have refrained from consuming. If I ever drink alcohol, it is sparingly when the symptoms have faded, and I never drink enough to get drunk because even small amounts cause my symptoms to worsen. I try to resist this, but going two years without drinking or having carbonated soda or spicy food is hard. No I have not had a hydrogen breath test or duodenal aspirate. Yes there is sometimes diarrhea, just yesterday for instance. More commonly there is constipation. Sometimes, like yesterday, there is the extremely painful combination of the two, so there is pockets of gas trapped behind liquid diarrhea and constipation, and it causes me immense internal pain, almost floors me. Thankfully, this is not all the time.
If the culprit was stomach or intestinal cancer, or there was even a non-malignant tumor, would it show up on the ultrasound? Can Ii rule out cancer? Given the information I have provided can you please rank the culprits from most likely to least likely so I know which tests to run first: Celiac, SIBO, lactose intolerance, intestinal pseudo-obstruction, pancreatic conditions, IBS, or IBD. Given the results of the tests that have already been run is there any of the above, or any other potential culprits that I can safely rule out? Can you please explain how my sinus symptoms runny nose seem to always be connected to my stomach symptoms? Can this shed greater light on what is causing this? Most recently the connection was assumed to be Candida, however, revealing absence of this in testing, is there another explanation? You mentioned fecal elastase tests, I had not considered the problem could be pancreatic in nature. How likely is it that I could have a mild form of undiagnosed cystic fibrosis since childhood, causing my walking pneumonia, sinus problems and constipation throughout most of my life and the more severe symptoms are only beginning to develop as an adult? Why is sucralfate the only medication that seems to help and why has it been less effective recently?
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Cancer does not necessarily show up on an ultrasound, so it is not possible to rule out cancer from the details provided. Celiac disease is still a possibility unless serological tests are negative. IBD (irritable bowel disease) is less likely as calprotectin is normal, though I am not sure, whether you had done it during periods of exacerbation and sometimes repeating calprotectin would be useful SIBO (small intestinal bacterial overgrowth) is possibility again, but cannot comment unless you have a hydrogen breath test or duodenal aspirate.
Chronic pancreatitis is still a possibility since pancreas is not well identified or characterised on ultrasound, if that was so we would not have needed these advanced imaging like CT (computerized tomography) or MRI (magnetic resonance imaging). Fecal elastase would be useful. Possibility of cystic fibrosis exits, though I have never heard of the term walking pneumonia in my 16 years career. Did you mean bronchiectasis?
In my opinion to come to a conclusion that this is IBS (IBS is mostly a diagnosis of exclusion) and IBS-M is a strong possibility here. I would need a colonoscopy, CT and MRI of abdomen, celiac markers and cystic fibrosis assessment (I presume you have not had a CT scan of chest, even though you have mentioned about walking pneumonia). You have mentioned about malar rash and low immunity and treatment with Prednisolone, which improved it during child hood, do you have any records of it ,were you evaluated for SLE? Was it glomerulonephritis? Your upper respiratory tract symptoms could just be rhinitis most probably allergic, or very less likely cystic fibrosis (runny nose and crusting in the nose is not related to sinuses, but to rhinitis). Your clinical scenario is not straight forward and is only partially evaluated with lacunae in investigation results which impairs proper clinical decision making. In the absence of these details, I would only be able to provide you generic advise and suggest A low FODMAP diet peppermint oil caps and advise you to get the suggested investigations.
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