thoracic back pain and abd pain

[drpainfree]

pt has upper back pain for about a year, intermittent, sore aching pain, no radiation, but often associated with cramp in epigastric area. the pain is worse when laying down or at night and massage seems to relieve it.

pt has peptic ulcer disease, otherwise normal ct abd except fatty liver. currently on PPI on and off which doesn't seem to correlate with onset/relief of the back/abd pain. pt also has moderate to severe osteoporosis, on hormone replacement, but there's no other significant abnormalities on T-spine MRI. pt has chronic lumbar radiculopathy due to DDD.

any thoughts about this presentation?

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[lobelsteve]

pt has upper back pain for about a year, intermittent, sore aching pain, no radiation, but often associated with cramp in epigastric area. the pain is worse when laying down or at night and massage seems to relieve it.

pt has peptic ulcer disease, otherwise normal ct abd except fatty liver. currently on PPI on and off which doesn't seem to correlate with onset/relief of the back/abd pain. pt also has moderate to severe osteoporosis, on hormone replacement, but there's other significant abnormalities on T-spine MRI. pt has chronic lumbar radiculopathy due to DDD.

any thoughts about this presentation?

If not done with STIR, she could have a T4 or T5 Fx with referred pain. Without loss of vertebral body height, this could be missed without STIR sequence. Especially in mid to high T-spine.

 

[clubdeac]

pancreatitis? That may not show anything on CT right? Get a lipase and amylase

 

[drpainfree]

amylase/lipase? acute pancreatitis or chronic (which she doesn't have) or maybe subacute? a/l might be normal in chronic pancreatitis, right?

maybe send to GI doc

 

[clubdeac]

amylase/lipase? acute pancreatitis or chronic (which she doesn't have) or maybe subacute? a/l might be normal in chronic pancreatitis, right?

maybe send to GI doc

And you KNOW she doesn't have chronic pancreatitis b/c??

According to emedicine:

Clinically, the patient experiences intermittent attacks of severe pain, often in the mid abdomen and occasionally radiating in a bandlike fashion or localized to the mid back. The pain may occur either after meals or independently of meals, but it is not fleeting or transient and tends to last at least several hours. Unfortunately, patients often are symptomatic for years before the diagnosis is established; the average time from the onset of symptoms until a diagnosis of chronic pancreatitis is 62 months, add or subtract 4 months. The delay in diagnosis is even longer in people without alcoholism, in whom the average time is 81 months from onset of symptoms to diagnosis.

• The natural history of pain in chronic pancreatitis is highly variable. Most patients experience intermittent attacks of pain at unpredictable intervals, while a minority of patients experience chronic pain. In most patients, pain severity either decreases or resolves over 5-25 years. Nevertheless, ignoring pain relief with the expectation that the disease eventually will resolve itself is inappropriate. Variability in the pain pattern contributes to the delay in diagnosis and makes determining the effect of any therapeutic intervention difficult.

After further reading it appears as though it's very difficult to diagnose and the diagnostic gold standard is either ERCP or MRCP

 

[drpainfree]

thank you so much for the citing. i'll let her know tomorrow. she's been pretty stressed out.

 

[lobelsteve]

And it is relieved by massage....


Makes me think msk.

 

[Tenesma]

I had a guy go COMPLETELY BESERK when I told him I was going to treat his thoracic back pain with Prilosec OTC for 14 days.... fit the same symptoms as above... he cursed me out for being a dumb doctor as I obviously didn't understand his thoracic MRI (which showed minimal degen changes)....

4 months later he calls and wants to sched f/u... i refuse based on his behavior... regardless, somehow, he ends up being seen... he apologizes for his behavior --- every time he complained of the above symptoms everybody told him that it was his back...

so after seeing me initially, he went to see spine surgeon, who told him to do PT and no surgery... PT didn't help ... so spine surgeon sent him to his pet injectionist who did a series of 3 thoracic epidural steroid injections... didn't help... finally his wife suggested that there is nothing to lose in taking the Prilosec... within 2 days he had COMPLETE resolution of his back pain... as long as he stays on PPI he has complete relief - being followed by GI now as I have nothing else to offer but more Prilosec

 

[bedrock]

nice one, Tenesma

 

[Tenesma]

come on ... i can't be the only person who has had pts with GERD back pain?

talk about thoracic back pain:

a few weeks ago - i get a "courtesy" call that a patient of mine is being admitted for intractable back pain - that I "don't have to worry", that the ER doc "is going to give him an IM shot of dilaudid/toradol" and that "i can do my consult in the morning"...

thing is: i know this patient well - and i thought it odd that they would go to ER during business hours when my office is literally 200 yards from ER... i have a funny feeling... go check on guy...

he is on stretcher, in horrible agony, can barely speak/catch his breath - i go to hold his left hand while i talk to him - except it feels cooler than the right hand... I check for a pulse - no pulse in left hand, bounding pulse in right hand... I tell ER doc (who didn't even examine patient - the PA saw the patient, heard my name as one of his docs, and assumed he was a "pain" patient) to get a STAT CT ... patient had dissecting aorta...

he is doing fine now....

argh

 

[drpainfree]

again, good catch...

 

[clubdeac]

Wow, that's awesome (your catch not the dissecting AAA). How do you get to see this stuff?

 

[Tenesma]

i dunno... it scares me to think of the stuff that I miss on a regular basis...

 

[jsaul]

i dunno... it scares me to think of the stuff that I miss on a regular basis...

it just goes to show you that nowadays patients are horded through pcp offices like cattle many not even examined and just referred from one specialist to another.