Chronic RUQ pain

[katoka2002]

Based on another post, my guess is this is not a hernia but since it’s been 2 years of abdominal pain, tests and still no diagnosis, I figured there was no harm in reaching out.

I don’t remember exactly when the pain started, just that it had been occurring for several months when I finally asked my chiropractor, in Feb 2014, what she thought so it’s been close to 2 years. My pain is located in the right upper quadrant, below my rib cage. When I do any twisting, walking or running, the pain radiates down. The severity of the pain depends on what I’m doing. Sitting, twisting, walking, swimming, etc it feels like there’s a lump under my rib cage and that from that point down, something is being pulled on, almost as if there’s a rubber band that’s getting pulled too tight. The pain is most severe when I run, which as a triathlete training for Ironman, is the most frustrating. If I run at a slow pace (HR under 175), the pain is usually tolerable. If I do sprint intervals (HR 185-200) I feel like I’m ripping my insides open and I get really nauseous. The pain will subside some once I’ve stopped running, but the nausea lasts all day.

When I mentioned the pain to my chiropractor in Feb 2014, she suspected gallstones and sent me to the ER. I had an ultrasound, chest x-ray (history of spontaneous pneumothoraces) and bloodwork but everything came back normal. I followed up with a gastroenterologist who said he thought it was muscular but was willing to run more tests to be thorough. Abdominal CT, upper endoscopy, and gallbladder function scan were all normal aside from a slightly distended gallbladder and inflamed spleen, neither of which he was concerned about. I took a break from running due to a torn labrum in my hip, had surgery for that and many months of rehab. As soon as I went back to running (after about 8 months off), the pain was back.

The GI doctor and my primary care doctor both said it was muscular so I had a treated as if it were muscular. My chiropractor treated the area with ultrasound therapy early last year, followed by months of manual work from an OT. She thought it was a ligament attached to my gallbladder causing the pain and after working on the area, I’d have pain relief for about half a day and it’d be back. During that time I also had acupuncture 2x/week for several months. I also tried massage and earlier this year while working with my PT for my hip rehab, I had him try dry needling, which also didn’t help.

A general surgeon said he’d go in a take a look as a last resort but didn’t think he’d find anything. I saw a pain specialist last week that ordered an MRI (scheduled for Monday) and said he wants to send me to Mayo Clinic.

So since so many things have been ruled out, could it be a hernia? I had laparoscopic surgery about 10 years ago to remove a cyst on my right ovary but the incisions weren’t near where my pain is.

Thanks for any insight or suggestions!

Katie

[Chaunce1234]

Chronic RUQ pain

Katie – I’ve heard this story many times before. My best guess is that is a muscle spasm. I usually recommend myoflex cream or aspercreme. The knotted, spasmodic muscle feels like a lump, and can sound like a hernia. Hope this helps! DE

[katoka2002]

Chronic RUQ pain

Thanks Dr. Earle,

Not surprised at all at your response since I’ve heard it from several practitioners… but do you have any idea or can direct me to someone that would have an idea of WHY it happens every time I run? There must be something structurally going on to make me more susceptible than any of my team mates. In order to find a solution, I need a diagnosis. If it’s a muscle spasm (which it could absolutely be based on my symptoms), is there someone who specializes in abdominal muscle spasms in athletes that would be able to help? I already take magnesium several times a week and electrolytes every day during training sessions. I’ve tried IcyHot, but will try Aspercream next week!

Thanks so much!
Katie

[Chaunce1234]

Chronic RUQ pain

Katie – I wish I knew why. All I know for sure at this point is that since it is a diagnosis of exclusion (can’t find any other reason), it’s really hard to say why this happens. It could be the way your anatomy was put together in utero, or something that happened during life, or some combination. In any case, it’s almost certainly not a hernia, but I would definitely do the MRI, and keep looking for an answer. May some sort of physical therapy, or alternative medicine things such as acupuncture as one example. Topical agents, ice or heat based on trial and error. Maybe even a steam bath or hot tub. Whether or not you go through a diagnostic laparoscopy will depend on the severity of symptoms, and your own risk/benefit assessment. I wish I had a magic wand, but hang in there, and don’t give up! DE

[drtowfigh]

Chronic RUQ pain

Very difficult problem because no mechanical problem to “repair.”

Some ideas:
– dry needling.
– Botox injection in the area

[sngoldstein]

Chronic RUQ pain

Katie;
I may have an answer to why this happens after having operated on a patient who actually had the spasm while in a CT scanner and was misdiagnosed as having a tumor. At surgery there was a thickened nerve coming through the connective tissue, supplying the area of muscle that was spasming. I cut the nerve and the patient has had no further problems. A chemical nerve ablation may solve your problem.

Good luck,
Steve Goldstein

[katoka2002]

Chronic RUQ pain

Thanks Dr. Towfigh,

I’ve tried dry needling several times with no success. I’ll talk to my pain specialist about the Botox. After examining me a few weeks ago, he said there wasn’t a safe place to inject me in the area because of all the organs in the area of pain, the lack of a muscle knot to inject and lack of nerve to block. But I think he was referring to lidocaine and cortisone injections, not botox, so I’ll mention that.

Thanks,
Katie

[katoka2002]

Chronic RUQ pain

Thanks Dr. Goldstein!

Sounds like a possibility! Not something I’ve heard yet so this is exciting… who would I talk to this about? The pain specialist wants me to consult with a different general surgeon than the one I had originally seen, so do I mention the nerve ablation to him? Would it require a diagnostic laparoscopy? Or is this something the pain specialist can do?

In the meantime, I’ve been using Lidoderm patches when I run and they do seen to be helping some, not completely, but an improvement.

Thanks so much!
Katie

[sngoldstein]

Chronic RUQ pain

It’s going to be tough finding someone who even believes what you have is real. No laparoscopy is required. I inject people with some lidocaine at the point of maximal pain and see what happens. If they like the way they feel with the lidocaine, I inject them with phenol 6%, about 2-3cc. Works about 80% of the time. Some pain management guys will do this. They may even be able to see the nerve in question with a high resolution ultrasound, but no promises on that.

[katoka2002]

Chronic RUQ pain

Exactly! That had been my experience with every doctor until I saw the pain specialist. He and I went though all my test results and discussed all sorts of strange possibilities and next steps. He does believe me that the pain exists but he’s said twice now that he was too concerned about injecting me and hitting an organ and causing more problems. Hmmmm…. I’ll ask again. Maybe he was thinking he’d have to go too deep with the injection? How do you typically do it, ultrasound guided?

[sngoldstein]

Chronic RUQ pain

I generally just place the needle by feel but I am a surgeon and pretty comfortable knowing exactly where I am, depth wise. A pain management doc may not be so comfortable. Unless you are really skinny it would be pretty hard to hit anything critical with a 1 inch long needle.

[katoka2002]

Chronic RUQ pain

I am thin, but not skin and bones skinny. He specializes in low back pain as I couldn’t find anyone that specializes in abdominal pain so maybe he just doesn’t have the experience to do abdominal injections. I’ll ask him next time I see him if he knows anyone that does. I live in northern IL… would you happen to know of anyone in the Chicago, Milwaukee areas or even Madison or Indianapolis?

Thanks again!
Katie

Attached photos… did my best to draw a line where the pain is. Starts under my rib cage and as I run, it radiates down.

[Chaunce1234]

Chronic RUQ pain

You may want to look for a plastic surgeon with an interest in peripheral nerve problems. Maurice Arregui in Indianapolis is a good general surgeon with expertise in abdominal wall problems. He may not be able to do the injection, but may know a plastic surgeon. Feel free to use my name as a referral to him, and mention hernia talk. DE

[lucywisem]

Chronic RUQ pain

sir,i had a recurrent open hernia surgery lasy year.i am born with an ingurial hernia and i had my first surgery when i was 15 but it reoccured after 5yr and i had to undergo another surgery last year,now i am 22 year old.
NOTE-in primary repair they had not used mesh but this time i had a hernioplasty at a local hospital.

sir, my problem now is that i have pain in my abdomin baically inside the stiches and sometimes in scotrum.Also i feel heaviness in my scotrum mainly when i lift some heavy item.
after the repair,i am not able to bend,run,lift and perform any activity which require strength.
i just want to know that what has gone wrong that i am not able to do these things.Also is this a sign that my repair has failed.

please sir help me to overcome this as i dont want to undergo another surgery at this young age.

thank you
aman

[drtowfigh]

Chronic RUQ pain

Dear Aman,
You need to be seen and evaluated by a specialist in hernia complications. This may be a general surgeon or a urologist. Where do you live, and we can help assist in referring you to a colleague of ours that is knowledgeable in this realm.
The question is whether you have a complication from the hernia repair, the mesh, nerve injury, injury to your spermatic cord (which leads to your testicle), hernia recurrence, etc. Many of these problems can be managed with local nerve injections, for example. However, some do require reoperation. A surgeon with expertise in evaluation and treatment of these problems can help you get back to normal and enjoy an active life.

[lucywisem]

Chronic RUQ pain

firstly thank u very much mam for giving ur precious time.

i live in Delhi,India

[lucywisem]

Chronic RUQ pain

please suggest a good hernia specialist in india so that i can get rid of this pain,heaviness and fear of reoccurence which is stopping me from choosing a marketing career as it requires an active lifestyle and regular travelling.

[drtowfigh]

Chronic RUQ pain

Aman,
There are a lot of great surgeons in India for hernia problems.
Try:
Rajesh Mohan Khattar
Sumeet Shah

Please let them know you were referred by HerniaTalk

[drtowfigh]

Chronic RUQ pain

Hi Aman,
Were you able to see a hernia specialist to treat your symptoms?

[fromindia25]

Chronic RUQ pain

I also live in delhi facing same type of problems. Please contact me at [email protected]

[katoka2002]

Chronic RUQ pain

An update would probably be helpful, especially if these symptoms are commonly seen!

I ended up going to Cleveland Clinic in February and met with Dr. Abraham, an anesthesiologist/pain specialist and Dr. Park, a vascular surgeon. Dr. Abraham did a diagnostic celiac plexus nerve block and after a few hours I went for a hard run to try and induce the pain. No pain! Also had a CTA and doppler ultrasound done. Although the arterial velocity of my celiac artery was normal, the CTA showed a minor compression of my celiac artery, such that with the pressure of blood flow with my heart rate high during running, there would be enough pressure on the celiac plexus nerve to cause the pain I’m having.

So the diagnosis is a mild form of MALS, median arcuate ligament syndrome. My treatment options are surgery to release the ligament and sever the celiac plexus nerve or live with it. I’m choosing to live with it right now as the surgery for this is relatively new and failure rate too high for me to take the chance. Most patients with it have pain with eating and nausea which I do not, so pain with running I can handle.

Hopefully this helps others with similar pain!

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