I need medical suggestions

My daughter's boyfriend (17 years old, good health, 6' 4" 220 pounds) entered the hospital last Sun night with severe lower right abdominal pain. This is day 6 and two hospitals later and they still can't find a problem. When I say severe, he's writhing in pain, sometimes screaming into a pillow. He hasn't slept for more than 15 minutes at a time since it started. All the test come back fine, kidneys, gall bladder, intestines, spinal, blood work, urine, stool and all the rest. No fever, no rash. It seems most like a kidney stone or shingles but all manner of test say no. He's been given Demerol, Morphine shots and then the pump, Oxycotin and who knows what else with little to no relief from the pain. Tonight they inserted a...can't remember the name but it's a spinal block. He's in MUCH less pain and should be able to sleep the night.

Here's why I need some ideas. Tomorrow they want to perform exploratory surgery on his belly. If they don't find anything they want to remove his gall bladder and appendicts while they have him open even though they don't have any indicators that's the problem. It sounds crazy to me but up to this point his folks are saying OK. I think he should be transferred again, maybe a Univ. hospital. Any ideas?

Sure sounds like appendicitis. Pancreatic cancer?

Not advise, just relating a story;

Friend's child had similar symptoms and had an obstructed bowel. They went in to remove what they thought was a bad appendix and they saw the obstructed bowel which doesn't show up well on scans. Everything is okay now.

I was going to say the same thing as Wolfen. A friend in high school had the same symptoms, same puzzled hospital staff. They had him swallow something oddly reminiscent of a goldfish on a string and found it. He ended up losing about 30 pounds (on a 175 pound body).

WOW, certainly not a med expert....going for the rightside would seem to be an appendix...left side perhaps diverticulitis...no idea! Maybe that obstructed intestine or kidney stone?

Maybe he's allergic to those huge shrimp? D really sorry about that statement...but levity can be good?!?)

Prayers & positive thoughts his way for sure!

I can't pretend to even venture a guess, but wishing all involved the very best. Hope all works out well.

Direct visualization is the best bet in this case (exploratory laparotomy), as odd as it seems.
Though all procedures have risk, an ex lap is pretty darn safe.

Some conditions aren't well diagnosed with imaging tests, and abdominal pain is easily the most difficult to nail down in the absence of specific indicators.
It is mind boggling how stealthy abdominal issues can be. The signs/symptoms are not always textbook, and the pain can be referred in such a manner that it can be difficult to pinpoint the focus.
For example, you would normally see a temp and WBC spike with infection or severe inflammation, but we have seen large retroperitoneal abscesses with no signs other than diffuse lower abdominal pain.

Yet, try not to let your mind roam to the "worst case scenario" (easier said than done!), it could be something relatively benign.

It sounds like they used some sort of block technique (trigger point, celiac plexus, etc), which is rather safe, and could give a clue as to where the problem is.

Keep us posted; prayers and kind thoughts sent.

Bob

Taking out the appendix and gall bladder when they have no indication of being problematic is just plain stupid. They're just shooting in the dark using the "process of elimination." What will they want to remove after that if he is still sick? I would keep him the hell away from those doctors, and find more competent diagnosticians who know what they are doing.

There are many organs in the body that medical science really doesn't understand very well. Twenty years ago the medical establishment thought that the tonsils and adenoids were not important and routinely recommended their removal in children that caught a lot of colds. But now they have figured out that they do serve a purpose and should not be removed routinely under those circumstances. Gall bladder removal is the number one surgical procedure (1/2 million/year in US) done in the US. Why? It's not a particularly dangerous procedure that most doctors can almost do in their sleep after a little practice, and it generates a huge revenue stream for the doctors and hospitals. Unfortunately, the gall bladder serves a very useful function and it just can't be removed without consequences, regardless of what some doc may tell you. Some people can function fairly well without it, but others go through hell everyday and are never normal after the surgery. We've been evolving for many thousands of years, it is ridiculous to think our body has organs that serve no purpose just because they can't figure it out
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From: http://www.diagnose-me.com/cond/C337709.html.
Reasons you want to keep your gall bladder:
Long-term consequences of removal of your gallbladder are related to the lack of a storage sack for bile acids. Bile is continuously synthesized by the liver. The purpose of the gallbladder is to store this greenish fluid between meals. When you eat, the gallbladder contracts, empting its contents into the small intestine, where the bile mixes with the food. If there is no storage sack (gallbladder), then the bile constantly drips into the intestine, even when no food is present. In this concentrated form, the bile acids are very irritating to the linings of the intestine. In the short term, irritation of the large intestine by bile acids often causes diarrhea - and long-term the irritation can cause colon cancer. This is the reason why cancer of the right side of the colon is more common in people who have had their gallbladders removed.
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You should read the info on that webpage concerning gall bladder surgery. Don't let this poor kid get hustled into something that will adversely affect him for the rest of his life without just cause. That's my opinion and it's worth exactly what you paid for it.

I guess some imaging (MRI; Scanner) has been done including some images of the spinal situation and maybe electrophysiological exams about possible neural lesions, too?
Checked for Porphyria?

If yes I shall agree that opening him up is probably the best way to proceed as nothing beets a close look by an experenced surgeon ... and that way, they can remove the appendix which is quite practical, too, and a good "investment" for the future.

Just IMHO ... 'cause I am not really qualified for such things being a Neurologist, and especially so via the internet on second opinions.

bernie

No offense but this is probably not the place to seek medical advice on what could be a serious condition. I'm saying this for your benefit and your daughter's boyfriend.

But if you're looking for opinions on what to do then if it were me I think a second opinion is always a good thing but if he's in serious pain then you need to act quickly to avoid uneeded suffering or potential risk on his part. Doctors often call in specialists in situations like this when they're not sure what's going on. Have they done that?

Again, this would just be my thought process and please don't take it as medical advice, I'm not a doctor. But I'll say a prayer for the best.

Regards,

Dave

I wouldn't be asking the question if two different hospitals weren't already out of ideas. Over the past 3 years I have found the CPF knowledge base an amazing thing.

They've checked for ulcers, done an MRI, Cat scan, scoped his rear end, barium test (sp), several sonograms and other stuff that I haven't heard about yet.

I just got word he's going to surgery in an hour. Since it's not my kid I don't get to make the call but if it was he would be heading for the next hospital not surgery.

Thanks for the ideas and prayers.

I use to be like the boyfriend and turns out I suffered gastratious attacks. I changed my diet and eating habits after that and it didnt come back.

Acute right lower abdominal pain is very indicative of an acute appendicitis, especially if it is associated with nausea and vomiting, with a tender McBurney's point, and a positive Rovsing's sign. Medical jargon, I know, but just to illustrate that acute appendicitis is a clinical diagnosis, which means that there are NO investigations that can accurately rule in or out an appendicitis unless a pathologist has a look at the appendix AFTER removal. Of course, diagnosis over the internet without looking at the patient is ambiguous, but I thought I should clear up some misconceptions. There are a lot of other things that can give rise to the pain, and a good history with examination should give a clue. I trust the doctors have not been able to find an obvious cause, and that the history and examination points to a surgical cause, and therefore an exploratory laparotomy may be indicated. By the way, there is sch a thing as abdominal pain of unknown origin, which is fairly common, though should not give rise to such severe pain. Another is irritable bowel syndrome.

Bernie and others have made good points, but at some point a laparotomy, (hopefully done laparoscopically) IS the next step.

My experience with University Hospitals is that they are no more reluctant to do surgery than anyone else, and that this kind of case, at least as described, would have surgery just about anywhere!

Good Luck to him!!

Bill

NicklePlate summed it up for me. It's always amazing how many people ask complicated medical questions here on CPF Doesn't hurt I suppose as long as you dont follow the advice of all us crazies

No fever almost certainly rules out an appendicitis. Sure sounds like kidney stones, but if they have scanned more than once and not found anything then thats ruled out too. Thing is that you might need to get a second scan somewhere else if the most obvious thing came up negative the first time. Same as getting a second opinion.

Getting a second opinion prior to anything major being done is vital. If you've been to two different hospitals already then thats probably already been done. But go ahead and tell the doc that you're not against getting a second scan for kidney stones and see what they say. Could be they aren't completely happy with the scan or the picture or something.

non-localized gut pain, even severe can be so many different things, not nearly enough information here for us to do a differential diagnosis.

It may be that they have reached the point where a little exploratory surgery would be a very good thing. After a point you need to look inside there for real. If you're lucky they will see right away what is going on and be able to fix it. I have no real problem with having his appendix out at this point, but unless they actually see something wrong with the gall bladder I'd ask them why you can't keep it. if it's plugged up with stones then you pretty much have to have it out. Thats not the end of the world, but I'd want to know that is really the problem before they did it as it will cause him problems, though minor ones compared to having it be blocked.

Often docs fail to ask if you're taking any "natural" or other supplements or herbs or anything. Does he take anything interesting that the doc might not know about? There are several things that come to mind that I know some people taking that have the ability to cause stones in the kidneys or gall bladder if you take too much. Just something to make sure that the docs know about.

How do you feel about the surgeon that is going to do the exploratory? Does he give you confidence? Has he shared the list of things he's going to do to look for issues? Does he have a plan beyond just taking out the appendix and gall bladder and seeing what happens? If you're not happy with him, or your future son-in-law just wants one more head wrapped around his problem before he goes under the knife asking the doc to recommend another doc for a second opinion is a perfectly normal and important thing to do. It's not like you're telling the surgeon that you dont trust him or something, he should be happy to have someone else review the tests so far and come and talk to you to suggest alternative things to do now, or to verify the decision to open him up for a peak inside.

If you've already had several docs involved and this is where we are now, then I'd not stop them from poking around a bit, but I'd ask that they actually have a justification or that they not take out the gall bladder just on a whim, test the ducts or take a biopsy or send some of it off for testing before they just pluck it out.

This off topic but I think it's worth mentioning....I had a friend who had her gallbladder removed and she developed a chronic diarrhea which persisted for 3 to 5 years and she was stating things similar to "I understand now how people can commit suicide". A pharmacist into herbal drugs recommended a product called "peppermint plus". Within a few days of starting the peppermint, her diarrhea disappeared and after one year her diarrhea is still under control. Since then, two others with the same problem began taking the peppermint capsules twice to three times a day and they obtained the same result. I was skeptical of the herbal therapy but now I'm a believer....

Here's a link to the product http://www.enzy.com/products/display.asp?id=375&cpmid=407. Many web sites stock it or perhaps your local stores have it.

They have done several scans for kidney stones but come up blank. His surgeon is a woman, not that it matters, and seems fine. They have second and third opinions and all of them end up at surgery. I'm hoping they find appendicitis but have my doubts.

He's in surgery now but my wife talked him out of letting them remove the gall bladder unless they find something wrong, against his parents and surgeons wishes. As you might guess my wife has her nose directly in someone else's business now so things are a little tense. His parents aren't the type to question the docs or do research so when the surgeon said removing the gall bladder might give him indigestion and diarrhea later it didn't seem like a big deal to them.


Update
He's out of surgery. They didn't find anything and they didn't take anything.

I'm glad the surgery went well, saddened that they still don't know.
You wife sounds caring, not nosy.
My mom's surgeon ran the OR like a military general. He exudes confidence and that's what you need when a guy is going to cut you open. She loves him and thanks him each time she visits. He was an Army Surgeon.
Regarding using this forum for advise, I think it's helpful. You'll never know what esle you're going to learn from other members. Some people are more open than others.
Best of Luck to the young man.

James S said:

No fever almost certainly rules out an appendicitis.

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Don't mean to be rude here, but are you sure?

Don't mean to be rude here, but are you sure

Click to expand...

No, of course not I am giving my thoughts, a thousand miles away with nothing but a paragraph of anecdotal, third hand description of his condition. There is no way the best doc in the world would be able to come up with a definitive diagnosis of even a classic appendicitis from here and I'm not even the worlds worse doc since I'm not one at all

Vast majority of cases of appendicitis though involve the standard description of pain and high fever, hardening of the muscles in the area and pain very sensitive to pressure, especially as it gets worse. This fellows pain has been going on for a week, if he was going to develop a fever due to an appendicitis he'd have done so by now. But what causes the pain is the infection and swelling of a raging bacterial infection, thats what normally gets you a fever too.

I'm sure that there are documented cases of appendixes close to rupture with the patient having no fever. But they would be very rare, something to keep in mind, but not a conclusion to jump to. And since these docs have just ruled that out as the cause by going in and looking at it, I think we can too.

Wish I had something else to tell you. All my best wishes for the young man and his family and your daughter. I think they followed the best course at this time, let them look around and didn't take anything that looked healthy or normal.

EDIT: just spent a few moments with google looking up atypical appendicitis information. In children and young people the presentation is almost always the classic symptoms I described from memory above. But in older folks, especially the elderly, it can present in many different ways including without fever. But as I suspected, thats very rare. Thats not to say that this fellow wouldn't be the exception to the rule, but it's unlikely. For this young man I dont think that appendicitis was ever a serious consideration. Something else is going on.