Dr. Ghulam Fareed
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
Hello doctor,
I have had upper left abdominal pain (below ribs) for at least two years, always in the same precise location. The pain feels like a sharp cramp and is intermittent but is particularly noticeable when sitting. Kindly suggest.
Thank you.
Hello,
Welcome to icliniq.com.
I will review your case history in detail, and will get back to you in a while. Please wait for my detailed response.
Thank you.
Patient's Query
Hello doctor,
In addition to the abdominal pain, I am experiencing pain in my shoulder and neck on the same side, which feels similar strangely. I have noticed bright red blood spots on my toilet paper occasionally in very small amounts. My stool itself varies, ranging from large sausage-like shapes to pellets and sometimes mushy consistency. I was diagnosed with IBS two years ago, and I am sure I mentioned to my GP as well that I had this pain for a while, but recently it has been more pronounced. I underwent a CT scan of my entire abdomen and pelvis last week. I am also waiting to see my urologist soon to discuss the CT scan results related to urinary tract issues.
Thank you.
Hello,
Welcome back to icliniq.com.
I have read your question and understand your concern.
Shoulder and neck pain is more towards muscular origin and less likely to be associated with the gut. Rectal bleeding is important, but quantity and frequency matter. A small amount of occasional bleeding can be due to simple hemorrhoids or anal fissures; this needs a simple digital rectal examination which can be performed by your urologist even. Changes in the consistency of stools can be due to irritable bowel syndrome. You should be mentioned along the lines of IBS (irritable bowel syndrome). If your symptoms are persistent even after medical trial and management of IBS, then one should consider a colonoscopy for gut evaluation. The CT (computed tomography) scan is unremarkable; there would be nothing major at the urology end.
I hope this helps you.
Thank you.
Patient's Query
Hello doctor,
To be more precise, I have pain within the general area of the mid to upper left abdomen (sometimes unsure where to consider upper left abdomen); it may be considered mid left, as it is not quite near the ribs and is in the soft part of my belly. My follow-up question was, considering the time scale, I have had the pain for two to three years. Does that make it more or less concerning? I am not sure if the chronic nature of the pain means it would have:
1. Less concerning as it would have gotten to a point by now where I would be more unwell if it was cancer.
2. More concerning as it is not a short-term thing. So, would I have gotten more unwell by now if I had had this pain for at least two to three years? Also, would the CT at this end of the two to three years have seen something, as two to three years of pain is enough time for a tumor to develop to a point where a CT would show something? You asked as well if I have any other persistent gut-related issues. My bowel habits have remained sporadic for the last two years, so it is a mixture but nothing bothersome. For example, I have no severe diarrhea; most I get is sometimes pale, mushy stool. On the other end, I do often get a solid pellet-like stool, not particularly difficult to pass. Kindly suggest.
Thank you.
Hello,
Welcome back to icliniq.com.
Regarding your site of pain; it is predominantly towards the left side of the abdomen, not very much pinpointed. Left-sided internal organs, including the gut, are the likely source, and a CT (computed tomography) scan has already been done. Prolong symptoms in the absence of red flag signs like (per rectal bleeding or blood in vomiting on and off, difficulty in swallowing foods, unintentional weight loss, first-degree relatives with cancer, CT scan evidence of anything unusual on abdominal examination) are not worrisome because prolonged illnesses cause gradual worsening of overall health. A CT scan is one of the best modalities for intraabdominal solid organs like the liver, kidneys, spleen, and others. It can pick large tumors in hollow viscera like the stomach, small intestine, and large intestine. Gastroscopy and colonoscopy are the investigations of choice for the evaluation of the stomach and large intestine from the inside. Simple anti-spasmodic medicine like tab Mebeverine (Lactose monohydrate and Sodium) is a good painkiller for gut-related symptoms; I think you should use simple medications, and if you are having persistent symptoms or any red flags signs, as I mentioned earlier, then endoscopic evaluations should be considered. Gut sensitivity, especially in sensitive people or little anxious people, can cause on-and-off abdominal pain; this is one of the possibilities, too. For this, you can judge whether your gut or bowel habits got disturbed under stress or uneasy conditions. If this is a growing tumor in the gut, two to three years is too much; it should have been picked on a CT scan.
I hope you find this helpful.
Thank you.
Patient's Query
Hi doctor,
Thank you for your reply.
All of the following has occurred over the last five weeks. About five weeks ago, I started having urinary tract issues, mostly at night when trying to sleep. I have the urge to go to the toilet, every 15 to 30 minutes to urinate, and only a small “dribble” would come out. I also had stinging at the end of my penis. (I had a similar issue three months earlier, and lasted a few weeks, just not as bad. It eventually resolved itself). This time it was worse, so I consulted a doctor, and was given antibiotics (Nitrofurantoin) for a suspected infection (UTI). However, one week of these antibiotics did not help. On my second visit to my doctor, they suspected inflammation and were given an anti-inflammatory (Naproxen). One week of this did not resolve the issue either.
I had taken normal blood tests with no infection. My kidney function was normal. My urine was also normal. The urinary issues did eventually resolve itself. But I started getting a pain, in the mid right side of my back. It felt like a golf ball stuck to my back. The pain eventually worsened. It started in the upper right abdomen, below the ribs. This abdominal pain feels like a colic. Moving, coughing, stretching, or straining would make it worse, and often cause a jolt in pain if I moved in a certain way. Felt like something was inside me causing pressure or being pinched, but large. My right abdomen generally felt heavier as well. (This pain remains, which is my main concern, and has not got better).
I went to go to emergency room one night, due to a sudden sharp pain in my right testicle, when masturbating. I saw a consultant urologist, and after ruling out torsion of the testicle, they diagnosed me with right-sided varicocele (spontaneous occurrence). This was diagnosed by Doppler ultrasound of the testicles. The urologist referred me urgently for a CT scan of the abdomen and pelvis (portal venous) IV contrast, to rule out renal malignancy, or mass in the kidney. I was told that right-sided varicocele (rarer than left-sided) can sometimes mean something in the kidney is compressing the renal vein, causing thrombosis and varicocele.
In the meantime, required another visit to the emergency room, due to my deterioration. (night sweats, malaise, persistent cough). I was checked over, my heart rate was fast, and I had a temperature of 38 degrees. (Mt blood pressure was normal). Blood tests now showed a slight increase in infection markers (not much). Previous blood tests showed no infection despite symptoms.
I was asked to take a chest X-ray due to the cough, and this was clear. Eventually, the temperature went down on its own. But night sweats have not stopped. I had my abdomen or pelvis CT a few days later. It later found out that this was clear apart from some incidental findings unlikely to be causing symptoms (CT report is included). I also had a renal ultrasound, with my bladder checked fully and then empty, and this came back clear. All of this leads me to believe, something serious is being missed, as I still have symptoms, and concerned about it being bowel-related.
I was diagnosed with IBS two years ago, due to bowel movements (a mix of constipation and diarrhea), and lower abdomen ache. Also starting two years ago, eating certain foods, like salads, causes me to need to need bowel movements straight away, and causes nausea. I have never had this before and used to be able to eat anything without symptoms.
My current symptoms are:
1. The upper right-sided abdominal pain. (Most concerning symptom), has lasted about four weeks, and started as back pain.
2. Right-sided back pain is still there, and a dull ache in the lower back too.
2. Varicocele causing low-level dull pelvic pain.
3. Night sweats and malaise.
4. Dark, hard, stools in pellet form.
I also had a few times in the last month where I saw small spots of red on toilet paper.
Yesterday a nurse practitioner did a rectal examination and found one hemorrhoid. My prostate is not enlarged. Currently awaiting results of stool tests:
1. Calprotectin.
2. H. Pylori.
I am most concerned that due to the CT scan ruling out other abdominal issues, the only remaining thing that could be causing these symptoms is a bowel obstruction. Especially due to abdominal pain. CT scans do not always show bowel cavities, especially in unprepared bowel, which makes me worry that this is the only thing that it could be. Please help.
Thank you.
Hello,
Thanks for your consultation with icliniq.com again.
I have reviewed your case history in detail.
There has been a multi-system involvement in the previous couple of weeks. Starting from urinary tract symptoms, then right-sided abdominal pain, followed by right-sided testicle pain, which came out to be right-sided varicocele. You have had an episode of fever cough (chest symptoms) and night sweats, which are persistent. Gut symptoms, previously labeled as IBS (irritable bowel syndrome), and now constipation, the occasional red color on tissue paper, and small hemorrhoids on examination. Your concerns regarding bowel obstruction and some of your investigations are pending.
So, multiple investigations have been done, and there is nothing clinically significant with all the above symptoms, which is reassuring. It is highly unlikely that a patient is suffering from multi-system problems and all relevant investigations would come out negative to explain his clinical conditions. Considering your history of IBS, you have a sensitive personality and your gut and internal organs are sensitive too.
If you have a normal urine analysis and radiological testing, there is nothing major inside, drink plenty of water and stay relaxed. Regarding your right-sided varicocele, if the urologist thinks there is no surgical intervention needed, then relax and continue your routine sex life, avoiding extra pressure or trauma to the right testicle.
Chest symptoms, fever and cough already settled, for night sweats, your physician must have evaluated you, through simple screening tests like ESR (erythrocyte sedimentation rate), LDH (Lactate dehydrogenase), and routine blood examinations. This would be an extensive list of the investigations, that must be clinically correlated first, I mean your frequency of symptoms, your body weight, your general anxiety status, etc.
A right-sided abdominal pain, in the presence of a normal CT scan, a simple anti-spasmodic should be tried to relieve your symptoms. Hard stools, blood, and hemorrhoids, all can be treated by just avoiding constipation. Drink plenty of water, take regular Psyllium husk, and even small doses of laxatives like Sodium pico sulfate if needed. Ensure you are passing soft stools daily. Bowel obstruction is very unlikely, it must have been picked on a CT scan because CT is a diagnostic investigation for bowel obstruction.
Our endoscopic examinations including gastroscopy and colonoscopy are remaining. If you have persistent symptoms, that would be done. Meanwhile, your health-related anxiety should be treated as well, which is one of the possibilities for all your symptoms. Avoid searching on the internet regarding your symptoms and investigations, as exposure to unfiltered information would increase health-related anxiety.
I hope this information helps provide some insight into your symptoms.
Please do not hesitate to reach out if you have any further questions or concerns.
Thank you.
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