Help, ed patient RUQ pain, no gallbladder

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Lmcmd

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33/f enters ed with acute ruq pain, radiates to back, diaphoretic, apneic breathing, comes in waves, builds up in intensity and then slows, patient has no gallbladder x 5 years, pain intermittent for 5 years, brought on by rare social drinking, but not every time the patient drinks and only a few sips will bring it on, brought on by not eating, brought on by artificial strawberry and ice combo, e.g. Icee, daiquiri, negative us, negative hida, negative MRI abdomen without, all done outpatient- all previously, patient is not jaundice and has never been, no vomiting, morphine increases pain, patient reports if the pain is caught early at first sign of peristalsis with either bentyl or nitroglycerin the pain will stop all together, if not caught in time the pain will go on for 4 hours duration leaving her bed bound, adjusting position does not help her, patient reports no constipation or diarrhea, no history of ibs or chron's, no fever, describes pain as someone stabbing her between the ribs in the same spot and when radiating to back the pain is equally bad for a few minutes and gives the front a break for a short time and then moves back building from 2/10 at onset and then within 15 minutes 8/10, 9/10, then for 30 minutes 10/10 at which she asks her partner to end her life, then moves back down to 0 at the same reverse intervals for 4 hours or more, allergy to morphine and derivatives, what should my next course of action be, labs unremarkable
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Lmcmd said:
33/f enters ed with acute ruq pain, radiates to back, diaphoretic, apneic breathing, comes in waves, builds up in intensity and then slows, patient has no gallbladder x 5 years, pain intermittent for 5 years, brought on by rare social drinking, but not every time the patient drinks and only a few sips will bring it on, brought on by not eating, brought on by artificial strawberry and ice combo, e.g. Icee, daiquiri, negative us, negative hida, negative MRI abdomen without, all done outpatient- all previously, patient is not jaundice and has never been, no vomiting, morphine increases pain, patient reports if the pain is caught early at first sign of peristalsis with either bentyl or nitroglycerin the pain will stop all together, if not caught in time the pain will go on for 4 hours duration leaving her bed bound, adjusting position does not help her, patient reports no constipation or diarrhea, no history of ibs or chron's, no fever, describes pain as someone stabbing her between the ribs in the same spot and when radiating to back the pain is equally bad for a few minutes and gives the front a break for a short time and then moves back building from 2/10 at onset and then within 15 minutes 8/10, 9/10, then for 30 minutes 10/10 at which she asks her partner to end her life, then moves back down to 0 at the same reverse intervals for 4 hours or more, allergy to morphine and derivatives, what should my next course of action be, labs unremarkable
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Sounds like she had a lap chole for similar symptoms 5 years ago without relief. Could be functional pain. Otherwise a retained stone or surgical complication (CBD stricture for ex) could cause these symptoms but should show up on imaging you listed. Pancreatitis is also possible. Peptic ulcer disease also. Some form of hepatitis, cholangiopathy all make it to the list.

Some people just have pain though. No matter what you do.
 
yea, I agree with the above that some people have that pain post chole.

but some people also have chronic pain regardless.

Given your hx, I get the picture of a pt who does not take good care of herself making her vulnerable to multiple pathologies.
 
lazymed said:
Sounds like she had a lap chole for similar symptoms 5 years ago without relief. Could be functional pain. Otherwise a retained stone or surgical complication (CBD stricture for ex) could cause these symptoms but should show up on imaging you listed. Pancreatitis is also possible. Peptic ulcer disease also. Some form of hepatitis, cholangiopathy all make it to the list.

Some people just have pain though. No matter what you do.
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She said when the gallbladder was removed, she didn't have a fever or a blockage, just very multiple large stones, patient lost 80 pounds over several years, not from surgery just hard work. No stone showing up on the imaging retained. Negative for hepatitis. After hours in the waiting room, her pain subsided before imaging, probably bentyl from home worked. I'm wondering if it could be sphincter of oddi dysfunction or something like that but it only shows up on imaging and labs when actively constricted, she's never had imaging done during this time and would be difficult for her to sit still for it. Could inject morphine during exam to produce the same symptoms. I just had her follow up with a g.i., she wasn't looking for pain medicine, she said was just scared it might be something more serious she was masking with anticholergenics and vasodilation. I don't suspect messenteric ischemia because she doesn't have a problem eating. Pain is all on the right side right above transpyloric plane, below septum, behind curvature of rib cage. She is scared of the risks involved with ercp. But more worried about the pain getting worse after getting pregnant with her husband and not being able to take medicine. Just wondering if anyone out there ever had something like this come in or could recommend any further testing.
 
EtOH and morphine bring on pain with partial resolution with nitro suggests sphincter of oddi dysfunction. ERCP with sphincterotomy
 
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Lmcmd said:
33/f enters ed with acute ruq pain, radiates to back, diaphoretic, apneic breathing, comes in waves, builds up in intensity and then slows, patient has no gallbladder x 5 years, pain intermittent for 5 years, brought on by rare social drinking, but not every time the patient drinks and only a few sips will bring it on, brought on by not eating, brought on by artificial strawberry and ice combo, e.g. Icee, daiquiri, negative us, negative hida, negative MRI abdomen without, all done outpatient- all previously, patient is not jaundice and has never been, no vomiting, morphine increases pain, patient reports if the pain is caught early at first sign of peristalsis with either bentyl or nitroglycerin the pain will stop all together, if not caught in time the pain will go on for 4 hours duration leaving her bed bound, adjusting position does not help her, patient reports no constipation or diarrhea, no history of ibs or chron's, no fever, describes pain as someone stabbing her between the ribs in the same spot and when radiating to back the pain is equally bad for a few minutes and gives the front a break for a short time and then moves back building from 2/10 at onset and then within 15 minutes 8/10, 9/10, then for 30 minutes 10/10 at which she asks her partner to end her life, then moves back down to 0 at the same reverse intervals for 4 hours or more, allergy to morphine and derivatives, what should my next course of action be, labs unremarkable
Click to expand...

Very interesting. Is this a a special case you're going to write up? Sounds like their vitals are unstable and related to the gallbladder surgery. Doesn't seem to be related to the bile ducts with labs being fine. I think this is some form of obstruction based on the temporal pattern of the pain as well as provocative patterns. Obviously, the trigger is acute pancreatitis but given the negative tests I dunno.
 
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DBV said:
EtOH and morphine bring on pain suggests sphincter of oddi dysfunction. ERCP with sphincterotomy
Click to expand...

I think this may be part of it and it's known to occur after cholecystectomy.

To add to it, there was no duct dilation on RUQ U/S? Perhaps if this was over a long period of time, it wouldn't be as dilated. According to UptoDate, there's a Rome IV criteria which lists 7 criteria that have to be met when SOD dysfunction is suspected.

Epigastric/RUQ pain.
30+ mins pain
Recurrent, irregular intervals
Pain gradually builds
Interfere with QOL
No change in pain after bowel
No postural change/acid suppression pain relief.

Furthermore, pancreatitis could be causing this sphincter dysfunction and I suppose if it's chronic pancreatitis, that would explain that absence of lab findings. I think the first thing to do would be a sphincter manometry?
 
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Backtothebasics8 said:
I think this may be part of it and it's known to occur after cholecystectomy.

To add to it, there was no duct dilation on RUQ U/S? Perhaps if this was over a long period of time, it wouldn't be as dilated. According to UptoDate, there's a Rome IV criteria which lists 7 criteria that have to be met when SOD dysfunction is suspected.

Epigastric/RUQ pain.
30+ mins pain
Recurrent, irregular intervals
Pain gradually builds
Interfere with QOL
No change in pain after bowel
No postural change/acid suppression pain relief.

Furthermore, pancreatitis could be causing this sphincter dysfunction and I suppose if it's chronic pancreatitis, that would explain that absence of lab findings. I think the first thing to do would be a sphincter manometry?
Click to expand...

Family history father's mother died of pancreatic cancer at 42. Platelets 451. Alt low at 15, range 30-45. Patient has pcos but insulin and glucose are always in normal range managed by metaformin. No n/v, not a drinker, triglycerides in normal range from labs she brought. No autoimmune disorders no cycstic fibrosis in family. I don't know about chronic pancreatitis unless that could be spontaneous with no n/v symptoms or evidence in a workup, but I'm leaning towards sod as well. I understand she doesn't want a sphincterotomy as there is a 10% chance of pancreatitis or other complications after procedure, but I don't know what else to suggest. Chronic pancreatitis can cause mutations to the pancreas as well.
 
Does the patient happen to say that there's only one pain medication that works and that it starts with a D...
 
masaraksh said:
Does the patient happen to say that there's only one pain medication that works and that it starts with a D...
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No when I greeted the patient in triage she was in obvious pain, diaphoretic, squirming everywhere, couldn't sit down. But there was no where to put her, busy day, holding admits, her pupils weren't dilated and showed no signs of having taken pain medicine once she came back to a room. She didn't ask for pain medicine, I didn't give her any, and her tox screen was negative. She stated narcotics make the pain worse, ibuprofen Tylenol and asa have effect, nor does medicine for heart burn. Only thing that ever worked is catching the pain at the beginning signs of building up and taking nitro or bentyl and sometimes whole milk or almond milk but she said that only would slow symptoms until she could get to the first two and even then sometimes wouldn't work at all.
 
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CBC, CMP, lipase, RUQ US. Try some hyoscyamine in ED. DC home when all is inevitably negative. Follow up with PCP/get a GI. Diagnosis abdominal pain. The workup she needs isn't something we're getting through the ED. Send her home with some SL hyomax to try and get her through to follow up.
 
Lmcmd said:
33/f enters ed with acute ruq pain, radiates to back, diaphoretic, apneic breathing, comes in waves, builds up in intensity and then slows, patient has no gallbladder x 5 years, pain intermittent for 5 years, brought on by rare social drinking, but not every time the patient drinks and only a few sips will bring it on, brought on by not eating, brought on by artificial strawberry and ice combo, e.g. Icee, daiquiri, negative us, negative hida, negative MRI abdomen without, all done outpatient- all previously, patient is not jaundice and has never been, no vomiting, morphine increases pain, patient reports if the pain is caught early at first sign of peristalsis with either bentyl or nitroglycerin the pain will stop all together, if not caught in time the pain will go on for 4 hours duration leaving her bed bound, adjusting position does not help her, patient reports no constipation or diarrhea, no history of ibs or chron's, no fever, describes pain as someone stabbing her between the ribs in the same spot and when radiating to back the pain is equally bad for a few minutes and gives the front a break for a short time and then moves back building from 2/10 at onset and then within 15 minutes 8/10, 9/10, then for 30 minutes 10/10 at which she asks her partner to end her life, then moves back down to 0 at the same reverse intervals for 4 hours or more, allergy to morphine and derivatives, what should my next course of action be, labs unremarkable
Click to expand...
Discharge.
 
that was too annoying to read so i didn't. any egd or pregnancy test?
 
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